Alexander Habte HabtemariamMarie Merci Cyuzuzo2025-09-102025-09-102025-07-10https://dspace.ughe.org/handle/123456789/915Background: Access to emergency and essential surgical care (EESC) remains a fundamental yet neglected component of health system strengthening in Low- and Middle-Income Countries (LMICs). In Rwanda, district hospitals serve as the primary surgical care providers for the majority rural population, yet there is limited recent, nationally representative data assessing their readiness and capacity. This study aimed to evaluate the availability, accessibility, and delivery of EESC across all district hospitals in Rwanda and to contextualize these findings within regional benchmarks from Sub-Saharan Africa as well as the Lancet commission on Global Surgery (LCoGS) benchmarks. Methods: A national cross-sectional assessment was conducted using the World Health Organization’s Situational Analysis Tool for Emergency and Essential Surgical Care (SAT-EESC) in all 43 district hospitals in Rwanda. Data was collected from key informants across three main domains, including infrastructure, workforce, and service delivery. Quantitative analysis included descriptive statistics, bivariate comparisons, and multivariate linear regression to identify predictors of surgical volume and spatial analysis for surgical capacity across Rwanda. Results: Infrastructure was consistently available across all 43 district hospitals, with each reporting at least one functional operating room. Additionally, 93% had uninterrupted electricity and running water, meeting the minimum benchmarks set by the Lancet Commission on Global Surgery (LCoGS). Anesthesia care was predominantly delivered by non-physician anesthetists, with a median of 2 providers per facility (IQR: 1–14). Specialist surgical providers (surgeons, anesthesiologists, obstetricians) were scarce, with a median SAO density of 0.54 per 100,000 (IQR: 0.00–1.07), far below the Lancet Commission’s target of 20 per 100,000. On the other hand, general practitioners, particularly in rural settings, performed most of the obstetric surgical procedures. The median of surgical volume per 100,000 population was 923.97 and an IQR of 585.85–1,508.13, reflecting substantial variability across provinces and between urban and rural settings. Multiple linear regression revealed that hospitals with a higher number of anesthesiologists, hysterectomies, and surgical admissions performed significantly more surgical procedures annually (p < 0.05). In contrast, the number of surgeons and obstetricians was not significantly associated with surgical volume. Referral frequency also showed no significant correlation with surgical output. Conclusion: While Rwanda has achieved notable infrastructure and policy advancements under NSOAP I, district hospitals continue to face critical gaps in workforce capacity, perioperative monitoring, surgical volume, and complex procedure capacity. The predominance of task-shifting underscores the need to redefine workforce metrics to include non-specialist surgical providers. Furthermore, focusing on specific specialties such as anesthesiology may enhance service delivery. These findings provide essential evidence to inform national surgical planning and broader efforts to achieve equitable, timely, and safe surgical care. Despite the aforementioned, future studies should be conducted incorporating longitudinal monitoring, patient outcomes, and cost analyses to deepen insight into surgical system performance and sustainability.enSurgical CareDistrict HospitalsEmergency and essential surgical careHealthcareRwandaSurgical InfrastructureSurgical Capacity Assessment.text::thesis