Objective To study paediatric surgery rates in south-western Uganda, compare them to rates in England, and determine if existing surgical facilities and workforce meet World Health Organization (WHO) standards. Methods To obtain information on surgical facilities and workforce, we conducted a cross-sectional survey of all hospitals performing major surgery in 14 districts of south-western Uganda in 2007–2008. Using theatre logbook data, we determined the surgical rates, types of surgery performed and in-theatre surgical outcomes. Findings Of 72 hospitals surveyed, 29 were performing major surgery. None met WHO standards for essential surgery. There were 0.7 accredited surgeons per 100 000 population and no paediatric surgeons. Most anaesthetists were not physicians (accredited anaesthetist per 100 000 population: 1.1). The annual surgical rate for children aged = 14 years was 180 operations per 100 000 population; most were emergency procedures. The annual surgical rate for patients of all ages was 652 operations per 100 000 population, with a median of 422 per operating theatre (range: 60–3497) and of 226 per surgeon (range: 60–1748). Mission or nongovernmental organization (NGO) hospitals, which had 44% of the hospital beds in the region, performed 3039 (55%) of the paediatric operations. Externally funded surgeons performed 80% of the 140 cleft lip and palate operations. Four in-theatre deaths occurred in children = 14 years old (in-theatre mortality: 7.7 deaths per 10 000 operations). Conclusion Access to all surgery, including paediatric surgery, is poor in south-western Uganda and investment in basic health-care facilities and surgical workforce and training is urgently needed. Mission and NGO hospitals make a valuable contribution to elective surgery, and externally funded surgeons make an important contribution to specialist surgery. In-theatre mortality was lower than reported for similar settings.