{ "background": "Operational inefficiencies in district hospitals across sub-Saharan Africa impede service delivery and resource utilisation. Existing diagnostic tools are often complex and not tailored for rapid, actionable assessment in low-resource settings.", "purpose and objectives": "To evaluate the efficacy of a novel, structured diagnostic framework in identifying and rectifying systemic inefficiencies, with the primary objective of quantifying resultant gains in operational throughput.", "methodology": "A parallel-group, randomised field trial was conducted in 24 district hospitals. Sites were randomly allocated to an intervention group, receiving the diagnostic framework and implementation support, or a control group. The primary outcome was the change in patient processing time. A mixed-effects linear model was fitted: $Y{ij} = \\beta0 + \\beta1 Ti + \\beta2 X{ij} + uj + \\epsilon{ij}$, where $Y{ij}$ is the outcome for hospital $j$ at time $i$, $Ti$ is the treatment indicator, $X{ij}$ are covariates, $uj$ is the hospital random effect, and $\\epsilon_{ij}$ is the error term.", "findings": "Hospitals using the framework demonstrated a significant reduction in median patient processing time (18.7%, 95% CI: 12.3 to 25.1). The most pronounced efficiency gains were observed in outpatient triage and pharmacy logistics. Uncertainty was quantified using cluster-robust standard errors.", "conclusion": "The targeted diagnostic framework is an effective tool for driving measurable improvements in hospital operational efficiency. Its structured approach facilitates locally-led, context-specific interventions.", "recommendations": "Health system managers should integrate structured diagnostic protocols into routine operational audits. Further research should adapt the framework for primary care facilities.", "key words": "health systems strengthening, operational research, randomised trial, process improvement, resource-limited settings", "contribution statement": "This study provides the first experimental evidence for a practical, hospital-level diagnostic tool that