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Over 107 000 non-emergency or elective surgeries were put on the back burner during the Covid-19 pandemic, according to figures from the national health department.
But challenges in addressing surgical backlogs were there long before Covid-19.
Professor Kathryn Chu, director of the Centre for Global Surgery at Stellenbosch University’s faculty of medicine and health sciences, says that compared to infectious diseases, such as HIV, TB, and Covid-19, surgical conditions and care are not a major priority in the public health system.
“Surgery as a whole has not really had a national strategy or plan and I think that is a problem,” she says.
The makings of a plan but no funding
In 2019, a technical working group on national safe surgical care was formed to write a national surgical plan, Chu said. This is now an official Ministerial Advisory Committee and Chu is a member of the core team.
“Now that the NHI [national health insurance] is coming, the idea is to have a surgical benefits package defined through this and there will be different factors to consider to identify surgical best buys, which conditions should be covered, how much should it cost the system and what is the burden of disease of that surgical condition.”
The plan – a National Surgical Obstetric and Anaesthesia Plan (NSOAP) for SA – is described as a “blueprint to define a national surgical package of care” and focuses on key areas, including human resources, service delivery, infrastructure, supply chain, governance, finance and informatics. Among the main objectives of this plan is to ensure the “implementation of an equitable, accessible and comprehensive surgical, obstetric and anaesthesia care system” for the country.
READ: In-depth: The human cost of surgical delays
The initial start date for the plan to be implemented was January 2022. According to Chu, however, there have been many delays and the research is still under way. She says there are several challenges and there has been no money forthcoming from government to fund this.
“It’s still planned, but there are definitely delays,” Chu says. “It is very much necessary, but it is taking a lot longer than we thought. It’s going to cost millions of rands to even do the work. Government will have to put in the money if they want to prioritise this.”
Health spokesperson Foster Mohale was asked about the progress and resources for this plan but no response was received by the time of publication.
Shortages in the surgical workforce and the maldistribution of surgical capacity have been a particular challenge over the years. Many specialists are in the private sector and those that are working in the public sector are often working in the bigger tertiary hospitals in urban centres.
Many patients have experienced multiple cancelled procedures – even before Covid.
“Patients would drive in for elective surgeries for a gall bladder removal, for example, but then there would be no beds or there would be another emergency and they would get bumped from the list.”
Chu says for 12 to 18 months, almost no elective surgeries have been done. At present, different hospitals across the country all have different strategies to deal with surgical backlogs, and some direction from the provinces or national government can be helpful.
Exploring solutions
1. Devolving surgical care
One possible way to better coordinate surgical care is to devolve some surgical care procedures to smaller district hospitals nearer to healthcare users.
According to Chu, however, district hospitals are hamstrung by resource and capacity constraints. Many of these district hospitals, for example, do not have the necessary ICUs and CT scanners and there are a lot of things that surgical care needs post-operatively that are not there. So, the surgical care package they can provide is limited, she says.
Also weighing in on possible solutions to improve the coordination of surgical care, Associate Professor Lydia Cairncross, University of Cape Town’s global surgery oncology lead at Groote Schuur Hospital, says from a cost-efficiency point of view, it is much better to treat patients at a district rather than a central hospital level.
“A lot of relatively minor surgery that could be done at district level hospitals is being done at central or regional hospitals.”
2. Beefing up the surgical workforce
Both Chu and Cairncross flagged staff shortages, especially of theatre nurses, as a huge challenge.
According to Cairncross, the more immediate priority for government is to unfreeze all posts so that surgical teams can be capacitated.
According to figures from the national health department, by May this year, there was a 15.47% vacancy rate of critical skills personnel in the nursing category, which meant 22 655 vacant posts.
“When someone resigns or retires, the post is often left unfilled for six to 12 months and the whole system spirals into chaos while that person isn’t in place and this obviously has knock-on effects with other people who then get burnt out and also leave,” says Cairncross.
Chu echoes this and says there’s a shortage of nurses. Opening up theatres on weekends will, therefore, not address the backlogs.
So far, the health department has been citing budget constraints as the reason posts in the public health sector are not filled immediately.
Many health budgets, also in the Western Cape, took a knock with Covid-19.
What makes South Africa unique, Chu says, is that you don’t have to be a specialist to perform surgery or anaesthesia.
“There are many GPs and medical officers that do some operations and who give anaesthesia that never qualified as specialists per se. But on the other hand, their training is variable and not that well-regulated and there isn’t really a standard of care on what procedures they should know how to do. So it’s a bit hit or miss and personalised, depending on where the person is working and who their mentor is.”
Health Minister Dr Joe Phaahla in response to a written parliamentary question recently said the South African Nursing Council’s figures showed that 52 887 specialist nurses completed their studies and registered as nursing specialists over the past 10 years. The figures, however, showed that despite this number of qualified specialist nurses, the number of appointments in the public sector remained low. This, Phaahla said, was, among others, due to the private sector absorbing some nurse specialists such as ICU-trained nurses who “preferred to work for agencies as proven during the height of the Covid-19 pandemic”.
3. Co-opting private sector resources
Another way of beefing up surgical capacity is to lean on the private sector. During the height of Covid-19, there was a small taste of what this relationship could look like when the government bought private sector beds for Covid-19 patients.
According to Cairncross, theatre space is an area where this partnership could be effected. This will mean private hospital theatres are used for public sector patients.
“The question then arises: who’s the theatre team that does that? Is that theatre team in the private hospital or does it come from the public hospital? It sounds like a good solution on paper, but in terms of really impacting with hundreds of operations, it can be quite difficult to do.”
*This article was published by Spotlight – health journalism in the public interest.
