Surgical resources in South Africa: a review of the number of functional operating theatres

Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop

BACKGROUND

Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care.

OBJECTIVE

To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa.

METHODS

A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped.

RESULTS

Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider's knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing.

CONCLUSIONS

This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.

The contribution of family physicians to surgical capacity at district hospitals in South Africa

The World Health Organization states that essential, cost-effective surgical care should be delivered at district hospitals. In South Africa significant skills gap exist at district hospitals, particularly in the area of surgery and anaesthesia. These small to moderate sized hospitals are too small to support a range of full time specialists even if they could be recruited and were cost-effective. Family physicians (FPs) are trained in the clinical skills required for district hospitals and primary health care. Clinical associates have also been introduced to perform procedures at district hospitals. This report illustrates the contribution of a FP to surgical care at Zithulele Hospital in the Eastern Cape. Family physicians not only bring the necessary clinical skills set but also increase the confidence and capacity of the whole team. Outreach and support by surgeons, as well as continuing professional development, are important. Surgical and anaesthetic skills must be developed together. Family physicians also bring leadership and clinical governance skills that ensure the inputs to support surgery, such as equipment and information systems are available. The contribution of FPs to surgery and district hospitals is overlooked in both policy and practice. Human resources for health policy should recognise their contribution and increase the numbers available and FP posts at district hospitals. There is also a need to update the package of emergency and essential surgical procedures in policy.

An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola

BACKGROUND

The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014-2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country's maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

METHODS

Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible.

RESULTS

Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1-3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided.

CONCLUSIONS

Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.

Anesthesia Health System Capacities in Public Hospitals of Punjab, Pakistan

Purpose: This study intends to outline the capacity of anesthesia health system in public hospitals of Punjab, Pakistan.

Methods: A cross-sectional survey among public hospitals of Punjab was carried out that provide emergency and elective surgical care. We measured capacity in terms of infrastructure; surgical, anesthetic, and obstetric (SAO) workforce; surgical interventions; information management; equipment; and medication which was accomplished between October 2020 and February 2021.

Results: Out of 106 public hospitals in Punjab, almost 40% had only one anesthesia provider. Only 50% of the hospitals reported round the clock availability of anesthesia providers for surgical cases. While caesarean sections were carried out in more than 90% of health facilities, general surgery, pediatric surgery, and open fracture surgery were conducted only in 50% of the hospitals. Although local and general anesthetic agents were available in the majority of hospitals, essential medicines for safe anesthesia were not available in all hospitals.

Conclusion: This first comprehensive assessment of anesthesia health system capacity exposed a crucial deficiency of critical supplies and workforce for providing safe anesthesia and, hence, safe surgery. The surveyed facilities had an uneven division of resources.

A geospatial analysis of two-hour surgical access to district hospitals in South Africa

Background

In a robust health care system, at least 80% of a country’s population should be able to access a district hospital that provides surgical care within 2 hours. The objective was to identify the proportion of the population living within 2 hours of a district hospital with surgical capacity in South Africa.

Methods

All government hospitals in the country were identified. Surgical district hospitals were defined as district hospitals with a surgical provider, a functional operating theatre, and the provision of at least one caesarean section annually. The proportion of the population within two-hour access was estimated using service area methods.

Results

Ninety-eight percent of the population had two-hour access to any government hospital in South Africa. One hundred and thirty-eight of 240 (58%) district hospitals had surgical capacity and 86% of the population had two-hour access to these facilities.

Conclusion

Improving equitable surgical access is urgently needed in sub-Saharan Africa. This study demonstrated that in South Africa, just over half of district hospitals had surgical capacity but more than 80% of the population had two-hour access to these facilities. Strengthening district hospital surgical capacity is an international mandate and needed to improve access.

Innovative financing to fund surgical systems and expand surgical care in low-income and middle-income countries

Strong surgical systems are necessary to prevent premature death and avoidable disability from surgical conditions. The epidemiological transition, which has led to a rising burden of non-communicable diseases and injuries worldwide, will increase the demand for surgical assessment and care as a definitive healthcare intervention. Yet, 5 billion people lack access to timely, affordable and safe surgical and anaesthesia care, with the unmet demand affecting predominantly low-income and middle-income countries (LMICs). Rapid surgical care scale-up is required in LMICs to strengthen health system capabilities, but adequate financing for this expansion is lacking. This article explores the critical role of innovative financing in scaling up surgical care in LMICs. We locate surgical system financing by using a modified fiscal space analysis. Through an analysis of published studies and case studies on recent trends in the financing of global health systems, we provide a conceptual framework that could assist policy-makers in health systems to develop innovative financing strategies to mobilise additional investments for scale-up of surgical care in LMICs. This is the first time such an analysis has been applied to the funding of surgical care. Innovative financing in global surgery is an untapped potential funding source for expanding fiscal space for health systems and financing scale-up of surgical care in LMICs.