South Africa: COVID-19 - Stark Differences Between Public and Private Sector Testing

In South Africa's private healthcare sector, COVID-19 tests are typically processed within a day or two. Tests are also relatively easy to get, provided you or your medical scheme are willing to pay the R900 plus that it costs. Even if you don't want a COVID-19 test, many private hospitals require you to have one should you plan to be admitted for even a relatively minor elective procedure unrelated to COVID-19.

In stark contrast, healthcare workers and patients in the public sector often have to wait a week, or even weeks, for test results. This has serious implications - including samples being in the queue for so long that they become unusable before they are tested.

Testing crisis

"About a month and a half ago is really when we started to experience a crisis," says a medical doctor, emergency medicine specialist and manager at a public sector hospital in Gauteng. The doctor asked not to be named for fear of potential consequences for her job.

The "crisis" started soon after the testing eligibility criteria were expanded on the recommendation of the National Institute for Communicable Diseases (NICD) and tests started being referred through government's ambitious testing and screening campaign.

"Then, the turnaround time for test results went from 48 hours to anything up to two weeks or more," she says. "Some samples we were waiting for two weeks and at the end of the period the samples were too old to process and then new samples would have to be acquired from patients. In one case, this happened to a patient three times."

That test turnaround times have shot up in the public sector is confirmed by the NICD. According to their most recent weekly COVID-19 testing report, mean test turnaround times in the public sector went from 2.1 days in early May to 12.4 days in the week ending 13 June.

The consequences of these delays in hospitals are severe. As the Gauteng doctor explains, not only is this a waste of time and resources, but, for isolation and infection-control purposes patients suspected to have COVID-19 have to be kept in a separate ward to both confirmed COVID-19 patients and the wards set aside for negative patients. The test result delays caused many patients to remain in overcrowded wards for longer than is needed, potentially infecting negative patients stationed with them while they wait. As a result, the doctor says, isolation wards in their hospital are always full.

"Receiving a result within 48 hours is a workable solution, anything beyond that becomes impossible, endangers patients and makes everything harder," she says.

While a week's wait in a district or academic hospital is problematic, things are even worse in some rural areas. Russell Rensburg, Director of the Rural Health Advocacy Project, says that in the vast majority of rural areas "test turnaround time is between 14 and 20 days - arguably rendering this tool useless". For example, patients could wait weeks to be told they are positive and need to self-isolate, but by then, they may have exposed and infected untold numbers of individuals in their community.

Different picture in private sector

While public sector patients, who make up the vast majority of the population, sometimes wait weeks, private sector patients typically get results in a day or two. The Gauteng doctor Spotlight spoke to has opted to test privately due to the public sector backlog and, in one case, she says, her results came back to her on the same day.

According to Dr Mzukisi Grootboom, former head of the South African Medical Association and now working as a physician consulting in the private sector and who consults at a Life Healthcare hospital in Durban, results of tests he performs on his patients return in under 48 hours and the longest wait would be 72 hours.

More recently, he says the turnaround time averages at 24 hours or less. Grootboom suggests that competition and quick turnaround time from smaller labs have pushed the big private laboratories to shorten their times to match for fear of losing business.

Grootboom also says the private sector has taken healthcare worker testing seriously and has prioritised samples from these individuals with a 24-hour turnaround time having been the norm for this group for some time.

Wasteful testing?

Various sources Spotlight spoke to, shared the concern that, while the public sector suffers with capacity, the private sector is testing too liberally. On the face of it there appears to be something to this argument given that roughly half of the country's almost 1.4 million COVID-19 tests have been done in the private sector (which serves less than 20% of the population) and half in the public sector (which serves over 80% of the population). The actual numbers might be a bit more balanced given that some people without medical scheme coverage may have paid the R900 out of pocket to get a test in the private sector.

In the private sector, criticism has been levelled at the fact that, in most hospitals, health workers who test positive for COVID-19 have to provide two negative results, 48 hours apart, in order to return to work - a practice regarded by some as both wasteful and unnecessary.

There have been further concerns related to private sector testing practices, especially since the downgrade to level 3 and elective surgeries once again permitted.

Grootboom says all elective patients have to provide a negative COVID-19 test before they can be admitted, regardless of how healthy or symptom-free they are. In contrast, the public sector rations testing to individuals with symptoms.

"The private sector has a policy that absolutely all admissions must be tested - regardless of risk or symptoms. Since the first week of May, every single admission who comes through the doors of a private hospital need a COVID-19 test - even if they are coming in for a fractured toe," said a well-placed source. This source also mentioned a case of a private specialist in Cape Town requiring COVID-19 tests for consulting with outpatients.

The public sector has however had its own controversies around low-yield testing in the form of the mass screening and testing campaign. It seems likely that the extra testing from this campaign in part drove the large public sector testing backlogs (at times over 80 000) reported in recent weeks. Some experts have called for tests to be discarded if it was in the public sector testing queue for too long but Health Minister Dr Zweli Mkhize has rejected these calls.

According to the NICD, the proportion of people testing positive in the week up to 13 June was higher in the public sector versus the private sector (14.9% and 14.3% respectively). This difference may or may not indicate that there is more unnecessary testing in the private sector at the moment than in the public sector, but the difference could also be due to several other factors. Taken over the entire epidemic until 13 June, the proportion testing positive is higher in the private sector than in the public sector (7.6% and 6.4% respectively).

Supply challenges

While the test backlog has reportedly been cleared in the Western Cape, the backlog in Gauteng reportedly now stands at 35 000.

"I am greatly concerned by this huge backlog of tests which is 12 000 higher than the 23 000 backlog reported last week," says DA MPL Jack Bloom in a statement. "The long delays undermine the test, trace and isolate strategy in hot spot areas that is so critical in Gauteng as infections climb exponentially."

Bloom also raised his disappointment that the National Health Laboratory Services (NHLS) "has failed to expand capacity despite claiming earlier that they could do 36 000 tests a day". "I hope that testing is speeded up in future including greater use of private and university laboratories," says Bloom.

There appears to be broadly two related factors contributing to South Africa's public sector testing backlogs: Testing criteria and supplies of test kits and reagents. Some emphasise the prior and some the latter.

Speaking to Spotlight, NHLS spokesperson Mzimansi Gcukumana places the blame solely on a scarcity of supplies needed to perform the tests. "The unprocessed specimen backlogs are due to sporadic supply of some of the key products from international suppliers," he says. Mkhize has also blamed shortages of test kits and reagents for public sector backlogs.

Grootboom, however, points out that the private sector experienced the same international supply shortages of key products needed to perform the tests, yet the turnaround times have recovered and are down to 24 hours in many cases.

The public sector testing strategy has come in for criticism from several leading health experts, arguing that there is a mismatch between the testing strategy and the public sector's capacity to do tests. In one recent opinion piece published in the Daily Maverick, the case was made to "stop random testing" and for the "elimination of unnecessary and wasteful testing countrywide".

While Gcukumana blames the backlogs on supply issues and does not admit errors in the testing strategy, he says that prioritisation of tests is part of the solution. He says the "challenge" of the long turnaround times had been addressed through several interventions, including priority testing and working with the private sector. (You can see a list of NHLS interventions at the end of this article.)

He also says that "in many cases the turnaround time has gone down to two days or lower" and that the NHLS "is making steady progress in clearing unprocessed specimen backlogs".

In some instances government is paying for tests from the public sector, but we understand that this is not done at scale.

"The most important thing as far as I'm concerned is that the outbreak is a public health problem and we as a country need to move away from this thinking of public versus private, especially in the time of COVID-19," says Grootboom. "We should start sitting around a table to see how we can collaborate because we are all working towards the same goals."

When to test healthcare workers

One area in which testing criteria and guidelines is particularly controversial, relates to healthcare workers. The Gauteng doctor says she is "very, very concerned" by a guideline issued by the Gauteng Department of Health requiring that health workers who test positive for COVID-19 must, after the mandatory 14-day quarantine period, produce a negative result to return to work.

"A big problem with these long turnaround times using the NHLS is that many health workers are sitting at home much longer than they should or need to awaiting a negative result," she says.

This has potentially serious ramifications for a further shrinkage of the public sector's already overstretched workforce. However, because COVID-19 is such a new disease, there is some confusion when it comes to healthcare worker management.

According to the Gauteng doctor, while the provincial department has issued this rule, guidance from the National Department of Health does not recommend the production of a negative test, provided the health worker is well enough.

The National Department of Health declined to comment on this and other issues put to it by Spotlight and instead referred requests for comment to the NHLS.

"We don't know for sure, but the evidence suggests people are probably not infectious after seven days after they first show symptoms," says the Gauteng doctor.

There is some international guidance suggesting drastically shortened quarantine periods for asymptomatic individuals. The United States' Centers for Disease Control has recommended that, as long as one has had no symptoms for three days, one can return to work.

"Another problem is that an individual can remain positive for COVID-19 for up to two months after showing symptoms, with the majority of this time spent asymptomatic and un-infectious," she says. However, Grootboom says that testing positive for COVID-19 for extended periods of time is usually limited to individuals who become severely ill. "Those with mild symptoms clear the virus rapidly from the body," he says.

NHLS interventions implemented to address the public sector COVID-19 testing backlogs as communicated to Spotlight include:

Prioritising all in-hospital tests, patients under investigation, contacts and critical care workers.

Monitoring the rate of test positivity in the provinces and districts to ensure that the NHLS is prioritising resources to these high positivity hotspots.

Improving sample workflow and testing process with innovative methods of extraction, including heat and lysis to manage the demand of extraction and testing kit shortages. The supply of extraction kits has improved slightly.

Engage private and academic research laboratories to assist where they have spare capacity and test kits available.

Reaching out to smaller private laboratories with molecular testing platforms to help manage the increased testing demand.

Note: An unnamed source is quoted in this article. While we generally avoid quoting unnamed sources, we sometimes do so when the following three conditions are met: (1) We have good reason to believe the information to be true, (2) publication of the information is clearly in the public interest, and (3) the source might suffer harm if identified.

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