By September this year, public hospitals in the country were buckling under backlogs of over 175 000 surgeries. Spotlight earlier this year published a two-part series on the human cost of surgical delays and asked what could be done about it.
One solution proposed by some surgical experts is to devolve less complicated surgical procedures to district hospitals closer to patients. The AfroSurg3 Conference held at the end of September, which brought together surgical stakeholders from 11 African countries to improve access to care, shed some light on the often sub-optimal conditions for surgical care at district hospitals, especially in rural areas and showed that it will take time, effort, and resources to make such an approach work.
Setting the tone of the conference, Professor Kathryn Chu, Director of the Centre for Global Surgery at Stellenbosch University's Faculty of Medicine and Health Sciences, stressed that access to surgical care is less equitable in rural areas as most hospitals that perform surgery are located in urban areas, there are also fewer trained providers based in these areas, equipment and budget constraints, long distances to travel, and referral and communication challenges with regional and tertiary hospitals where patients would be transferred.
Hub and spoke model
Being a predominantly rural province, accessing healthcare has always been a challenge in the Eastern Cape, where people have to travel long distances, often at great cost to access healthcare in more urban areas. At the height of the COVID-19 pandemic when the provincial health department briefed Parliament, the department stressed that there were not enough critical care beds or ICU capacity in far-flung rural areas and many cases are referred to metros, eating away at critical care capacity there.
With the increased waiting times for elective surgery and huge bottlenecks in emergency surgery due to COVID-19, rural communities are especially affected - Dr Jenny Nash
To increase access, the department tried to streamline rural health services along a hub and spoke model. Dr Sibongile Zungu who led the province's project management unit at the time told MPs this model was essentially a rearrangement of the health system "to ensure that anyone requiring medical attention in any corner of the Eastern Cape was aided within a maximum of two hours".
Putting these challenges into context, Dr Jenny Nash, a family physician from the Amathole District in the Eastern Cape, told AfroSurg3 delegates that with the increased waiting times for elective surgery and huge bottlenecks in emergency surgery due to COVID-19, rural communities are especially affected.
Family medicine colleagues are essential partners in rolling out #globalsurgery in rural areas. Great to hear the perspectives of Jenny Nash (Eastern Cape) and Hans Hendricks (Northern Cape) at #Afrosurg3 pic.twitter.com/qWdXMOJQlU
-- Simon Le Roux (@Spdpleroux) September 28, 2022
Explaining the hub and spoke model, Nash said since many of the small district hospitals have very low bed utilisation rates, the department had identified 28 priority hospitals in the province that now act as 'hubs' and provide services to a surrounding area. The idea is that these hub hospitals will provide a broad basket of services, including surgical services.
Despite this attempt at rationalising services, however, there is still a disproportionate burden on some hospitals.
We are sitting with ridiculous referral pathways as many hospitals are at least 400 kilometres away from each other - Dr Hans Hendriks
In the Northern Cape, the challenges posed by long distances are even more pronounced.
Dr Hans Hendriks, a family physician working in Upington, reminded delegates that the Northern Cape is the biggest province with the smallest population. "So, we are sitting with ridiculous referral pathways as many hospitals are at least 400 kilometres away from each other. I think the furthest hospital referring to [Dr Harry Surtie Hospital] is 520 kilometres away, which is ridiculous as there is often only one ambulance servicing a hospital and they often run out of petrol." Some other challenges Hendriks highlighted included a lack of specialists and the chronic challenge of attracting skills to the province - something the Northern Cape Health MEC Marupeng Lekwene has often alluded to. In some district hospitals, there is also key equipment lacking or when the equipment is there, maintaining them often comes with exorbitant price tags.
Theory vs reality
Increasing surgical access, however, is more than overcoming long distances. Expanding the types of services provided at district hospitals is also a challenge.
According to Hendriks, there are certain obstetric services that should be available at the district hospital level based on the national Maternal Care Guidelines (2015). In a province like the Northern Cape, however, challenges with resources and skills often hamstrung this service provision. He noted that based on the guidelines, these services should include, among others, antenatal care for high-risk women, labour ward admissions, 24-hour services for deliveries and Caesarean sections, general anaesthesia, 24-hour lab services, postnatal and postoperative care, as well as serving as a referral centre for clinics. To provide this basket of obstetric services, there should be advanced midwives, midwives, enrolled nurses, full-time medical officers and even a visiting obstetrician at a district hospital. These district hospitals should also have equipment and resources, including emergency blood, a resuscitation trolley, a fully equipped operating theatre, XR- facilities, and reliable transport services to and from tertiary hospitals, among others.
In reality, says Hendriks, often many items on this list are lacking.
He said surgical skills (including anaesthesia, surgery, and obstetrics) across provinces and within provinces are also not universal. "The biggest challenge I found more and more is in terms of providing general anaesthesia - not so much the surgery as the general anaesthesia." In addition, according to Hendriks, the number of doctors and nurses needed to cover a 24-hour operating theatre roster is also not enough.
Our #AfroSurg3 Conference ended on a high. We, the CGS team, want to thank all participants for their insightful and thought-provoking presentations and input on how to strengthen rural surgical care, and empower communities in surgical networks #GlobalSurgery@kathryn_chu_sa pic.twitter.com/kl05etXFqm
-- SU Global Surgery (@SU_GlobalSurg) September 30, 2022
In the Eastern Cape, there is also a visible disconnect between what should and could happen at the district hospital level in theory and what plays out in reality.
Nash, for example, referred to the District Health Management Office (DHMO) NHI document that lists certain services that can be provided at district level in an attempt to expand the basket of care services in rural areas. For example, in terms of maternal health, district hospitals should be managing obstetric emergencies such as eclampsia, and performing some surgical procedures, including Caesarean sections, a laparotomy for ectopic pregnancies, and endometrial biopsies. In terms of emergency care surgical procedures, district hospitals should be able to manage, among others, head injuries (the closure of open head injuries), tracheostomy, draining of an abscess causing airway obstructions, a thoracotomy for stabbed heart, abdomen injuries, as well as limb injuries such as managing fractures and joint dislocations.
In the Eastern Cape, there is also a visible disconnect between what should and could happen at the district hospital level in theory and what plays out in reality.
But, in the Eastern Cape, as is the case across provinces, trauma/emergency cases often gobble up much of the surgical care capacity. This is often skewed among hospitals. Frere Hospital in East London, for example, receives a disproportionate number of referrals for orthopaedics from district hospitals. Most of these cases, Nash told delegates, were a result of interpersonal violence over weekends. Between January and June this year, Frere Hospital received 3 253 orthopaedic referrals from district hospitals, with Butterworth Hospital topping the list with 829 referrals during this period. Most of the orthopaedic referrals were for arms and hands but, according to Nash, about 10% of the patients who arrive at Frere Hospital could be managed at the district hospital, and free up resources at Frere Hospital.
So why is more not happening at district hospitals in the province?
Skills deficit
An electronic skills audit that Nash and a colleague Dr JD Lotz developed at the beginning of the year may provide part of the answer. They distributed the skills audit among doctors and clinical associates in district hospitals, first in the Amathole District and then across other districts in the province. Nash told delegates they wanted to assess these healthcare workers' confidence levels in performing a variety of clinical skills.
#Afrosurg3 Bringing surgery to the community @kathryn_chu_sa pic.twitter.com/p2tShUrKN7
-- UCT General Surgery (@UCTSurgery) September 28, 2022
The findings show that on performing general anaesthesia most respondents were not confident and said they will need refresher training.
In terms of maternal health in the Eastern Cape, the majority of the respondents indicated they are not confident in performing an ectopic laparoscopy, for example. In terms of surgical skills, 79 (of 84 total respondents) stated they are not confident in performing appendectomies, 75 indicated they are not confident in performing below-the-knee amputations (BKA) and 69 were not confident in performing skin grafts.
Plugging the holes
Optimising district health services for surgical care is about more than just attracting skills. According to Dr Anthony Reed from UCT's Department of Anaesthesia and Perioperative Medicine who also attended the conference, the real work is in building a sustainable rural service by creating long-term capacity in terms of skills and resources and getting enough people who feel looked after and who will stay.
Nash agrees.
Improving access to surgical care by using district hospitals, according to her, will require trained people with the skills to support these services. In this respect, she argues, family physicians can play an important role as part of bigger multi-disciplinary teams.
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"We know that if someone is admitted in a district hospital, it's far cheaper than at a regional hospital and it also reduces congestion at tertiary hospitals," says Nash. "And we know that specialists can then concentrate on specialist procedures. It's important to understand that we need to work together to see what can different specialists do in different areas and if a family physician can assist with some of the procedures, it would make sense to do that at a district level." Nash says this will then free up surgeons to do some more complex procedures at the next level of care. "The role of family physicians really is to support and to make sure that we are able to provide training and support where there are gaps."
A paper co-authored by Chu shows that South Africa does not have the minimum specialist workforce density of 20 per 100 000 required to provide adequate essential and emergency surgical care. By the end of 2019, the Health Professions Council (HPCSA) register showed that of the 6 329 specialists in the country's surgical workforce, "3 096 were surgeons (50.4%), 1 268 (20.6%) OBGYN (doctors specialising in both obstetrics and gynaecology), and 1 780 (29.0%) were anaesthesiologists".
A recent position paper by the South African Association of Family Physicians also stressed that given the skills gap in smaller district hospitals, particularly in surgery, and anaesthetics. family physicians can help reduce the number of referrals from district health services to regional and tertiary facilities.
Other cadres who can be key in building a sustainable rural health service, especially in the surgical care cascade, are clinical associates and community healthcare workers. Community healthcare workers like those working in the Enable programme in the OR Tambo district in the Eastern Cape have played a crucial role in pre and post-operative care such as caring for wounds after surgical procedures.
On training and supporting healthcare workers, Hendriks said there are so many ways to train and upskill doctors for surgical care and different things work in different areas. "A lot of people have the skills. They just need a little bit of support and that doesn't actually mean somebody standing next to them. Quite often, for example, post-COVID we are working more and more virtual. So there are a lot of possibilities," he said.
According to Chu, to improve access to surgery in South Africa we need to address the gaps in rural access. "Strengthening rural district hospitals will be paramount. This will require improved political support around what services should be delivered, support for better equipment, and expansion of the qualified surgical, anaesthesia, and obstetric workforce." Chu says outreach training by specialists as well as task sharing with non-specialist cadres can be part of the solution.
