Information and research: Local high-quality collaborative research is required to inform radical changes in surgical provision

In South Africa, there is a need to accurately identify the current surgical provision in the country and then set in place methods of audit that will allow a measurement of change and success. Global surgery research requires internationally standardised definitions of both risk factors and outcomes in order to be able to compare results across countries. Using standards such as the LCoGS six indicators4 and adapting them to the South African context allow this audit. Table 1 summarises these global indicators and their application for South Africa. Current research effort aiming to address these indicators that arose from the NFSASA is further summarised in the table.

Within the country, standardised national methodology will allow comparison over time and across hospitals. Some of the strategies required to advance this agenda are summarised in box 1. Following the NFSASA, with the aim of a National Surgical Plan in mind, a Programme for Equitable Access to Surgical Care (PEASC) was created in the Department of Surgery at the University of the Witwatersrand with the primary aim of initiating the collection of data points towards the LCoGS indicators or identifying where processes for collection are in place.

Further to this national effort, the international collaboration between regions and countries undergoing this audit process of surgical provision through the LCoGS allows identification of successful methodology in other countries. This may be used to model and guide strategies for improving surgical and anaesthesia care in South Africa, with the aim of further standardisation internationally. Two available audit tools, the LCoGS Tool (http://www.lancetglobalsurgery.org/#!implementation-tools/tx1dd) and the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, have been adopted and adapted for this purpose.

Patient outcomes are influenced by a myriad of variables: direct and indirect barriers to surgical diagnosis and care, adequacy of operative and perioperative care, and long-term postoperative follow-up. Successful examples of outcome studies are the Perinatal Problem Identification Programme and ‘Saving Mothers’ confidential enquiries, which have helped characterise perinatal and maternal mortality, including identification of haemorrhagic and other surgical complications.29 Neglected fields such as in general surgical procedures and in postoperative care areas (ward/high care/intensive care unit/rehabilitation) need further characterisation.30 The simple surgical ‘Bellwether procedures’ (caesarean section, laparotomy and open fractures) identified by the LCoGS4 can be considered primary indicators for the success of the entire surgical system in South Africa. The same outcome-based variables in these procedures measured and remeasured at the same hospitals over time will quantify quality improvement in surgical and anaesthesia care in South Africa. Areas requiring audit will include access to surgery, district hospital service delivery, staff competencies at all levels, budgets, facility resources and government engagement. Results of continuous audit should provide reliable indication as to South Africa’s progress towards achieving the six LCoGS indicators by 2030.4

In addition to large-scale, observational, pragmatic studies designed to document the incidence and timeline of disease presentations and subsequent complications, smaller detailed projects identifying specific causes for specific inadequacies in surgical care can be complementary in providing information. All these types of studies benefit from interdisciplinary multicentre collaborations made possible with effective novel technology integration and feedback.31 Important stakeholders essential to the process include clinicians from university clinical departments and public health specialists, nursing departments and organisations, and healthcare professional societies. The second group of role players are specific research groups already working in these areas, leading national and international agendas. Some of these are summarised in box 2.

Finally, in South Africa, there is a wealth of as yet unpublished literature presented over the last decade at the national conferences of surgical and related specialities. Current work is ongoing to identify current research, strengthen analysis and prevent duplication by linking similar studies in different centres and recognise nascent researchers to integrate into collaborative works.

Workforce and training: a national workforce must be shaped and mobilised to suit specific environments and resources

The health worker crisis in the sub-Saharan region has numerous dimensions. In addition to the described public/private disparity, the population and doctor density across South Africa still shows a major rural/urban inequity.32 The national surgical care work force must meet the needs of the whole country and specific focus needs to be put on factors that pull medical staff into rural facilities.

South African studies have been undertaken to establish the needs of rural doctors in South Africa and to seek possible solutions to their problems. Although those studies have identified some of the major problems, implementation of the solutions to these issues is still required. Box 3 describes some factors suggested by rural doctors, which require urgent attention to retain them in their current rural practices.

The Department of Health in South Africa has attempted to address the shortage of rural doctors by introducing various interventions, including an increase in salaries and the introduction of scarce skills and rural allowances, mandatory community service for all health workers, deployment of foreign-trained doctors and upgrade of clinics and hospitals. Despite these, the maldistribution of doctors working in South Africa has not improved significantly. This attests to the multifactorial nature of this problem, requiring sustained efforts to rectify it. Resolving one isolated factor without improving the host of push factors currently present in the health system cannot lead to significant improvements in the retention of rural doctors. Government legislative attempts to redistribute doctors such as the provision of a certificate of need prior to opening a private practice have been unsuccessful and unpopular with individual doctors and the professional societies27 and highlights the importance of the professional societies in ensuring workforce plans are acceptable and implementable.

In South Africa, the government’s Programme of Action on Human Resources has laid emphasis on accelerating staff appointment into vacant positions to reduce the staffing crisis and to reduce workloads prioritising financial and non-financial incentives. Although it has been shown in numerous studies that financial incentives are less important to non-financial incentives to retain staff,25 33 34 the combined approach of both financial and non-financial incentives has been successful in rural regions of Kenya, Malawi, Lesotho and Swaziland.24 Novel local schemes enabling learners from rural areas to succeed in healthcare courses at tertiary institutions, through mentorship during training followed by integration into the local workforce on graduation, have also shown some success35 as well as offering provincial bursaries to students and requiring them to return to repay the bursary.36 37

A strong message from the participants of the NFSASA was the lack of interaction between rural and tertiary clinicians. A community of professionals who provide a reliable network of support for one another also aids in recruitment and retention in rural areas32 and is critical for the success of a National Surgical Plan in South Africa. This can only be established with adequate numbers of generalists and specialists (a challenge in a system currently burdened by a shortage of health professionals) and through effective communication and task sharing with strong relationships between district and regional hospitals.

Part of this network is explicit support for clinical staff when things go wrong within set scopes of practice. This requires accountability, review of the morbidities and mortalities and accreditation of facilities to perform appropriate surgical procedures. It is crucial that staff should be well supervised in their clinical practice and that providing service and training in these hospitals is mandatory for specialists. Redefining sites and providing ‘joined-up’ surgical care includes reframing traditional working practices. This will also require a marked improvement in information technology services to longitudinally track patients, establish hospital disease databases and ensure adequate referral. Retraining and upskilling of staff, which allows for easier ‘down referral’ of patients from regional care, should be done on site and in context by the appropriate specialists.

Infrastructure and service delivery: strengthening the surgical system through the district hospital

In addition to workforce provision, perhaps the biggest challenges of all will be improving access to life-saving surgery within 2 hours, a hallmark of universal surgical care.4 An aim of this should be to relieve tertiary facilities of ‘non-specialist’ operations, while ensuring patients have adequate access to specialist services. This must include transport and accommodation provision, which is an indirect barrier to accessing distance or specialist surgical services. The supplementary benefit, above that of the community receiving improved healthcare, is that local improved surgical care can lead to better economic development for the region.4 Failure to retain services and staff results in losses that primarily disadvantage poor, rural and underserved populations.

In South Africa, a governmental white paper outlining the proposed restructuring of health provision with a National Health Insurance (NHI) system details ‘district healthcare teams’38 responsible for service provision in a geographical area. These district clinical teams (DCTs) comprise a family physician, a PHC nurse, an obstetrician and gynaecologist, an advanced midwife, a paediatrician, a paediatric nurse and an anaesthetist to oversee emergency and perioperative care. They will have a clinical and an administrative role in maintaining clinical services, auditing services and predicting growth based on infrastructure and finance access.38 These teams do not explicitly have surgical specialists, but the integration of surgical care into the NHI can be achieved by establishing surgical care centres where populations are currently placed, with the adequate infrastructure to provide suitable surgical care, and direct routes of rapid bidirectional referral between district and regional (tertiary) surgical care.

Furthermore, the South African Department of Health wishes that minor surgery should be available at all district hospitals. However, as the Deputy Minister of Health noted, ‘… as soon as minor surgery requires a general anaesthetic, there is an immediate escalation of the risk. Even with a “simple caesarean section”, anaesthesia remains high risk’.39 This latter comment is borne out in the Confidential Enquiries into Maternal Deaths in South Africa.40 The development of ‘district’ or ‘rural’ surgery into an acute specialty, encompassing surgical, obstetric and anaesthetics competency, would form the basis of district hospital care and would integrate into the DCT model. The level of competency required of the LCoGS ‘Bellwether procedures’ would also allow provision of other procedures, which are common to the primary hospital context such as intercostal drain placement, incisions and drainages of abscesses, management of haemorrhoids, circumcisions, evacuations of the uterus, spinal anaesthesia, rapid sequence inductions and emergency airway management.

The development of rural surgical care as a specialty would require a paradigm shift. The traditional hierarchy between specialists and generalists can be replaced by the diverse but harmonised skill sets between pathology-specific (traditional) specialists and new geographical (rural/district surgery) specialists. Filling this gap in rural care at present is the family physician practising in rural district hospitals. Family medicine specialists are integral to a move to holistic surgical care, and although the scope of practice of a rural surgeon should be differentiated from that of a family physician, increasing the skill set of family physicians may be part of this solution (task sharing). To facilitate this, South African tertiary education facilities should include rotations in rural or district-level surgery where trainees, either undergraduate students or postgraduate in the relevant current specialities, are exposed to emergency surgical cases and gain competency in the ‘Bellwether procedures’.

Despite many of these changes to the scope of specialist care, shortages in numbers remain problematic. Alternatives to the traditional route of medical student to doctor to specialist have been considered in many parts of the world and particularly successful in areas of need. A recent addition to medical training in South Africa is the Bachelor of Clinical Associate Degree, which has the capacity for rapid training, and is particularly appropriate for students who have an interest in staying within their communities.41 The opening of postgraduate diplomas of anaesthesia and surgery to non-MBBCh degree holders may further facilitate upskilling while candidates remain in practice. It also allows for competency-based practice and skills development rather than hierarchical practice based on level or type of healthcare provider.

This skills sharing, task sharing and upskilling is also imperative in allied medical and nursing care. Training platforms for all staff who will be involved with surgery and anaesthesia should be improved so as to ensure that there are enough allied health professionals trained in theatre, perioperative and critical care skills—especially with regards to specialist nurses.25 This will complement the current structure, which includes many career medical officers with high levels of surgical and anaesthetics skills ensuring continuous professional development and create opportunities for career progression and greater job satisfaction. Furthermore, the focus of training in surgical care has historically been on operative interventions and perioperative care. Although operative interventions are important, all parties involved with provision of these services should be integrated into holistic patient care and preventative medicine with a public health policy approach incorporating the social determinants of health and the contributions that are made by poor lifestyle choices such as reckless driving, alcohol abuse, obesity and smoking, which increase the likelihood and risk of surgery.

Leadership and finance: the essential place for healthcare managers locally and nationally to partner with clinicians in reform

Perhaps the most critical group of key players in changing surgical care in South Africa are from governmental organisations, and it is important to recognise the essential place of healthcare managers partnering with clinicians in reform. This includes hospital managers at a district and tertiary level in South Africa, the Office of Health Standards and Compliance and the National Department of Health. Quality improvement guidelines have been developed with varying degrees of implementation. Participation across the board is essential to impact patients’ access to hospitals, for accurate institutional data and to ensure the integrity of the surgical and anaesthetics care data in South Africa. During his speech at the NFSASA, the Deputy Minister for Health, himself a doctor, acknowledged that the Department of Health’s vision of ‘a long and healthy life for all’ could not be achieved without reviewing ‘…the essential package of surgical and anaesthetics services that are—and should be available—especially at district and regional hospitals in the country.’39

Financing such radical changes in surgical service provision is hard, and any National Surgical Plan will only be successful if fully and realistically costed. Calls for wide-scale financial investments in the current economic climate are difficult, and access to ‘new money’ beyond the current budget may be challenging. Creative and innovative ways to use the current resources available in South Africa need to be found. At present, the National Treasury budget has specific programmes for HIV/AIDS, child and maternal health and violence and trauma among others.42 However, it was noted by the representative from the Treasury at the NFSASA that a surgical programme has never been requested. Identifying surgical care to the National Treasury as an area for specialised budget allocation must be a priority in order to ensure dedicated funding. A major aspect will be developing a workforce payment structure, which makes rural practice incentivised.