Equitable access to quality trauma systems in Low and Middle Income Countries

Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 (‘Delays to receiving quality care’). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for peoplewho have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality car

Breast Cancer Rehabilitation Services in South Africa and Survivor Experience of These Services in Two Dedicated Cancer Units

Purpose Integrated rehabilitation health care pathways are implemented to meet both physical and clinical needs of breast cancer survivors as they transition from medical treatment to long term survivorship. The aim of this study was to assess current South African upper limb rehabilitation service provision, and perspectives of these from health professionals and breast cancer survivors.

Methods A sequential explanatory mixed-methods design informed this study. Service provision was evaluated via an online survey questionnaire completed by health practitioners working in public and private breast cancer units. Focus groups were conducted with both public health practitioners providing the services and breast cancer survivors accessing the services.

Results This study has revealed a dearth of rehabilitation services for breast cancer survivors in the public health sector of South Africa. Data reveal an overstretched, understaffed and poorly trained public health sector, unable to deliver adequate upper limb services to breast cancer survivors. Focus group data suggests that this is due to financial austerity rather than poor recognition of the need. Limited patient education is driving poor upper limb outcomes and barriers to change in exercise behaviour.

Conclusion Current South African upper limb rehabilitation services do not cater for the needs of breast cancer survivors, leading to poor health outcomes.

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Paediatric anaesthesia care in Africa: challenges and opportunities

In 2015, the World Health Organization and member states recognised surgery and anaesthesia care as a component of universal health coverage, yet 1.7 billion children and adolescents continue to lack access to safe surgical care. An overwhelming proportion of these children are from low- and middle-income countries (LMICs).1,2 In Africa, where almost 50% of the population is under the age of 15, children are disproportionately affected. Without sustained global efforts, these inequities and injustices will persist.1 Findings from previous studies suggest a 10–100 times increase in paediatric perioperative mortality in children in LMICs as compared to high-income countries (HICs).3,4 While pieces of the puzzle may be missing, it is clear that not only is access a problem, but also the safety and quality of the perioperative care provided is of concern.

Improving District Hospital Surgical Capacity in Resource Limited Settings: Challenges and Lessons From South Africa

Strengthening surgical capacity of district hospitals (DHs) in low- and middle-income countries (LMICs) has been recognised globally as key to improving equitable access to surgical care. This commentary considers the benefits and challenges of surgical mentoring in South Africa and applies the lessons learned to other low-resource settings.
Surgical team mentoring programs require consideration of all stakeholders involved, with strong relationships between mentors and mentees, and the possible establishment of roaming district surgical teams. Other components of a surgical ecosystem must also be strengthened including defining a DH surgical package of care, ensuring strong referral systems through a hub and spoke model, and routine monitoring and evaluation. These recommendations have the potential to strengthen surgical capacity in DHs in low-resource settings which is critical to achieving health for a

Overweight and obesity in non-pregnant women of childbearing age in South Africa: subgroup regression analyses of survey data from 1998 to 2017

Overweight and obesity in adults are increasing globally and in South Africa (SA), contributing substantially to deaths and disability from non-communicable diseases. Compared to men, women suffer a disproportionate burden of obesity, which adversely affects their health and that of their offspring. This study assessed the changing patterns in prevalence and determinants of overweight and obesity among non-pregnant women in SA aged 15 to 49 years (women of childbearing age (WCBA)) between 1998 and 2017.

This paper conducts secondary data analysis of seven consecutive nationally representative household surveys—the 1998 and 2016 SA Demographic and Health Surveys, 2008, 2010–2011, 2012, 2014–2015 and 2017 waves of the National Income Dynamics Survey, containing anthropometric and sociodemographic data. The changing patterns of the overweight and obesity prevalence were assessed across key variables. The inferential assessment was based on a standard t-test for the prevalence. Adjusted odds ratios from logistic regression analysis were used to examine the factors associated with overweight and obesity at each time point.

Overweight and obesity prevalence among WCBA in SA increased from 51.3 to 60.0% and 24.7 to 35.2%, respectively, between 1998 and 2017. The urban-rural disparities in overweight and obesity decreased steadily between 1998 and 2017. The prevalence of overweight and obesity among WCBA varied by age, population group, location, current smoking status and socioeconomic status of women. For most women, the prevalence of overweight and/or obesity in 2017 was significantly higher than in 1998. Significant factors associated with being overweight and obese included increased age, self-identifying with the Black African population group, higher educational attainment, urban area residence, and wealthier socioeconomic quintiles. Smoking was inversely related to being overweight and obese.

The increasing trend in overweight and obesity in WCBA in SA demands urgent public health attention. Increased public awareness is needed about obesity and its health consequences for this vulnerable population. Efforts are needed across different sectors to prevent excessive weight gain in WCBA, focusing on older women, self-identified Black African population group, women with higher educational attainment, women residing in urban areas, and wealthy women.

Cochlear implantation in South Africa (part 2)

Cochlear implantation is a timeous and cost-effective solution for severe-to-profound sensorineural hearing loss (SNHL) and has transformed the lives of many individuals with significant hearing loss. The advent of cochlear implantation has meant that, for the first time, one of the senses (hearing), having been entirely lost, can be restored. The previous article in this series sketched the problem of severe-toprofound SNHL, and how cochlear implantation can overcome this, how a cochlear implant (CI) works, the history of cochlear implantation and the principles of the multidisciplinary CI team. The current status of cochlear implantation in South Africa (SA) is the subject of discussion in this article, the second of this two-part series on cochlear implantation. It comprises a study of the best available current data on the status of CI in SA.

Cochlear implantation in South Africa (part 1)

Cochlear implantation is a timeous and cost-effective solution for severe-profound sensorineural hearing loss, and has transformed the lives of many individuals with significant hearing loss. The advent of cochlear implantation has meant that, for the first time, one of the senses (hearing), having been entirely lost, can be restored. This, the first of a two-part series on cochlear implantation in South Africa (SA) puts global (and especially SA) hearing loss in perspective, sets out the principles of cochlear implantation and briefly sketches the history of this world-changing technology.

The acceptability of delayed consent for prehospital emergency care research in the Western Cape province of South Africa

Informed consent is an essential prerequisite for enrolling patients into a study. Obtaining informed consent in an emergency is complex and often impossible. Delayed consent has been suggested for emergency care research. This study aims to determine the acceptability of prehospital emergency care research with delayed consent in the Western Cape community of South Africa.

This study was an online survey of a stratified, representative sample of community members in the Western Cape province of South Africa. We calculated a powered sample size to be 385, and a stratified sampling method was employed. The survey was based on similar studies and piloted. Data were analysed descriptively.

A total of 807 surveys were returned. Most respondents felt that enrolment into prehospital research would be acceptable if it offered direct benefit to them (n = 455; 68%) or if their condition was life-threatening and the research would identify improved treatment for future patients with a similar condition (n = 474; 70%). Similar results were appreciable when asked about the participation of their family member (n = 445; 66%) or their child (n = 422; 62%) regarding direct prospects of benefit. Overwhelmingly, respondents indicated that they would prefer to be informed of their own (n = 590; 85%), their family member’s (n = 593; 84%) or their child’s (n = 587; 86%) participation in a study immediately or as soon as possible. Only 35% (n = 283) agreed to retention data of deceased patients without the next of kin’s consent.

We report majority agreement of respondents for emergency care research with delayed consent if the interventions offered direct benefit to the research participant, if the participant’s condition was life-threatening and the work held the prospect of benefit for future patients, and if the protocol for delayed consent was approved by a human research ethics committee. These results should be explored using qualitative methods.

Drivers of Disparities in Stage at Diagnosis Among Women With Breast Cancer: South African Breast Cancers and HIV Outcomes Cohort


In low- and middle-income countries (LMICs), advanced stage diagnosis of breast cancer (BC) is common, and this contributes to poor survival. By understanding the determinants of the stage at diagnosis will aid in designing interventions to downstage disease and improve survival from BC in LMICs.


Within the South African Breast Cancers and HIV Outcomes (SABCHO) cohort, we examined factors affecting the stage at diagnosis of histologically confirmed invasive breast cancer at five tertiary hospitals in South Africa. The stage was assessed clinically. To examine the associations of the health system, socio-economic/household and individual factors, hierarchical multivariate logistic regression with odds of late-stage at diagnosis (stage III-IV), was used.


The majority (59%) of the included 3497 women were diagnosed with late-stage BC disease (59%). The effect of health system-level factors on late-stage BC diagnosis was consistent and significant even when adjusted for both socio-economic- and individual-level factors. Women diagnosed in a tertiary hospital that predominantly serves a rural population were almost 3 times (OR=2.89 (95% CI: 1.40-5.97) likely to be associated with late-stage BC diagnosis when compared to those diagnosed at a hospital that predominantly serves an urban population. Taking more than 3 months from identifying the BC problem to first health system entry (OR=1.66 (95% CI: 1.38–2.00)), and receptor subtypes [luminal B (OR=1.49 (95% CI: 1.19–1.87)), HER2 enriched (OR=1.64 (95% CI: 1.16–2.32))] were associated with a late-stage diagnosis. Whilst having a higher socio-economic level (a wealth index of 5) reduced the probability of late-stage BC, OR=0.64 (95% CI: 0.47 – 0.85).


Advanced stage diagnosis of BC among women in SA who access health services through the public health system was associated with both modifiable health system-level factors and non-modifiable individual-level factors. These may be considered as elements in interventions to reduce the time to diagnosis of breast cancer in women.