Estimating the Specialist Surgical Workforce Density in South Africa

Background: South Africa is an upper middle-income country with inequitable access to healthcare. There is a maldistribution of doctors between the private and public sectors, the latter which serves 86% of the population but has less than half of the human resources.

Objective: The objective of this study was to estimate the specialist surgical workforce density in South Africa.

Methods: This was a retrospective record-based review of the specialist surgical workforce in South Africa as defined by registration with the Health Professionals Council of South Africa for three cadres: 1) surgeons, and 2) anaesthesiologists, and 3) obstetrician/gynaecologists (OBGYN).

Findings: The specialist surgical workforce in South Africa doubled from 2004 (N = 2956) to 2019 (N = 6144). As of December 2019, there were 3096 surgeons (50.4%), 1268 (20.6%) OBGYN, and 1780 (29.0%) anaesthesiologists. The specialist surgical workforce density in 2019 was 10.5 per 100,000 population which ranged from 1.8 in Limpopo and 22.8 per 100,000 in Western Cape province. The proportion of females and those classified other than white increased between 2004–2019.

Conclusion: South Africa falls short of the minimum specialist workforce density of 20 per 100,000 to provide adequate essential and emergency surgical care. In order to address the current and future burden of disease treatable by surgical care, South Africa needs a robust surgical healthcare system with adequate human resources, to translate healthcare services into improved health outcomes.

Preliminary model assessing the cost-effectiveness of preoperative chlorhexidine mouthwash at reducing postoperative pneumonia among abdominal surgery patients in South Africa

Background
Pneumonia is a common and severe complication of abdominal surgery, it is associated with increased length of hospital stay, healthcare costs, and mortality. Further, pulmonary complication rates have risen during the SARS-CoV-2 pandemic. This study explored the potential cost-effectiveness of administering preoperative chlorhexidine mouthwash versus no-mouthwash at reducing postoperative pneumonia among abdominal surgery patients.

Methods
A decision analytic model taking the South African healthcare provider perspective was constructed to compare costs and benefits of mouthwash versus no-mouthwash-surgery at 30 days after abdominal surgery. We assumed two scenarios: (i) the absence of COVID-19; (ii) the presence of COVID-19. Input parameters were collected from published literature including prospective cohort studies and expert opinion. Effectiveness was measured as proportion of pneumonia patients. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainties. The results of the probabilistic sensitivity analysis were presented using cost-effectiveness planes and cost-effectiveness acceptability curves.

Results
In the absence of COVID-19, mouthwash had lower average costs compared to no-mouthwash-surgery, $3,675 (R 63,770) versus $3,958 (R 68,683), and lower proportion of pneumonia patients, 0.029 versus 0.042 (dominance of mouthwash intervention). In the presence of COVID-19, the increase in pneumonia rate due to COVID-19, made mouthwash more dominant as it was more beneficial to reduce pneumonia patients through administering mouthwash. The cost-effectiveness acceptability curves shown that mouthwash surgery is likely to be cost-effective between $0 (R0) and $15,000 (R 260,220) willingness to pay thresholds.

Conclusions
Both the absence and presence of SARS-CoV-2, mouthwash is likely to be cost saving intervention for reducing pneumonia after abdominal surgery. However, the available evidence for the effectiveness of mouthwash was extrapolated from cardiac surgery; there is now an urgent need for a robust clinical trial on the intervention on non-cardiac surgery.

Epidemiology and Anatomic Distribution of Colorectal Cancer in South Africa

Background: Colorectal cancer (CRC) is the 5th most common cancer in subSaharan Africa (SSA) and the 3rd most common cancer in Southern Africa. CRC characteristics in SSA, including anatomic distribution, are not well described. Objective: To describe patient characteristics and anatomic location of colorectal adenocarcinoma (CRC-AC) in South Africa. Design: This was a retrospective study of CRC using the South African National Cancer Registry from 2006-2011. Main Outcome Measures: Patient age, gender, racial/ethnic group, province, histology type, and tumour location. Results: 6146 patients were included in the analysis. Among patients with adenocarcinomas, the median age of presentation was 60 (interquartile range, 49-70) years. 1372 (25%) of patients were < 50 years and 2870 (52%) were male. There were 5498 (89%) cases of adenocarcinoma (AC). 1277 (26%) CRC-AC were right colonic lesions, 1214 (25%) were left colonic lesions, and 2404 (49%) lesions were located in the rectum. Patients ≥ 50 years at presentation (OR=1.29. p< 0.001) and from Limpopo province (OR=1.46, p=0.029) were more likely to have left colonic and rectal adenocarcinoma on multivariate analysis. Patients who were black (OR=1.67, p< 0.001), had right colonic lesions (OR=1.25, p=0.007), and were from Mpumalanga (OR=1.67, p=0.007), Limpopo (OR=1.60, p=0.002), or Northwest (OR=1.76, p=0.001), were significantly associated with early onset adenocarcinoma. Conclusion: CRC-AC in South Africa presents at an earlier age than in HICs, such as the US. Early-onset CRC is higher in black South Africans who live in Mpumalanga, Limpopo, and Northwest in comparison with other provinces. The majority of colorectal cancer were leftsided and rectal; thus screening flexible sigmoidoscopy should be considered. Further studies on the age-specific incidence and the genetics and epigenetics of CRC-AC in South Africa are needed.

A Qualitative Analysis of Burn Injury Patient and Caregiver Experiences in Kwazulu-Natal, South Africa: Enduring the Transition to a Post-Burn Life

Over 95% of fire-related burns occur in low- and middle-income countries (LMICs), an important and frequently overlooked global health disparity, yet research is limited from LMICs on how survivors and their caregivers recover and successfully return to their pre-burn lives. This study examines the lived experiences of burn patients and caregivers, the most challenging aspects of their recoveries, and factors that have assisted in recovery. This qualitative study was conducted in KwaZulu-Natal, South Africa at a 900-bed district hospital. Participants (n = 35) included burn patients (n = 13) and caregivers (n = 22) after discharge. In-depth interviews addressed the recovery process after a burn injury. Data were coded using NVivo 12. Analysis revealed three major thematic categories. Coded data were triangulated to analyze caregiver and patient perspectives jointly. The participants’ lived experiences fell into three main categories: (1) psychological impacts of the burn, (2) enduring the transition into daily life, and (3) reflections on difficulties survivors face in returning for aftercare. The most notable discussions regarded stigma, difficulty accepting self-image, loss of relationships, returning to work, and barriers in receiving long-term aftercare at the hospital outpatient clinic. Patients and caregivers face significant adversities integrating into society. This study highlights areas in which burn survivors may benefit from assistance to inform future interventions and international health policy.

An assessment of human resource distribution for public eye health services in KwaZulu-Natal, South Africa

Background: The development of human resources for eye health (HReH), aimed at achieving a 25% reduction in visual impairment by the year 2020, was one of the VISION 2020 objectives.

Aim: To assess HReH in the public sector of KwaZulu-Natal (KZN), and its effect on the accessibility of eye care in the province.

Setting: All public eye facilities in KZN.

Methods: A quantitative cross-sectional study using a close-ended questionnaire to assess distribution and outputs of HReH. At the end of the questionnaire, respondents gave general comments on their ability to provide services.

Results: Human resource rates were 0.89 for ophthalmologists, 2.44 for cataract surgeons, 4.8 for optometrists and 4.7 for ophthalmic nurses per 1 million population. Most health facilities had some HReH working in them, albeit none had dispensing opticians. Regression analysis showed that 67.1% of variation in cataract surgery was because of the number of surgeons available. Cataract surgical rates were low with a waiting period of up to 18 months. In addition to the refractive error regression analysis of 33.7%, spectacle supply was low, with a backlog of up to 9 months in some facilities.

Conclusion: Overall, HReH targets as per VISION 2020 and the National Prevention of Blindness have not been met in this region. Dispensing opticians are not employed in any of the province’s health districts. An increase in the eye health workforce is necessary to improve the eye health outcomes for people dependent on public eye facilities.

The implementation of a national paediatric oncology protocol for neuroblastoma in South Africa

Purpose
The aim of the World Health Organization-International Paediatric Oncology Society is to improve childhood cancer survival in low- and middle-income countries to 60% by 2030. This can be achieved using standardised evidence-based national treatment protocols for common childhood cancers. The aim of the study was to describe the development and implementation of the SACCSG NB-2017 neuroblastoma (NB) treatment protocol as part of the treatment harmonisation process of the South African Children’s Cancer Study Group.

Methods
The Consolidated Framework for Implementation Research was used to identify factors that could influence the implementation of the national NB protocol as a health care intervention. The evaluation was done according to five interactive domains for implementation: intervention characteristics, inner setting, outer setting, individual or team characteristics and the implementation process.

Results
The protocol was developed over 26 months by 26 physicians involved in childhood cancer management. The process included an organisational phase, a resource identification phase, a development phase and a research ethics approval phase. Challenges included nationalised inertia, variable research ethical approval procedures with delays and uncoordinated clinical trial implementation.

Conclusion
The implementation of the national NB protocol demonstrated the complexity of the implementation of a national childhood cancer treatment protocol. However, standardised paediatric cancer treatment protocols based on local expertise and resources in limited settings are feasib

District hospital surgical capacity in Western Cape Province, South Africa: A cross-sectional survey

Background. The role of the district hospital (DH) in surgical care has been undervalued. However, decentralised surgical services at DHs have been identified as a key component of universal health coverage. Surgical capacity at DHs in Western Cape (WC) Province, South Africa, has not been described.

Objectives. To describe DH surgical capacity in WC and identify barriers to scaling up surgical capacity at these facilities.

Methods. This was a cross-sectional survey of 33 DHs using the World Health Organization surgical situational analysis tool administered to hospital staff from June to December 2019. The survey addressed the following domains: general services and financing; service delivery and surgical volume; surgical workforce; hospital and operating theatre (OT) infrastructure, equipment and medication; and barriers to scaling up surgical care.

Results. Seven of 33 DHs (21%) did not have a functional OT. Of the 28 World Bank DH procedures, small WC DHs performed up to 22 (79%) and medium/large DHs up to 26 (93%). Only medium/large DHs performed all three bellwether procedures. Five DHs (15%) had a full-time surgeon, anaesthetist or obstetrician (SAO). Of DHs without any SAO specialists, 14 (50%) had family physicians (FPs). These DHs performed more operative procedures than those without FPs (p=0.005). Lack of finances dedicated for surgical care and lack of surgical providers were the most reported barriers to providing and expanding surgical services.

Conclusions. WC DH surgical capacity varied by hospital size. However, FPs could play an essential role in surgery at DHs with appropriate training, oversight and support from SAO specialists. Strategies to scale up surgical capacity include dedicated financial and human resources.

Inequity in paediatric oncology in South Africa – The neuroblastoma case study

Background: The South African Constitution affords everyone the right to access healthcare services, but in children the care must ensure survival.

Aim: This study aimed to determine whether there was access to equitable paediatric oncology services for the management of neuroblastoma in South Africa.

Setting: Paediatric oncology services in South Africa between 2000 to 2014.

Methods: A literature review was carried out, focussing on access to healthcare in South Africa for children with neuroblastoma. Services were classified in accordance with the International Society of Paediatric Oncology resource settings for neuroblastoma diagnosis. Supplementary data from a retrospective study of the management of neuroblastoma in South Africa were evaluated.

Results: The neuroblastoma care services in South Africa were not uniformly resourced and accessible across the provinces. Two provinces (2/9 provinces) had excellent healthcare services that included access to transplant facilities, whilst three (3/9 provinces) had no services. Traveling distances to healthcare services pose major challenges, whilst number of medical staff providing oncology care were unequally distributed. The Constitution did not define basic healthcare for children, nor did the National Cancer Control plan acknowledge childhood cancer as a defined entity without provision until 2022.

Conclusion: Children diagnosed with neuroblastoma do not have equitable access to healthcare as stated in the South African Constitution. The case of neuroblastoma highlights the inequitable access to childhood care as a whole in South Africa. As the health of children is a national priority, it is therefore necessary to sensitise policymakers to the needs of children with cancer.

The scope of operative general paediatric surgical diseases in South Africa—the Chris Hani Baragwanath experience

Background
Infectious diseases have always been the lime light of global health with very little focus on childhood surgical conditions despite the fact that children constitute about half of the population in LMICs. A significant proportion of the burden of global disease can be reduced by surgical intervention. South Africa is one of the pioneers of the practice of paediatric surgery in Africa with a great burden of paediatric surgical conditions.

Few studies, if any, have investigated the burden of operative paediatric surgical procedures in South Africa. Therefore, this retrospective study aimed to look at the scope of operative paediatric surgical procedures at the Chris Hani Baragwanath Academic Hospital (CHBAH) based in Johannesburg, South Africa, and reports on the numbers of elective and emergency procedures over a 12-month study period.

Results
There were 1699 operative general paediatric surgical procedures of which 61.7% were electives and 38.3% were emergencies. The scope of general paediatric surgical conditions operated on fell under the categories of congenital anomalies, infections and tumours. Of these, surgeries for congenital anomalies were performed in almost all the subspecialties.

Conclusion
There is a high operative paediatric surgical burden at the CHBAH. The role of paediatric surgical care as an essential component of global health cannot be underrated.

Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study

Background
Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice.

Methods
From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was ‘days alive and at home up to 30 days after surgery’ (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice.

Results
Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3–5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25–27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%).

Conclusion
Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if ‘buy-in’ from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative.