Little access to safe surgery in SADC, conference hears

Only 5% of people in Sub-Saharan Africa have access to safe surgery and many countries in the region have no surgical policies, delegates heard yesterday at an agenda setting conference hosted by Stellenbosch University’s Centre for Global Surgery. Surgical practitioners from South Africa were joined at the so-called AfroSurg conference by representatives from Zimbabwe, Botswana, Namibia, Zambia and Malawi. The 5% estimate was originally published in a landmark 2015 article in the Lancet medical journal, while information presented at the conference on policies and current staffing levels in the region is new. Though South Africa’s healthcare system is the most developed out of the six countries, all six face similar issues. These include a lack of national surgical policies, human resource shortages, insufficient funding and a lack of government initiatives aimed at improving access to surgery.

Policy and universal healthcare  As countries across the world look towards a future of universal healthcare, ensuring access to safe surgery is a key component of making universal healthcare a reality. In South Africa, the current National Health Insurance (NHI) Bill contains little information on what types of surgeries would be covered, as well as how healthcare systems would be strengthened to manage this. In 2015 the Lancet Commission on Global Surgery recommended that countries establish National Surgical Obstetrics and Anaesthesia Plans (NSOAPs), but so far these have only been developed by two countries in the Southern African Development Community (SADC) region, Zambia and Tanzania. While these plans are a step in the right direction, implementation remains difficult without evidence to support them. Currently there are plans underway in one region of Zambia to test for outcomes of their NSOAP, but achieving this requires extra support. Since 2018 the SADC has taken steps to develop a regional SOA strategic plan which is set to be reviewed in a ministerial meeting later this year. The regional approach combined with individual country’s NSOAPs aims to ensure patients have access to safe surgical care within their home country, rather than seeking care outside of their borders. SADC Countries at a Glance  Botswana

• There are 14 general surgeons, 11 obstetricians and 16 anaesthetists (including practitioners from China and Cuba) in the public sector.
• 20 percent of people are on private medical aid.
• A team has been appointed to develop a NSAOP. However, this has not been costed nor has a situational analysis taken place.
• The biggest challenge is a lack of specialists and retaining specialists in the country.

Malawi

• One survey found that 35 percent of people in rural areas are living with untreated surgical conditions.
• Surgical provider density is 5.4 (per 100 000) in district hospitals, and 3.8 in central hospitals.
• There are 36 Malawian surgeons working in the country.
• A NSOAP is not yet developed due to a lack of funding.

Namibia

• There are 14 surgeons, 11 anaesthesiologist physicians, 129 general doctors providing surgery (including obstetrics) and 66 general doctors providing anaesthesia in the public sector.
• Currently there are 4 obstetrician/gynaecologists. In prior years there were none.
• The surgeon population ratio is 1 per 69 385 people.
• An NSOAP was expected to be developed by May 2019, but an alleged lack of government interest has delayed progress.

South Africa

• South Africa has no specific surgery plan, nor taken steps to develop a NSOAP.
• The word “surgery” is mentioned in the Department of Health’s National Strategic Plan 2015/2016 – 2019/2020 only once (in relation to cataract surgery).
• In the Western Cape more than 95 percent of district hospitals had surgical, anaesthesia and obstetric providers. Only 15 percent had a surgeon, anaesthesiologist and obstetrician.
• Digital resources have been engineered to improve the referral process to specialists, as well as streamline the booking process for Caesarean sections using WhatsApp.

Zambia

• More than 80 percent of Zambians live more than two hours away from emergency and essential surgical facilities.
• There are 1.1 surgeons per 100 000 people.
• Zambia’s NSOAP was integrated into their National Strategic Plan in May 2017.
• Zambia’s NSOAP can be found here

Zimbabwe

• Roughly 10 percent of the population are on private medical aid.
• Physician density is .08 (per 1 000 people), while midwife/nurse density is 1.3.
• There are 54 general surgeons, 70 physicians providing anaesthesia and 108 obstetricians/gynaecologists.
• A situational analysis has been done for a NSAOP, and a stakeholder meeting is scheduled to take place next month.

 *The above figures were taken from slides presented by country representatives at AfroSurg on 16 January. Representatives included: Dr Moneimang Makgasa (Botswana), Dr Judith Mkwaila (Malawi), Dr Akutu Munyika (Namibia), Dr Emmanuel Makasa (Zambia), Dr Kathryn Chu (South Africa) and Prof Godfrey Muguti and Dr Nyaguse-Chiurunge (Zimbabwe).