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South African Journal of Surgery

On-line version ISSN 2078-5151
Print version ISSN 0038-2361

S. Afr. j. surg. vol.58 n.4 Cape Town Dec. 2020 



Global surgery: a South African action plan



TC HardcastleI; KM ChuII, III

IClinical Department - Trauma & Burns, Dept of Surgery, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, South Africa
IICentre for Global Surgery, Department of Global Health, Stellenbosch University, South Africa
IIIDepartment of Surgery, University of Cape Town, South Africa




Global surgery is the study, research, and practice of improving access for all people to quality and timely surgical care locally and transnationally. This relatively new academic field was kick started in 2015 with the launch of the Lancet Commission on Global Surgery1 and a World Health Assembly declaration that essential and emergency surgical care (EESC) is an essential component of universal health coverage.2 What does global surgery mean to the South African surgeon and how can it improve healthcare provision for surgical conditions within our region? Surgical care is an indispensable, cross-cutting health service that is necessary to improve health in diverse areas, such as cancer, injury, cardiovascular disease, infection, and maternal/child health. The high burden of trauma, non-communicable diseases (including cancer), maternal and child-health challenges, and communicable diseases (HIV and TB in particular) are a quadruple threat to the health and well-being of South Africans.3 Poor access to high-quality surgical, obstetric and anaesthesia care remains a major contributor to the global disease burden, accounting for large numbers of deaths worldwide.1

Some surgeons, locally and internationally, have the misconception that "global surgeons" are from high-income countries who conduct outreach missions and research in low- and middle-income countries (LMICs). These persons can be perceived as trying to implement expensive or seemingly irrelevant solutions and ask research questions that are not contextually useful for local surgeons or patients. However, global surgery should be locally driven and South African surgeons can champion global surgery in our own country as well as in the southern African region. Indeed, as South Africa is a middle-income country with a high burden of surgical conditions and large inequities in access to high-quality surgical care, our surgeons are well-positioned to become global surgery leaders, having both robust clinical and research experiences in resource-challenged settings.

Three South African universities (University of Witwatersrand, University of Cape Town and Stellenbosch University) have recently established dedicated global surgery entities. These groups are establishing locally-driven research agendas that will translate evidence-based solutions into service implementation and policy in order to improve quality, timely and safe surgical care in South Africa and the region.4-6 This includes advocating for EESC to be a key component of universal health coverage,3 strengthening district hospital surgical capacity particularly in rural areas7,8 and augmenting human resources of health for surgery.9, 10

The current SARS-CoV-19 pandemic has severely affected healthcare delivery in SA especially the provision of surgical services with the re-distribution of many surgical and anaesthesia providers to care for critically ill patients.11 This and the baseline maldistribution of surgery, anaesthesia and obstetric services between the private and public health sectors has necessitated the National Department of Health to look closely at more equitable options to provide access to surgical services.

The first step in this regard was the establishment in early 2020 of the National Department of Health Technical Working Group for surgical services. The technical working group is comprised of surgeons, anaesthesiologists, obstetricians, critical care specialists, emergency medicine physicians and other surgical stakeholders from several South African institutions and was formed with two primary aims: to create a "return to service" scoring system for surgery post SARS-CoV-19 and in the long term, and to develop and implement a National Surgical Obstetric and Anaesthesia Plan (NSOAP) for South Africa.

The NSOAP concept is not new but has been late in formation in South Africa compared to other African countries. An NSOAP is a blueprint to define a national surgical package of care. Seven work streams around critical areas are included, namely human resources, service delivery, infrastructure, supply chain, governance, finance and informatics. This will be a multi-step approach and include analysis of baseline indicators (what we have and where it currently exists), partnership with local champions, broader stakeholder engagement, consensus building and synthesis of ideas, language refinement, costing, dissemination and ultimately implementation (of an equitable, accessible and comprehensive surgical, obstetric and anaesthesia care system).12

One specific aim is to strengthen decentralised surgical health systems at district hospitals to improve equitable access to surgical care. To this end, family practitioners, rural doctors, public health specialists, emergency medicine physicians, and hospital clinical managers will also be key stakeholders, and the NSOAP must be incorporated into the national health strategic plans for provision of EESC.

Buy-in from provincial health departments, who will be critical role players, along with surgical professional associations and private healthcare groups, will be critical to ensure that local hospitals implement the frameworks and improve services. A pragmatic approach to implementation will be needed that can be easily understood by early users. Frontline surgical providers, for example, will be the first to interact with the policy, requiring a change in how they function, behave and adapt within changing hospital settings. Such an approach demands effective cooperation and partnerships across the stakeholder continuum, spanning academia, public and private sectors (including the biomedical sector), non-government organisations, civil society and, most importantly, patient representatives and advocacy groups.

The timeline for the development and implementation of the NSOAP is 12-18 months. Timelines for the development of a fully costed plan are currently aimed for July 2021 with initiation of the implementation phase by January 2022.

The importance of this work requires that all surgical practitioners in South Africa are both aware of the process and participate where necessary in the provision of data, sharing of wisdom, and holding both the NSOAP workgroup and the national and provincial Departments of Health accountable to complete this process for the benefit of the South African population.

In conclusion, global surgery is the implementation of evidence-based solutions to improve access to surgical care. Solutions should be locally relevant and locally driven. The creation of a South African NSOAP will be the first step to ensuring that surgical care is an essential component of universal health coverage and the National Health Insurance.3 EESC saves lives and the field of global surgery will ensure that it is accessible to all.


TC Hardcastle ©

KM Chu ©



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2. World Health Assembly. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage; 2015.         [ Links ]

3. Reddy CL, Makasa EM, Biccard B, et al. Surgery as a component of universal healthcare: where is South Africa? S Afr Med J. 2019 Aug 28;109(9):624-5.         [ Links ]

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8. Chu KM, Naidu P, Hendriks HJ, et al. Surgical care at rural district hospitals in low- and middle-income countries: an essential component of universal health coverage. Rural and Remote Health. 2020 Jun;20(2):5920.         [ Links ]

9. Naidu P, Fagan JJ, Lategan C, Devenish LP, Chu KM. The role of the University of Cape Town, South Africa, in the training and retention of surgeons in Sub-Saharan Africa. Am J Surg. 2020;220(5)"1208-212.         [ Links ]

10. Dell AJ, Kahn D. Surgical resources in South Africa: an international comparison and deficit calculation. World J Surg. 2018 Feb;42(2):541-8.         [ Links ]

11. Chu KM, Smith M, Steyn E, et al. Changes in surgical practice in 85 South African hospitals during COVID-19 hard lockdown. South African Medical Journal. 2020;110(9):916-19.         [ Links ]

12. Truché P, Shoman H, Reddy CL, et al. Globalisation of national surgical, obstetric and anesthesia plans: the critical link between health policy and action in global surgery. Global Health. 2020 Jan 2;16(1):1. PMC6941290.         [ Links ]




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