Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop

Abstract

Background Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. Objective To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. Methods A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. Results Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider’s knowledge, training and experience , and Limited surgical outreach . The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. Conclusions This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.

Sustainable surgical resource initiative for Haiti: the SSRI-Haiti project

“…This work describing the creation and evolution of a single surgical unit adds to the large body of the literature on medical care and surgery in LMIC environments in general and Haiti specifically, which includes discussions of facility funding, barriers to effective care and shortcomings of current volunteer programs, comments on how to improve access to care, surveys of multiple facilities, and a combined description of previous cases at St Luke’s and a similar institution in Honduras [ 2 , 5 , 8 , 10 , 12 , 19 , 21 , 23 , 26–38 , 45 , 46 ]. In the existing literature, there are similar examples of scaling up of surgical care in rural Haiti, which has been described by the Partners in Health and the Zanmi Lasante (PIH/ZL) organisations.…”

“…Establishing surgical care in resource-limited nations continues to represent a difficult and multifaceted effort combining acquisition and maintenance of medical infrastructure and equipment, training and recruiting local and foreign physicians, and sustaining long-term high-quality performance [ 47–49 ]. We have demonstrated that a three-phase plan, detailed earlier, can address these simultaneous challenges, and here we briefly discuss our plan in the context of the so-called delay framework (or delay model) to global health, which owes its origin to a maternal mortality program in sub-Saharan Africa [ 8–12 ]. Our three-phase plan, which led to a sustainable surgical centre in Haiti, addresses the main barriers to surgical care recently identified with the four delay framework, apparent by considering the description herein compared with barrier prioritisation in Table 1 [ 8 ].…”

“…We have demonstrated that a three-phase plan, detailed earlier, can address these simultaneous challenges, and here we briefly discuss our plan in the context of the so-called delay framework (or delay model) to global health, which owes its origin to a maternal mortality program in sub-Saharan Africa [ 8–12 ]. Our three-phase plan, which led to a sustainable surgical centre in Haiti, addresses the main barriers to surgical care recently identified with the four delay framework, apparent by considering the description herein compared with barrier prioritisation in Table 1 [ 8 ]. Note for barrier identification, the four delay framework (seeking care, reaching care, receiving care, and remaining in care) is equivalent to its predecessor, the three delay framework which originated as part of maternal mortality studies (its three delays being seeking care, reaching care and receiving care).…”

“…We describe the development of a sustainable surgery program in an LMIC environment, building on the literature regarding similar programs and key priorities in their implementation [ 8–12 ]. This three-phase plan is described below.…”

“…Some indicate this volume is increasing as part of the ‘epidemiological transition’, in which the surgical burden of non-communicable diseases and injuries associated with increased life expectancy and demographic changes outpaces the concomitant increases in medical staff, facilities, education and mobility associated with socioeconomic development [ 5–7 ]. A recent prioritising of barriers to equitable surgical care in South Africa within the often-applied ‘delay framework’ (in this case, the four delay framework: seeking care, reaching care, receiving care and remaining in care) identified the following key barriers: provider education/training, surgical outreach, continuity of care, medical infrastructure, inadequate referral system, long waiting times and equipment capability and maintenance, seen in Table 1 [ 8 ]. As will be discussed below, we have created a three phase plan (build facility and acquire equipment; train staff and perform surgeries; provide continued education and expansion including regular specialist trips) for establishing and operating a sustainable surgical centre in a resource-limited environment; this straightforward plan addresses the aforementioned key barriers as well as surgical care within the broader delay framework of global health [ 8–12 ].…”