Over 70% of surgeries in SA will be cancelled or postponed due to Covid-19 – how will we catch up? 

The Covid-19 pandemic is an unprecedented global health emergency. While South Africa has delayed and possibly mitigated the peak of this pandemic, we are now seeing an increasing number of cases in the country and in our hospitals.

The delay gained by the lockdown and other interventions has allowed us to increase our “surge capacity” to handle large numbers of sick Covid-19 patients, through a reorganisation and reprioritisation of medical services. This has been an appropriate and largely unavoidable response to the health crisis, but has resulted in the reallocation of scarce health resources away from other lifesaving health services such as surgery. For many thousands of patients needing surgical care, the impact of Covid-19 now, at the peak of the pandemic and in the aftermath of Covid-19, will be devastating.

The Covid-19 pandemic in South Africa lands on a pre-existing crisis of under-resourced surgical services, evidenced by the unacceptably long waiting times for clinic visits, diagnostic procedures and operations.

We have witnessed the buckling of health systems in well-resourced countries in the global north. In our health environment, which is both under-resourced and unequal, the impact of the pandemic is likely to be more severe. We have fewer healthcare workers, fewer hospital beds and fewer critical care beds per 100,000 population than high-income countries. The order of magnitude for these differences in resources can be between 10 and 50 times less than that of high-income countries (see here and here). Studies reveal that if we consider critical care beds alone, there are 15 times fewer beds in Africa than in Europe.

During the lockdown, not only have surgeries been cancelled, but there has been a  disruption of normal surgical care pathways which include symptom awareness, presentation to primary levels of care, diagnosis, pre-operative assessment, surgical procedures and post-operative recovery and rehabilitation. Outpatient clinics have been scaled down and have become more difficult to access, primary level facilities have in some places provided only limited services and patients themselves have avoided hospitals out of fear of contracting the virus.

The breakdown in these pathways to care results in delays even before the decision to book an operation has been made. While difficult to quantify, it is likely that there is a growing unmet need for surgical care, which will manifest in the period after the pandemic.

In addition to the disruption of surgical pathways, operations already booked have been cancelled due to the pandemic. The need to postpone elective surgery that can be delayed has been a necessary strategy for several reasons: to decrease hospital occupancy to make space for Covid-19 patients in wards and ICUs; to protect patients from contracting the virus while travelling to and from the hospital and in the hospital itself; and to protect patients from inadvertently adding the risk of surgery to a co-existing Covid-19 infection.

Such a massive unmet health need will have profound implications for surgical services. If we managed a 10% increase in surgical capacity post Covid-19, it would take 90 weeks (almost two years) to catch up with the surgical backlog.

For us to honour the constitutional right of everyone to have access to healthcare services, it is appropriate that our health resources are focused on Covid-19 during the pandemic. But it is also necessary to plan a post-Covid-19 Health Recovery Plan for surgical patients and patients with non-Covid-19 conditions such as HIV, TB, cancer, hypertension and diabetes, whose care has been disrupted.