International Café: Surgical Care in South Africa

The ACS South Africa Chapter was established in 2018, and this article provides additional background on the surgical care in the country.

The South Africa Chapter was recently announced as a new and independent American College of Surgeons (ACS) Chapter. Pradeep Navsaria, MBChB, FCS(SA), FACS, has been appointed Governor-at-Large of the chapter for a three-year term. He also is the President of the chapter and will be assisted by his esteemed colleagues Ifongo Bombil, MD, FACS, as alternate Governor; Elmi Muller, MBChB, FACS, as Vice President; and Ramazani Adelin Muganza, MD, FACS, as Secretary/Treasurer. To date, there are 41 Fellows and one Associate Fellow in South Africa. On behalf of the members of the chapter, we take this opportunity to thank the Officers, Regents, Executive Committee of the Board of Governors, and the Executive Director of the College for recognizing the International Fellows and Associate Fellows in South Africa.

Brief Commentary of General Surgery in South Africa

South Africa is an anomaly among developing countries. It is both a developed country with good infrastructure and a country with huge social and economic problems. There is a wide gulf between recipients of development aid and skilled professionals. South Africa’s Gini coefficient is one of the highest in the world, which simply means that we are one the most unequal societies in the world.

There is a major shortage of surgical providers in South Africa, especially in the public sector. There are significant disparities in the number and distribution of general surgeons in South Africa. 

There is one hospital per 100,000 people. There are 186 hospital beds, 41 surgical beds, 1.7 specialist general surgeons, 2.9 non-specialist general surgeons, and 3.6 operating theaters per 100,000 people in South Africa. These numbers fall far below international recommendations for developed countries, such as the United Kingdom and the U.S. There are six specialist general surgeons per 100,000 insured people working in the private sector, which is comparable to the U.S.

The College of Medicine of South Africa (CMSA) has been appointed by the Health Professions Council of South Africa to be the sole examining body for postgraduate medical specialists. The College of Surgeons of South Africa (CSSA) is one of the colleges within the CMSA and is responsible for the assessment of surgical trainees. Graduates need to pass the Final Fellowship examination of the CSSA to be awarded the Fellowship of College of Surgeons (FCS) in order to practice independently as a specialist in general surgery. South Africa produces approximately 50 general surgeons per year, and over the past five years there has been an increase in the college examination pass rate from 60 to 80 percent.

In comparison with the South Africa College of Surgeons, the Australian College has a 96.9 percent pass rate resulting in a larger number of surgical registrars or residents qualifying each year. If the current ratio of 1.78 surgeons per 100,000 people remains the same through 2030, this will result in a deficit of 352 surgeons. If a ratio of five general surgeons per 100,000 people is to be achieved in the next 15 years, an additional 2,600 specialist surgeons need to be trained. South Africa is currently producing an average of 50 surgeons per year. If the surgeon output was increased to 150 per year, South Africa could achieve these numbers in approximately 17 years. The surgical training programs need to triple their output of specialists or this goal will remain beyond reach.

The full extent of both the local and global burden of surgical disease is largely unknown. Unfortunately, surgical services are not accessible to many who need it most. It has been reported that “Africa has less than three percent of the health care workers, one percent of the surgical workforce, and yet has nearly 25 percent of the burden of surgical disease.” It also is estimated that across 23 lower middle income countries (LMICs), the ratio of general surgeons per population ranges from 0.13 to 1.57 per 100,000. In comparison, the U.S. has nine general surgeons per 100,000 people. Africa, and thus South Africa, is experiencing a surgical crisis.

Global surgery research “hubs” are slowly appearing in academic centers in and around Southern Africa (for example, Universities of Cape Town, Stellenbosch, and Witwatersrand) with international collaborations from the U.S. and United Kingdom. These groups are committed to advancing the global surgical and perioperative disease research agenda in order to help decrease the global burden of surgical disease. From a local perspective, it is unfortunate that the funding for these hubs is primarily directed at the U.S./United Kingdom principal investigators and very little is directed at local researchers. In my opinion, the funding should be made available and channeled to local research groups who work closely with the foreign research academics.

The South Africa Chapter is currently in the process of identifying goals, procedures, and activities and invites readers to attend the following regional meetings held in Cape Town, South Africa, later this year:

International Association of Pancreatology Congress 2019 in Association with ASSA/SAGES/HPBSA/SASES
August 16–20, 2019

Second Cape Town International Trauma Conference
November 21–22, 2019

Further Reading

Global surgery: Socioeconomic and geographic maldistribution of surgical resources
Dr. Angela Dell
PhD thesis, 2016

An audit of the outcomes of the Fellow of College of Surgeons (General Surgery) final examinations
Dr. Miriam Kahn
MMed thesis, 2018