Breaking Down the UCT Study on Peri-Urban Surgical Care Access

A groundbreaking study from the University of Cape Town (UCT), published in the prestigious South African Medical Journal (SAMJ), has shed light on persistent barriers to high-quality surgical care in peri-urban communities surrounding Cape Town. Titled "Community experiences of surgery in peri-urban Cape Town," the research reveals that despite physical proximity to hospitals, nearly one in three residents faces significant delays in receiving timely treatment. Led by Dr. Moses Isiagi from UCT's Division of Global Surgery, the cross-sectional household survey involved 432 adults across 10 neighbourhoods in the Klipfontein subdistrict, including high-density areas like Gugulethu, Nyanga, and Manenberg. This marks the first comprehensive community-level assessment of surgical experiences in such settings, highlighting gaps that extend beyond geography.

Peri-urban areas, defined as transitional zones between urban centers and rural landscapes, often feature informal settlements with dense populations, limited infrastructure, and socioeconomic challenges. In Cape Town's context, these communities are mere kilometers from major facilities like Groote Schuur Hospital, yet systemic issues undermine access. The study's use of the Three Delays Framework—a model originally developed for maternal mortality but now adapted for broader surgical care—provides a structured lens to dissect these barriers step by step.

Defining Peri-Urban Challenges in Cape Town's Context

Cape Town's peri-urban zones, such as the Klipfontein subdistrict, embody South Africa's urban-rural divide. Home to over 100,000 residents, these areas grapple with high poverty rates, unemployment exceeding 40%, and violence linked to gang activity. Healthcare facilities are nearby—44% of respondents lived within 10 km, mostly public ones (97%)—but this hasn't translated to equitable care. The Western Cape province, while boasting better infrastructure than rural provinces, still faces national surgical workforce shortages, with specialist density below the recommended 20 per 100,000 population.

Cultural factors, transport costs, and mistrust in public services compound issues. For instance, minibus taxis—the primary transport mode—can be unreliable during peak hours or strikes, delaying arrivals. Women, who bear higher chronic disease burdens, are disproportionately affected, underscoring gender inequities in healthcare access.

The Substantial Surgical Burden Revealed

The UCT study uncovered a heavy reliance on surgery: 60% of participants (260 out of 428) had undergone at least one procedure in their lifetime, with 45% experiencing surgery in the past five years alone—equating to 195 recent operations. Caesarean sections dominated at 27%, reflecting ongoing maternal health pressures despite national reductions in maternal mortality. Trauma from assaults and road accidents, alongside non-communicable diseases (NCDs), drives demand.

Chronic conditions afflicted 56% of respondents (240 out of 431), led by hypertension (37% overall, 42% in women). Females reported higher rates (60% vs. 47% in males, p<0.05), often tied to elevated body mass index. These comorbidities elevate surgical risks, from anesthesia complications to poor wound healing, mirroring sub-Saharan Africa's NCD-surgical nexus.

Dissecting Delays with the Three Delays Framework

The Three Delays Framework categorizes barriers as: (1) delay in deciding to seek care; (2) delay in reaching the facility; and (3) delay in receiving adequate treatment. Applied here, it exposed pervasive issues:

• Delay 1 (Seeking Care): 20% (87/432) postponed due to unawareness, financial fears, or cultural beliefs.
• Delay 2 (Reaching Facility): 26% (114/432) faced transport hurdles, costs (R50-100 per trip), or safety concerns at night.
• Delay 3 (Receiving Care): 32% (95/432)—the highest—encountered long waits, staff shortages, or inappropriate referrals. Only 22% (95/432) had no delays.

This framework, extended from maternal care in Africa, reveals non-medical factors like poverty and education gaps as key culprits.

Photo by Jolame Chirwa on Unsplash

Alarming Postoperative Disability Rates

Post-surgery, 10% (43/432) reported disabilities—double high-income country rates (3-7%)—primarily body function impairments (51.2%, 22/43) like chronic pain or weakness, and activity limitations (16.3%, 7/43) such as mobility issues. Only 67% grasped post-op protocols, risking non-compliance.

In South Africa, where surgical volume is high but quality varies, these outcomes link to NCDs, inadequate follow-up, and resource constraints. Globally, low- and middle-income countries (LMICs) see 3.5 million annual surgical deaths, many preventable.

Insights from UCT's Global Surgery Experts

Dr. Moses Isiagi emphasized: "Geographical proximity has improved, but does not ensure optimal access. This is about complex factors preventing timely care." Professor Bruce Biccard, now at Oxford but UCT-affiliated, noted NCDs' role in complications, drawing from his book Safer Surgery for Africa. Head Prof. Salome Maswime called findings "crucial evidence for universal access."

Funded partly by the UK National Institute for Health and Care Research, the study exemplifies UCT's leadership via its Division of Global Surgery—a WHO Collaborating Centre fostering research, education, and partnerships. Initiatives include the MSc in Global Surgery and Research, Advocacy, and Innovation (RAI) program.

National and Regional Implications for Surgical Systems

South Africa's surgical challenges—workforce shortages, urban-rural disparities—affect 5 billion globally lacking safe surgery. Peri-urban gaps mirror rural LMIC issues, where NCD rise meets trauma burdens. Policymakers can leverage data for National Health Insurance (NHI) integration of surgical services.Read the full SAMJ study.

Stakeholders like the Department of Health and district clinics must address delays through subsidies and awareness campaigns.

Proposed Solutions and Targeted Interventions

Researchers advocate:

• Community education on NCD management via primary care.
• Elective surgery capacity boosts, e.g., task-shifting to mid-level providers.
• Structured protocols for peri-urban care, including telehealth follow-ups.

Explore higher education jobs in South Africa's health sector or university positions advancing global surgery.UCT News coverage.

Photo by Eswatini Photography on Unsplash

Future Directions in Research and Policy

Building on UCT's Global Surgery Research Strategy (launched 2022), longitudinal studies could track interventions' impact. Sub-Saharan collaborations promise scalable models. For academics, this underscores demand for experts in implementation science.

Prospective surgeons: UCT's programs offer training amid SA's specialist gap.

Career Pathways in Global Surgery at South African Universities

Institutions like UCT drive careers in global surgery through fellowships and research. Link theory to practice via South African academic jobs or career advice. Rate professors shaping the field at Rate My Professor.

In conclusion, the UCT-SAMJ study catalyzes action for equitable surgical access, positioning universities as pivotal in health innovation. Explore higher-ed jobs, university jobs, and career advice to contribute.