. 2017 Jun 14;2(2):e000170. doi: 10.1136/bmjgh-2016-000170

Table 1.

Indicators of assessment to safe and affordable surgical and anaesthesia care, their application and route of assessment in South Africa

LCoGS indicator	LCoGS time bound target for 2030	Time bound target adapted for South Africa (calculated on a population of 54 million)	Current status of data	Plans arising from the NFSASA and research networks in South Africa
Access to essential surgery within 2 hours	A minimum of 80% coverage of essential surgical and anaesthesia services per country	80% of the population within 2 hours travel (or 40 km as the crow flies) of a district hospital capable of surgical services	Population coverage unknown.	SAMaSS is a current project through PEASC in collaboration with StatsSA to map hospitals capable of carrying out surgical services. Using census data, population characteristics of those covered and uncovered will be described. Through design of an interactive map, identification of sites suited for upgrading to best attend underserved populations can be identified.
Specialist surgical workforce density	A minimum target of at least 20 surgical, anaesthesia and obstetric physicians per 100 000 population	At least 10 800 surgical, anaesthesia and obstetric physicians, with appropriate service of public and private sectors	6329 surgical, anaesthesia and obstetric physicians registered in the country.⁴³ Accurate division of time between public and private is unknown. Spectrum of non-specialist physicians capable of ‘Bellwether procedures’ unknown	SAMaSS will include layering of practising registered physicians onto interactive map as described above. The South African Society of Anaesthesiologists is currently engaged in a workforce, service delivery and equipment survey which may better characterise facility and personal provision (Safe Surgery SA available at www.ansa.org.za). Engagement with medical protection societies and provincial departments of health to determine on-specialist personnel capacity.
Surgical volume	Tracking of surgical volume by 2030; a minimum of 5000 procedures per 100 000 population by 2030	National tracking of surgical volumes, with at least 2 700 000 procedures per annum	World Bank statistics of 4852 surgeries per 100 000 (2012)⁴⁴	Small multicentre prospective cohort studies such as SASOS⁴⁵ and GlobalSurg (SA)¹⁷ allow a current indication of volumes and outcomes. Further studies, including the Surgical Access and Volume Evaluation study, leveraging a network of community service doctors around the country will aim to address these gaps.
POMR	Tracking of POMR by 2030; in 2020, evaluate global data and set national targets for 2030	National tracking of POMR in all levels of hospitals. Eventual prospective tracking of POMR and complications	SASOS⁴⁵ found a 3.1% in-hospital mortality. GlobalSurg (SA)¹⁷ found a 13.5% in-hospital mortality rate following intra-peritoneal general surgery and a 33.6% complication rate	Small multicentre prospective cohort studies such as SASOS,⁴⁵ ASOS³⁰ and GlobalSurg (SA)¹⁷ allow a current indication of volumes and outcomes. Further collaborative networks to prospectively continually gather these data are required. The South African Perioperative Research Group identified establishment of a national database of critical care outcomes as their first priority for surgical research.⁴⁶
Protection against impoverishing expenditure	100% protection against impoverishment from out-of-pocket payments for surgical and anaesthesia care by 2030	Identification of areas where out-of-pocket payments for surgical and anaesthesia care occur in public sector	World Bank statistics of 50% of people at risk (2014)⁴⁷	South Africa’s relatively unique situation of means testing for all government healthcare provision means that these figures, derived from a model encompassing other African countries, may not be accurate. This highlights the importance of accurate locally obtained information. In addition, the complex dynamics of government and private health systems in South Africa, including patient choice of service, mean this is a complex indicator to scrutinise. Engagement with civil society, public health entities and academic departments is still ongoing to determine the best methods to assess these indicators in South Africa.
Protection against catastrophic expenditure	100% protection against catastrophic expenditure from out-of-pocket payments for surgical and anaesthesia care by 2030	Identification of areas where catastrophic expenditure from out-of-pocket payments for surgical and anaesthesia care occurs in public sector	World Bank statistics of 25.5% of people at risk (2014)⁴⁸

LCoGS, Lancet Commission on Global Surgery; NFSASA, National Forum on Surgery and Anaesthesia in South Africa; PEASC, Programme for Equitable Access to Surgical Care; POMR, perioperative mortality rate; SAMaSS, South African Map to Safe Surgery; SASOS, South African Surgical Outcomes Study.