The health system in South Africa has both private and public sectors. The budget for our health system is 8.5 percent of the nation’s gross domestic product (GDP). An estimated 40 percent of the health system budget is allocated to the public sector and 60 percent is to the private sector.

South Africa has a population of 56 million people. About 41 million are uninsured and utilize the public sector facilities; the remaining 15 million are cared for in the private sector.

Orthopaedic services in the private sector are among the best in the world. Practically all the recent advances in orthopaedic management are available in the private sector facilities in the main cities. However, orthopaedic services in the public sector are significantly compromised by the low number of orthopaedic surgeons serving in that sector and the relatively low healthcare budget available to serve 75 percent of the population. The South African government is introducing a new financing mechanism—national health insurance—aimed at improving access to health care for all South Africans.

The government has also embarked on a revitalization program to improve facilities in the public sector. Management of these facilities remains a challenge, but teaching hospitals do provide reasonable quality orthopaedic services.

Human resources are the most critical components in the delivery of health services. From 1996 to 2008, the number of health professionals remained level, but the number of specialists declined. Since 2008, growth has been slow, primarily resulting from a 25 percent attrition rate due to emigration and a 6 percent loss due to death, retirement, and change in profession.

The training of medical doctors and specialists, including orthopaedists, is performed by nationally funded universities and accredited public hospitals. Currently, eight national universities are accredited to train medical professionals. The training of medical students has been stagnant over the past 15 years, and the training of specialists has actually declined due to unfilled accredited training posts.

There is inequity in the density of health professionals per 10,000 population between rural and urban areas and between public and private areas. Many doctors—including orthopaedic surgeons—opt to work in the private sector for a variety of reasons. To address this inequity, the South African government is attempting to recruit foreign-trained health professionals to work in the public sector and rural areas.

Orthopaedic surgeons
South Africa has about 700 orthopaedic surgeons; most also received their training here. Orthopaedic surgeons are primarily in private practice and in major cities. There are about 146 trainees in programs, and about 29 of them graduate each year. With some annual increase in the number of trainees, it will take at least 14 years to meet the target orthopaedic surgeon/population ratio of 0.16 per 1,000. That is why it is important to look at the training.

Training institutions
Orthopaedic training in South Africa is done at universities. Seven universities are fully accredited and one is accredited for only the first 2 years of training. The South African Health Professional Board accredits universities every 5 years. The ratio between academic staff and trainees should be 1:3 for the university to receive accreditation.

In addition, the accreditation committee reviews the number of outpatients, inpatients, case profiles, and operating theatre availability. The biggest challenge faced by universities is attracting orthopaedic surgeons to academic positions. The workload, number of students, and remuneration are not attractive when compared to the private sector.

Training programs
The training program is 4 to 5 years long. Each university has its own training program; each training program has three parts.

The primaries—Anatomy, physiology, and some basic pathology are learned during this first part of training, which is largely self-taught. The trainees take a multiple-choice question examination developed by the South African Colleges of Medicine (SACM), the accredited examination body for the Health Professions Council of South Africa, to graduate to the next level.

The intermediate—In this phase, trainees are expected to learn the general principles of surgical care of the patients, including preoperative assessment, intra-operative care, and postoperative care, with a good knowledge of postoperative complications.

They are also expected to focus on orthopaedics, including the management of bone and joint trauma, biomechanics of the musculoskeletal system, implants, biomaterials, prosthetics, and orthotics. Orthopaedic pathology will include infections (acute and chronic) and bone and soft-tissue tumours (benign and malignant).

To qualify to sit for examinations, the candidate must spend 18 months in an accredited teaching hospital, including a minimum of 3 months in an intensive care unit and a minimum of 6 months in a surgical trauma unit.

Orthopaedics—In this section, cognitive and technical competency is acquired in all orthopaedic conditions. The trainees have 4- to 6-month rotations in trauma, pediatric orthopaedics, hand surgery, spine surgery, arthroplasty, and other elective specialties such as foot and ankle, sports medicine, tumours, and sepsis.

This training phase is an apprenticeship, in which trainees are teamed with a consultant who is expected to them. Trainees can take their final examinations if they have spent a minimum of 3 years through these rotations. The examinations involve written papers, clinical cases, and oral examinations.

To register as a specialist orthopaedic surgeon, the trainee must also prove competency in research. Candidates are expected to have published at least one article or compiled a master’s dissertation with the university.

Challenges
Because each university has different admission criteria and different training strengths, exposure to orthopaedic training varies throughout the country. In some universities, trauma can account for up to 65 percent of the orthopaedic work, limiting the trainees’ access to elective procedures.

Another challenge is dealing with unqualified or unsatisfactory trainees. As value for services becomes more important, an aspect of professionalism needs to be incorporated into the curriculum.

The assessment of competency in the final examination is also challenging. The pass rate averages 60 percent. A more objective method of assessing competency needs to be explored and introduced. It is difficult to assess the surgical skills in the SACM examinations. It is only the head of the department of a particular university who would have some idea of the safety of the candidate in theatre. The use of log books has not been helpful in making that judgment.

Finally, attracting qualified academic staff remains a challenge. Universities attempt to address this by asking colleagues in the private sector to conduct sessions at teaching hospitals, but few are willing to do so.

Prof. Mkhululi Lukhele is the president of the South African Orthopaedic Association.

Editor’s Note: This is the first in a series of articles by the presidents of orthopaedic associations from around the world. Each article will cover an issue relevant to that country or organization that is also of interest to U.S. orthopaedic surgeons.