A public-private collaboration is being used in two KwaZulu-Natal hospitals to cut costs and time for surgeries. Those involved say it has proved highly effective in slashing years off waiting lists and relieving patients’ suffering and could be followed countrywide.
As is often the case with health-care innovation in South Africa, a doctor has used his struggles in the state sector to engineer a nimble way to unlock efficiencies of scale and halve the costs of knee and hip surgeries — and even other procedures.
Waiting lists for orthopaedic surgery at the Inkosi Albert Luthuli Central Hospital in Durban’s Cato Manor are between two-and-a-half and three years, with surgical lists running at 40% below capacity, according to senior surgeons working there. As one of a small number of central hospitals in South Africa, the tertiary hospital provides specialist services unavailable elsewhere in KZN and serves as a hub to train health workers.
Freezing posts for specialists and registrars in state hospitals has led to understaffed ICUs, too few doctors, shortages of surgical consumables and delays in diagnostic tests that health workers say are costing lives and aggravating patient conditions. Situations like the one at the Albert Luthuli Hospital are happening across the country.
Now a new surgery partnership in Durban is using beds and theatres at the private Busamed Hospital in Hillcrest over weekends for Albert Luthuli patients.
Orthopaedic surgeon Michiel Ter Haar, who qualified as a game ranger and then followed his father and brother into medicine, worked at Albert Luthuli as a specialist hip and knee surgeon before going into private practice in 2020.
When he began working at Albert Luthuli in 2012, the orthopaedic surgery waiting list was five to six months. It has deteriorated since then, but Ter Haar saw the potential for public-private collaboration between state and private hospitals. The demand for theatre time across all disciplines at Albert Luthuli over the past 14 years has resulted in six orthopaedic theatre lists per week being reduced to just one or two per week.
In the past 14 months, eight anaesthetists have resigned from Albert Luthuli, some citing burnout. There is a shortage of ICU and theatre nurses and only one cardiologist.
“This public-private partnership intervention goes a long way to helping out,” says Ter Haar, who dispatches a Busamed patient transport to collect two surgical patients from Albert Luthuli on a Friday morning. He and a Luthuli colleague operate on the advanced arthritic knees or hips at Busamed Hospital the same morning. After operations patients are kept in the private hospital, seen by an orthopaedic surgeon and receive daily physiotherapy until discharge, usually after day two or three.
After being discharged from the private hospital, patients go to Albert Luthuli two weeks later for routine outpatient consultations. The model uses available theatre time in the private sector at vastly reduced costs.
A global arthroplasty fee to get a joint replacement done in the private sector is R165,000 per person. Our entire project costs R58,000 per patient. That’s a reduction of about 65%
— Michiel Ter Haar, orthopaedic surgeon
Busamed doctors and physiotherapists taking part in the collaboration take a 65% cut in fees, and the KZN health department supplies the implants. Ter Haar’s company, Arthroplasty Solutions, foots the health-worker bills and pays for the theatre consumables.
The final cost comparison is dramatic.
A global arthroplasty fee to get a joint replacement done in the private sector is R165,000 per person, he says. “Our entire project costs R58,000 per patient. That’s a reduction of about 65%. There’s no capital layout; we use the existing infrastructure and facilities, no overheads — and management is done pro bono. Plus the profit margin is extremely low,” says Ter Haar.
“There are many other health-care projects in the country that are done for free. But to have a sustainable model one has to pay the people involved, even if it is at a reduced rate. This is what sets this unique model apart from all other health-care models,” he says.
Ter Haar and his colleagues have done 102 joint replacements in 13 months in what he sees as a three-phase project.
The first completed phase was to create a well-functioning model and show that the public-private partnership works. The second will be a rollout in other provinces, probably the Western Cape in January. Phase three will create a waiting list fund, spreading to other surgical disciplines and encouraging business, medical aids, hospital groups and pharmaceutical companies to back it.
“The big difference is private hospitals function so much better,” Ter Haar says.
The project has caught the attention of national director-general of health Sandile Buthelezi, who has met Ter Haar and intends to meet with Le Roux Viljoen, a Cape Town-based colleague of Ter Haar. Viljoen’s company, The Surgical Assistant, uses an app to supply vetted and qualified surgical assistants to private surgeons while using a corporate-funded NGO to help train registrars in the public sector.
Viljoen won third place in the SA Breweries social entrepreneur of the year awards last month.
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