South Africa appears to be woefully underprepared for a serious escalation in Covid-19 cases, with roughly 3 000 out of about 7 000 critical care beds available between the public and private healthcare sectors, according to best estimates.
On Thursday, News24 reported approximate projections used by the government indicated 80% of Covid-19 infections would be mild, while 15 to 20% might require hospital admissions. About 5% would require critical care.
According to those projections, a slow response to the Covid-19 outbreak could result in anywhere between 87 900 and 351 000 deaths that could cause the health system to be completely overwhelmed.
It also estimates that at an infection rate of 10%, more than 100 000 people will require a form of hospitalisation at some stage and at a 20% rate, more than 500 000 would need hospitalisation.
This according to epidemiological projections prepared for the Department of Health and government which was seen by News24.
From the data, included in a presentation shown to the government, however, it is not clear what the time frames are for infections, deaths or spread are. It does, however, provide a snapshot of data at a specific point in time on which the government is reliant in its response to the virus.
Alex van den Heever, a professor of social security and management studies at the Wits School of Governance, said one of the health system’s vulnerabilities was its number of critical care beds.
He added, based on figures from around 2013, there were 4 957 critical care beds in the private sector and 2 238 in the public healthcare sector. Occupancy in state hospitals is around 80%, with about 50% of critical care beds available for use in private hospitals.
Based on these figures, less than 3 000 critical care beds are theoretically available for use.
Van den Heever said about half of that – 1 500 – were intensive care beds which were necessary if a patient needed to be on a ventilator fulltime.
A healthcare system under pressure
A general picture of unpreparedness emerges when considering the state of the whole healthcare system. And its public counterpart is already under significant strain.
Research by the South African Human Systems Trust (HST) suggests that there are about 18 hospital beds per 10 000 people in South Africa. And according to the HST’s 2018/19 district health barometer, there were about 32 medical practitioners in the public sector per 100 000 uninsured people, or people without medical aid.
There are about 144 professional nurses in the public sector per 100 000 uninsured people
At issue is not just the number of beds, but the number of critical care beds. In serious cases, Covid-19 patients would need assisted breathing equipment, oxygen or ventilators. Ventilators-per-bed are typically only available in intensive care units (ICUs).
The private sector has under a third of the total hospital beds in the country, and more critical care beds available than the public sector.
Co-operation between the two sectors would be crucial if the 3 000 critical care beds were to be made available. Yet while talks between the two sectors have been ongoing, it is not clear whether the private sector has been asked to make these beds available specifically, and whether people without medical aid will have access to them.
So far, the country has seen just a handful of hospitalisations and 150 cases as of Thursday afternoon, although the rate of infection has increased exponentially in the last week.
But experts said the country’s healthcare systems could only handle a mild escalation in Covid-19 cases, and nothing more. The public sector could not survive anything beyond a small escalation, and the two sectors would have to pool beds in a high-escalation scenario.
Co-operation between the public and private healthcare sector
It is not clear whether detailed expectations have been put on the table for future resource-sharing scenarios.
The spokesperson for the Hospitals Association of South Africa, Mark Peach, said it was difficult to plan for different scenarios with the rate of infection being a moving target.
“We don’t know what kind of load there’s going to be; we don’t know how many people will need to be admitted.”
He said the hospitals had not yet discussed the issue at a per-bed and per-ventilator level, and the priority right now was for the public to practice social distancing and avoid overburdening the system by requesting tests unnecessarily.
A public healthcare academic and expert who spoke to News24 anonymously said the National Institute for Communicable Diseases (NICD) had done a brilliant job so far, and healthcare professionals had been trained and put on alert for the crisis at hand.
And from a clinical point of view, the nation’s healthcare professionals, both public and private, were excellent, she said.
But from a resource point of view, the country would not be able to handle anything beyond a mild escalation in Covid-19 hospitalisations, she added.
According to Van den Heever, there was currently an oversupply of critical care beds in the private sector and an undersupply in the public sector. Getting through a significant escalation in cases would require the public and private sectors to pool their resources.
And even then, he said, the country would probably only cope with a mild outbreak, whereas the public healthcare system alone would be overwhelmed by even a small one.
Critical care includes ICUs and high care. Van den Heever added it was not clear how many ICU beds were available but he estimated it was about half the number of critical care beds.
Research by economic advisory firm Econex indicates about 35% of all hospitals are in the private sector, and 28% in the public sector. The private sector, therefore, has far fewer beds in general than the public sector but many more available critical care ones.
General wards will also be necessary in the event of a mass escalation in Covid-19 admissions, so an “every bed counts” situation is likely.
A public health expert said this would probably see a temporary halt of elective surgical procedures to free up space for Covid-19 cases, although few of these actually happen in the public sector as it is, as surgeons are too occupied by emergencies.
Netcare, Mediclinic and Life
News24 asked Netcare, Life Healthcare and Mediclinic for details about their bed availability and what would happen should the public sector run out of beds.
Netcare’s director of strategy and public healthcare policy, Melanie da Costa, said the group had about 1 200 ICU beds, about 12% of its total beds. She added the occupancy levels of ICU beds in the industry was high.
Asked whether the group would make resources available to the public healthcare sector should the need arise and whether Netcare had been approached by the government about this, Da Costa said: “Netcare is working closely with the government, [the NICD and the Department of Health], and the finance sector [Business Unity SA] on Covid-19.
“At this stage, there have been only a few hospital admissions and we have begun transferring patients on medical aid from public facilities to private hospitals.”
Mediclinic South Africa said it could not disclose information about their bed availability.
It added it had actively engaged in cross-sector discussions around the provision of care for South Africans in this situation. “At this stage, we continue to operate in our existing capacity. This stance will be reviewed regularly in industry forums as the Covid-19 situation evolves.”
Life Healthcare did not answer specific questions about its critical care capacity and whether it will make resources available to the Department of Health, and at what rates.
In a statement, Dr Charl van Loggerenberg, the general manager of emergency medicine, said: “We continue to work closely with the National Institute of Communicable Diseases (NICD) and have put in place a number of measures to support our current infection prevention and risk protocols for suspected and positive Covid-19 cases.
“As it is standard practice in every medical environment, patient confidentiality remains a high priority.
“All relevant hospital staff, including emergency units, have been briefed and trained according to NICD and World Health Organisation guidelines and are prepared to manage suspected and positive cases of the virus within specified protocols.”