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EF: Could you elaborate on your role as head of the Department of Clinical Care at the University of Pretoria and co-chair of the African telehealth collaboration?
FP: My day job comprises heading the Department of Critical Care at Steve Biko Academic Hospital and the University of Pretoria. This really entails overseeing and coordinating clinical services, training and research at both facilities. Co-chairing the Africa Telehealth collaboration (ATC)is one of the many other hats that I wear. The ATC is essentially geared to promote knowledge and resource sharing for telehealth adoption. In particular to identify approaches to telehealth access for all South Africans.
EF: What role does critical care play in South Africa, what is its status and opportunities, and how can it be improved? Is critical care handled differently in other countries?
FP: COVID-19 brought home the pivotal role that Critical Care plays in our health system as well as the deficiencies and inequalities within our system.
In the South African landscape, critical care is administered by sub-specialists, and there is a dire shortage of critical care specialists in the country. Despite our population being well over 60 million, we only have a hundred registered Critical Care sub-specialists (doctors trained in Critical Care) e in the country, a severe shortage compared to the rest of the world. Most Critical Care sub-specialists are clustered in the public sector. We also have a minuscule number of ICU beds in the public sector, which manages 83% of the South African population. These ICU beds are mainly in the area in the Western Cape, Gauteng and KZN region leading to regional disparities We only have between one and five beds for every hundred thousand patients. In stark discrepancy, Germany, for example, has thirty-nine beds per hundred thousand people.
Additionally, we have a lot of regional disparities in the country; a person in the Western Cape has a much higher chance of getting an ICU bed in the public sector, five per hundred thousand, whereas, in the Northern Cape, they are lucky to get one bed per hundred thousand patients. The critical care terrain in South Africa is very uneven and disparate, and the lack of resources in the public sector plays a huge role in access to necessary care. The COVID pandemic brought to light a system under pressure; the entire nation became aware of the importance of critical care and the disparities that lie in our system, particularly if compared to the South African private sector, where the number of ICU beds is virtually unlimited whilst they only service 17% of the population. The global shortage of ICU nurses is a problem in South Africa and worldwide.
EF: Is telehealth's role advancing in the country? Can digitalization be used in critical care, and can they be easily combined?
FP: Telehealth uptake is certainly on the rise in SA as is around the globe. Because of its many benefits, I am a strong proponent of Telehealth in critical care and healthcare in general. My advocacy for digitalization Telehealth largely stems from my personal experience during the pandemic when we were under immense pressure due to the shortage of ICU beds and clinicians as well as the supportive evidence that emanates from resource-limited settings. I was fortunate to have the opportunity to collaborate with the clinicians at the telehealth hub at Charité University. In periods of adversity, much can be achieved in a short space of time; within five or six weeks of our first conversation, we were able to have on SA soil a telehealth robot, which we call Stevie, and have telemedicine clinical rounds with Charité. It was remarkable to experience first-hand the benefits of telemedicine. The support of the Charité clinicians was phenomenal; they assisted our junior doctors in managing patients and offered tutorials and as such ongoing academic education also continued during the pandemic. Tele-ICU's greatest benefits are reaped in the context of resource constraints, but it also potentially could significantly reduce critical care disparities in South Africa. We have regions that don't have intensive units or ICU beds; however, we could offer tele-ICU support to remote areas with resource constraints, for instance, we could advise how to stabilize patients until they are transferred, or if it isn't so serious, maybe guide the doctor through the required therapy or procedure. Its impact would be huge in terms of improving patient outcomes, improving our system's efficiencies, and addressing some of the apparent inequities. Tele-ICU would be beneficial to the South African health system and its population. The burden on ICUs is growing everywhere; patients are getting older and living longer, and the demand for ICUs is rising; even the global north is struggling to support surrounding feeder hospitals and regions. We need to invest in Telehealth now rather than later, as the ICU situation is saturated and will only worsen, Embracing and enabling new technologies is the way forward as we shape future healthcare delivery in SA.
EF: How can we foster public-private sector collaborations, specifically in critical care? Do you think they are possible with the current setup? How can we increase investment in the space?
FP: Collaboration and building bridges are key to achieving improvements. The private sector critical care may seem to have unlimited resources in terms of ICU beds, but it also faces the reality of having very few trained Critical Care sub-specialists. Most ICU units in private hospitals in South Africa are also “open units,”, by that I mean they are not managed or overseen by a Critical Care sub-specialist or even a general specialist. Having an intensivist in the ICU not only improves patient outcomes and reduces adverse events but also improves cost efficiencies and impacts the overall outcomes of the patients. A public-private collaboration (PPC), where ICU subspecialists could support their private colleagues with telemedicine is a simple mechanism to help uplift the private sector's critical care. The telemedicine infrastructure in public hospitals could be utilised to support feeder public hospitals. Such a PPC would benefit both sectors. Ultimately, we want to improve patient outcomes in both sectors.
EF: You actively promote women's roles in South Africa. What can be done to increase awareness and reduce disparities in women's roles in the healthcare space in South Africa?
FP: It would be fair to say that disparities exist in health as do they across all sectors in the country. It is not necessarily a South African or African problem but indeed a global problem. Fortunately, awareness is on the increase as more women are raising their voices and advocating women’s rights. Fundamentally there needs to be a framework and policy on how to promote awareness, generate a culture of equity and promote equity in the health space. It would be great if undergrad training curriculums could highlight gender equality, leadership training programs were made more accessible to women and regular surveys were conducted to ascertain if there were issues that needed to be addressed. Organisational culture is also important. Workspace flexibility is another area that needs to be addressed.
We also need to acknowledge that much has been done to address this problem in recent years, but more improvement is still required. Academic support and encouragement and an organizational culture permitting women to be heard, taken seriously and supported in terms of their needs is crucial. Recognition of women's unique needs and support for those needs are needed. Empowering women in all the different aspects of healthcare is important.
EF: What improvements would reduce women's disparities in the academic world or among medical professionals?
FP: Academic and hospital organisations have the power to elicit change be it through policy, availability of Mentorship programs, accessibility to leadership programs, accommodating diversity and being inclusive and transparent. Acknowledging women’s contributions, promoting women and showing support by listening and responding to their needs would go a long way.
Respect for women is a fundamental aspect. Listening and offering support are important for women to open, especially in South Africa, where we have a huge problem with gender-based violence. By respecting women, we grow their confidence and enable them to become more empowered to vocalize what they need to say. To this end, we use various platforms. The ICU provides the patient or the patient's family with the opportunity to attend meetings, we can identify issues and refer patients to the necessary areas of help. The Critical Care Society supports professionals and the public in general, educating our public and conducting educational activities that highlight the importance of gender disparity and bring it to society's attention. We also encourage men to advocate for women, a powerful tool; some men are stepping up to that call. We recently crafted a diversity policy where part of it speaks to empowering women; for example, we have a certain number of women speakers, ensuring women's voices are included in our activities. We use various strategies to raise awareness and audit ourselves to see how we perform in advocating for women. We have an open channel to address their needs while promoting education diversity and inclusion policies.
