The introduction of a system such as the National Health Insurance is borne of the intention to create and promote equitable and accessible health care. Health-care delivery within the South African context echoes the economic divide in the country, where access to private health service is primarily by the skilled, educated and affluent sector of the population, leaving the poor marginalized.(1) Solid organ transplantation requires an extensive skill set as well as intense human, financial and institutional resources. As a consequence, transplantation centres in South Africa are restricted to a few centres of excellence. With regards to liver transplantation, there are only two transplant centres in the South Africa; Wits Donald Gordon Medical Centre (WDGMC), a private academic hospital in Johannesburg, and the other, a public sector unit in Cape Town.(2)
The inequalities in transplantation rates between the insured and uninsured patients as well as between urban and rural patients in South Africa have been labelled an ‘indictment on distributive justice in the country’.(3) Thus an innovative novel model, which prioritized financial efficiency, accessibility and equity, was needed to address the iniquities in transplantation. One model that attempts to address social disparity is the private–public partnership (PPP), which describes an agreement between a public sector enterprise and a privately funded party whereby one party undertakes to perform a function and bear the financial, technical and operational risks of a project at hand for a common social goal. The integrity of the PPP is maintained through emphasis on a fair exchange of resources and skills, and with a clear understanding that it is not a simple outsourcing of function by the public sector nor commercialisation of a public function.(5)
The PPP in the health sector may broadly exist in one of three ways:
‘Infrastructure-based model – to build or refurbish public health-care infrastructure
Discrete Clinical Services Model – to add or expand service delivery
Integrated PPP model – to provide a comprehensive package of infrastructure and services’ (4)
The gold standard therapy for liver failure worldwide is liver transplantation, and currently within the sub-Saharan region, this remains inaccessible to millions of people.(2,5) There are limited studies that have assessed the value of a PPP model for liver transplantation. Following the initiation of a PPP, a study in Tamil Nadu in India found an increase in deceased donor rate from 0.1 to 1.1 per million population.(6) Similarly, the Sindh Institute of Urology and Transplantation in Pakistan has demonstrated a sustainable approach to renal replacement therapy and transplantation using a PPP, which has been sustained for 25 years.(7) The key principles of PPP in optimum health-care delivery are transparency, shared risk, accountability, autonomy between partners and aligned objectives.
The Wits transplant program echoes the PPP model described above. The University of Witwatersrand Medical Faculty, WDGMC and the Gauteng Department of Health are the key stakeholders with Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) as the main referral centre for public patients. The WDGMC PPP for liver transplantation was established in 2008 and makes use of a single patient transplant listing protocol in which patients are prioritized according to clinical and laboratory criteria using the model for end-stage liver disease score as opposed to affordability. The indications and criteria for listing on the transplant list are standardized in both private and public sectors. The Gauteng Department of Health is billed a set global fee which covers all the consumables and medication cost with WDGMC covering the remaining costs, which is estimated at approximately 70% of the total cost of liver transplantation.(5) Blood products required for transplantation are provided by the public sector, and the WDGMC Radiology Department offers pro bono services for advanced interventional radiology procedures using public sector funded consumable items when needed. The PPP Wits transplant program performed the first liver transplant for a public patient in 2006 on a young female patient with Wilson's disease and who currently is still alive and well.
Since 2014, more than 90 paediatric transplants on state sector patients have been performed with referrals from public centres across South Africa, including patients from rural centres. Also there are an increasing number of state sector patients being offered living related donor transplantation. Of note the program at WDGMC has now been expanded to improve outcomes in the acute liver failure patients in the paediatric population. Paediatric patients from all over South Africa are now directly referred to WDGMC, including those from the Cape Town Transplant Centre as the WDGMC Transplant Centre is the only centre in Southern Africa performing living related liver transplantation.
Public sector patients are generally worked up by the state hospital and transferred to WDGMC for the transplantation procedure. Thereafter, they remain at WDGMC intensive care unit until being fit to be transferred back to CMJAH for continued care. Following this, patients are then referred to the nearest hospital with specialist physician care. All post-transplant interventions and medications are identical between public and private hospitals. However, interventional radiology remains a challenge in the public sector. The long-term outcomes of the state sector patients who have received liver transplantation as a result of the PPP and who are being followed up in the public sector are similar to those patients in the private sector. National referrals have resulted in engaging other centres to encourage post-transplant care and ongoing support. Furthermore, direct admissions for any emergencies to WDGMC and or CMJAH have improved outcomes. Currently the majority of liver transplants being performed on public sector patients are at the Wits transplant unit with referrals even coming from the Cape Town unit.
All paediatric patients in the public sector with fulminant liver failure are now referred directly to WDGMC from anywhere in South Africa, and this has increased the opportunity for living related donor transplants to be conducted within 36 h. The donors are worked up at WDGMC within 24 h. This protocol has resulted in an increase in survival of these patients for a disease process which has a greater than 75% mortality in the absence of appropriate liver specialist intensive care or transplantation.
Of some concern is the low number of adult public sector liver transplants compromising only about 10%–15% of the total number of adult patients who have undergone liver transplantation. Combining the adult and paediatric liver transplantation numbers, the proportion of state sector patients receiving liver transplants is 30%. Challenges with adequate work-up of patients requiring liver transplantation in the state hospital are one of the major limitations to transplantation.(2) To improve access of public sector patients to transplantation, another model for improving work-up in the state sector needs to evolve.
The organ donor foundation estimates that 4300 South Africans are awaiting life-saving transplantation.(8) A third transplant centre in South Africa, built on the principles of a PPP where the public sector is able to work up patients and execute transplantation with the acquired skills and support of the private sector, will be hugely beneficial in bridging this gap. It is imperative that all transplant units publish their data on numbers and outcomes and this will allow quality assurance and accreditation of transplant units irrespective of being a private or public transplant unit. A national registry for all solid organ transplants will assist in public reassurance and transparency in this scarce national resource.
Solid organ transplantation worldwide faces several challenges and limitations both in procurement and service delivery. It is a unique component of health care that requires extensive multidisciplinary collaboration and commitment. Adopting a PPP approach allows for greater access to resources in all facets. The current WDGMC and Gauteng Health Department PPP model can serve as a blueprint for future collaborations of expert mutualism which ultimately prioritizes the commitment to equal, efficient and accessible health care for all within a framework that integrates the public and private health ecosystems with minimal compromise to service delivery.