South Africa is facing a severe shortage of intensive-care unit (ICU) beds compared to global benchmarks. While countries like Germany average 39 ICU beds per 100 000 people, South Africa has about five at best, according to pre-COVID-19 data. In some provinces, the figure is closer to one.

Professor Fathima Paruk, Head of the Department of Critical Care Services and Emergency Medicine at the University of Pretoria’s (UP) Faculty of Health Sciences, recently highlighted these alarming statistics during her inaugural address, titled ‘Carpe Diem: Achieving efficient and fair allocation of critical care across South Africa’. She said the shortage of ICU beds in the country is a complex challenge.

“Hospitals are going to need more and more ICU beds because patients are living longer. ICU can save lives, and when patients live longer, they have more co-morbidities, so they end up getting sick more often.”

Advances in medicine and a shift to out-patient and home-based care have reduced the need for long hospital stays. Paradoxically, these dynamics have increased the demand for high-level, short-term critical care, Prof Paruk explained.

“In the private sector, you can literally create an ICU bed. In the public sector, you have x number of beds and that’s it.”

Geographic disparities, she explained, further complicate access.

“If you’re in Cape Town, you’re much better off than in Limpopo.”

Structural shortages and workforce constraints

Prof Paruk said the limited number of beds is just one part of the problem.

“You can’t run an ICU bed without nurses and doctors who are trained in critical care, and we are extremely short on them in both the public and private sectors. Across the country, only 25% of our ICU nurses are trained in critical care.”

In South Africa, a critically ill patient requires care from a specialist who has additional training in critical care – these practitioners are known as intensivists or critical-care subspecialists. Their oversight is associated with shorter ICU stays and better patient outcomes. There are fewer than 100 in the country, according to Prof Paruk. As a result, many ICU patients, especially in the private sector, are managed by general specialists. She attributes these shortages mainly to a lack of training posts.

Prof Paruk highlighted the role of the Critical Care Society triage guidelines to help staff during times of limited access. Using an ethical framework that is grounded in fairness and transparency, the guidelines outline how to prioritise critical-care patients based on their likelihood of survival. This ensures the efficient utilisation of resources.

Another aspect of critical care that Prof Paruk highlighted was end-of-life decision-making. Her research in this domain explores the various approaches to end-of-life care and end-of-life decision-making, and takes into consideration several factors such as personal requests, and religious and cultural sensitivities.

During her address, Prof Paruk also touched on the changes that COVID-19 had brought about.

“COVID-19 caused a huge disruption in the healthcare sector and beyond, but it also brought a lot of good, including opportunities,” she said. “It showed us that we can pivot, adapt and respond. We did a remarkable job. We responded with much-needed guidelines and did research both in South Africa and across the African continent, showing that despite the increased workload, we were capable not only of treating our patients but also of responding to the needs of society collaboratively.” 

Prof Paruk explained how she employed telemedicine support for Steve Biko Academic Hospital and UP during the pandemic, using it for additional insights at a time of great uncertainty as well as for proof of concept. She described how a robot, Stevie, enabled collaboration between UP’s Department of Critical Care Services and Emergency Medicine and the telemedicine hub at Charité University in Berlin, Germany.

Prof Paruk pointed out that telemedicine can play a significant role in addressing gaps in critical care in South Africa, and is one of the most promising solutions for extending access to critical care in the public and private sectors.

“With telemedicine, you can help stabilise patients,” she said. “You can even help with a procedure. We can ultimately uplift the level of care to our community.”

Acting now to shape the future

Looking ahead, Prof Paruk is part of the steering committee for a new national ICU audit, led by the Critical Care Society of Southern Africa.

“The last audit was conducted about 15 years ago, and a great deal has changed since then,” she said. “There was a lot of generosity during COVID-19. Equipment was given, beds were created, people were trained. We want to see how this has changed things for patients.”

The audit will collect data from all public and private hospitals regarding available resources, including information about the number of ICU beds, staffing levels and equipment. The goal is to inform future planning – particularly as the country moves toward implementing the National Health Insurance – and to lay the foundation for a live dashboard that can help monitor and manage ICU capacity in real time.

“I’ve covered the strengths and the gaps in critical care in South Africa, but the message I want to leave you with is that there is hope for a better future and it lies in our hands,” Prof Paruk said as she concluded her address. “The future is now, and is ours to shape.”