OPINION PIECE

 

Surgeons for little lives: The success story of a public-private collaboration

 

 

Juan Scribante^{I, II}; Andew Grieve^{I, II}; Derek Harrison'^I; Sonya Leslie^I; Mpumulelo Mbangwa^I; Nirav Patel^{I, II}; Anthony Smith^I; Adelle Wapnick^I; Ansie Welthagen^I; Chris Westgarth-Taylor^I; Jerome Loveland^{I, II, III}

^ISurgeons for Little Lives, Johannesburg, South Africa
^IIDepartment of Paediatric Surgery, School of Clinical Medicine, Faculty of Health Sciences, Johannesburg, South Africa
^IIIDepartment of Transplant Surgery, School of Clinical Medicine, Faculty of Health Sciences, Johannesburg, South Africa

Correspondence

 

 

INTRODUCTION

The 2015 United Nations Sustainable Development Goals have placed a renewed focus internationally on universal health coverage and quality health care.(1) In South Africa, the National Health Insurance (NHI) policy is planned to transform the health system to achieve universal health coverage.(2) NHI also aims to align with Section 27 of the Constitution, which proclaims the right of access to healthcare services for all.(3)

The South African healthcare system faces several challenges, including:

• Persistent and widening disparities and inequities in healthcare

• The predominance of HIV/AIDS, ageing, and the growing burden of disease

• Inadequate human resource capacity and management

• Public-private divide - disparity, fragmentation, and lack of national unity.(4)

South Africa's broader infrastructure investment gap highlights the magnitude of one of the challenges faced by the public sector. In 2022, the combined public and private investment was 14.2 per cent of GDP, well below the 30% target for 2030 set out in the National Development Plan. (5) A non-traditional approach is needed to assist in reaching the National Development Plan goals.

Resolving these challenges is complicated because the healthcare system has many interconnected parts and a complex history.(6) Aikman highlights, "When historical and present problems manifest in various parts of the system, there is synergistic damage to all of the parts. This overall damage to the system becomes very difficult to repair owing to the complexity and interrelatedness of the problems. The crisis in the healthcare system is comparable to a multifactorial medical disorder, in which each of the factors needs to be addressed to improve the overall health of the system."(6) There is no single solution to the healthcare crisis; instead, a range of complex issues must be addressed to avert its collapse.

As part of the response, public-private partnerships have emerged as a pivotal strategy to enhance the healthcare system in South Africa.(7) Different types of public-private partnerships have been identified,(8) and mixed results from these partnerships have been reported.(9) An alternative, less formal interaction to consider is public-private collaboration. Private-public collaboration "is a term used where the objective is not to shift responsibility and risk from one party to another but to deliver greater shared public benefits than each sector could accomplish as an individual player."(10) In the 2025 State of the Nation address,(11) President Ramaphosa stated that "Through strategic partnerships, meaningful collaborations and innovation approaches, efficient, equitable and improved health outcomes can be achieved."

Multiple stakeholders have a social accountability to contribute to improving healthcare delivery in South Africa, including medical schools at universities. In 1995, the World Health Organization (12) defined social accountability of medical schools as "... the obligation of medical schools to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have the mandate to serve. The priority health concerns are to be identified jointly by governments, healthcare organizations, health professionals, and the public."

In this article, we highlight the successful public-private collaboration between the non-profit organisation (NPO), Surgeons for Little Lives (SFLL), the University of the Witwatersrand, and the Gauteng Department of Health, showcasing a scalable public-private collaboration model that supports national health system strengthening priorities - designed to complement, not replace, the public sector.

Surgeons for Little Lives

SFLL, a non-profit organisation, was launched in May 2015 by paediatric surgeons in the Department of Paediatric Surgery at the University of the Witwatersrand (Wits) with a commitment to improving the lives of children requiring surgery and supporting their families. SFLL is structured on pillars similar to those of the Wits Faculty of Health Science, namely clinical service, education and training, research, and community engagement. (13) Furthermore, it has a collaborative relationship with the Gauteng Department of Health.

A diverse 10-member board of directors governs SFLL, comprising paediatric surgeons involved in care at a service level and external non-medical members.

SFLL supports the three Wits paediatric surgery clinical training platforms, but predominantly the Chris Hani Baragwanath Academic Hospital (CHBAH) site. To date, SFLL has raised in excess of R160 million, which has been spent on ensuring improved patient experience and outcomes. A summary of the various infrastructure, service delivery, training, and education of healthcare professionals, outreach projects, and initiatives is shown in Table 1.

 

 

Lessons learned

The challenges of implementing and sustaining a private-public collaboration, and how SFLL mitigated these challenges, are briefly discussed.

Establishing an NPO

The regulatory landscape for NPOs in South Africa can be complex and burdensome, posing challenges for registration and ongoing compliance. Registering an NPO remains a daunting task. SFLL made use of an attorney to guide and assist. It is crucial for SFLL to be registered and stay compliant by submitting annual reports and audited financial records. Non-compliance limits access to funding, limits operational capacity, and endangers the sustainability of non-governmental organizations.

Establish the leadership: The board of directors of the NPO is of utmost importance. NPOs' leadership is often criticised for consisting of international members, local elite, or members who do not truly understand the focus of the NPO. The majority of the SFLL board members are paediatric surgeons who work in the Wits department of Paediatric Surgery, where SFLL is nested. These surgeons have first-hand knowledge of the needs and a passion to deliver a high standard of paediatric surgery in a dignified manner. The non-medical members provide oversight regarding accountability, transparency, and professional guidance in areas such as financial management, marketing, and fundraising.

Establishing a constitution, goals, and objectives of any NPO requires careful deliberation. These documents not only guide the activities of the NPO but are also important when engaging with potential funders. NPOs functioning in a private-public collaboration are "filling the gaps" in the public sector and are criticised for their focus on technical solutions instead of the underlying social issues. SFLL addresses technical issues, but also has a strong emphasis on challenging injustice in the healthcare system by delivering ongoing world-class care for pediatric surgery patients and their families.

Relationship with the public sector

The lack of governmental support for specific health initiatives can impede the work of NPOs. Thus, projects sometimes require persistence and adaptability, often requiring an out-of-the-box approach. However, as paediatric surgeons at the service level determine the SFLL agenda, they usually find innovative solutions to address the identified needs.

Data management

Poor data quality and inadequate use of data for monitoring and evaluation can hinder NPOs' efforts to assess the impact of programs and improve service delivery. Thus, SFLL has recognised the importance of research in guiding the functioning and expansion of its activities. It has actively worked toward creating a culture of research and employs a Director of Research within the department of Paediatric Surgery. This focus has contributed to significant publications, often changing clinical practice for the better.

Infrastructure Development

Healthcare infrastructure is frequently commissioned by bureaucrats who have no or limited insight into the healthcare needs. Also, healthcare infrastructure projects often lack transparency, accountability, and a long-term maintenance plan.

On the other hand, SFLL can identify the infrastructure needs, but lacks the required design and building expertise. To this end, SFLL has established a close working relationship with the Mediclinic Hospital Group, which is an expert in the design and construction of healthcare facilities. With the assistance of the Mediclinic Hospital Group and its rigorous tender processes, reputable architects and medical industry contractors were identified and contracted to undertake the projects reliably, sustainably, often using trade and artisans from the local community in these projects. It is important to note that when engaging with the Gauteng Department of Health on these projects, SFLL always managed tender and procurement processes to ensure transparency and accountability. All capital building planning was "spade-ready" before funders were approached for funding. Although the responsibility for maintaining these projects lies with the Gauteng Department of Health, SFLL has a maintenance budget to ensure the operational sustainability of these projects.

Over and above contributing to improved and holistic patient care, these infrastructure projects have provided the multidisciplinary medical staff with a professional environment, one that they are particularly proud of. In addition to improving staff morale, creating such work environments contributes to the retention and attraction of high-calibre, dedicated staff.

Funders

Many NPOs rely heavily on a small number of major funders, which can lead to funder fatigue and create significant risk if this revenue stream is lost. This dependency may also create an unequal power dynamic, where NPOs shift their mandates to align with donor priorities, becoming more accountable to funders than to the communities they serve. As a result, a substantial portion of resources is often directed toward fundraising, with NPO leadership frequently exclusively focused on maintaining donor relationships and seeking additional funding sources.

Countering this, SFLL benefits from a large and diverse pool of both traditional and non-traditional funders. Its strong credibility has positioned it such that funders often seek out SFLL, rather than the reverse. When appropriate, funders are approached with research-backed data demonstrating the need for a particular initiative. By conducting targeted fundraising for specific projects, SFLL maintains absolute control over its mandate.

Sustainability

The sustainability of any NPO remains a universal challenge. Strict adherence to SFLL's mandate and Memorandum of Incorporation, in conjunction with tight financial oversight, accountability, and transparency, has ensured sustained growth over the last 10 years. Coupled with a sound investment policy and a robust board, SFLL has been well-positioned as a sustainable entity for the foreseeable future.

 

CONCLUSION

The story of Surgeons for Little Lives is a powerful example of how strategic public-private collaboration can transform health care in South Africa. Through its sustained partnership with the Gauteng Department of Health and the University of the Witwatersrand, SFLL has helped fill critical gaps in the public health system through targeted fundraising efforts, commitment to sustainable infrastructure, education, research, and service delivery. Its success lies not in replacing public responsibility but in complementing it, mobilising resources, enhancing care, and building capacity where it is most needed. As SFLL enters its second decade, it stands as a replicable model for impactful, community-rooted health innovation across the continent.

 

ACKNOWLEDGEMENTS

The authors would like to acknowledge and thank the patients and their caregivers, Wits University, the Gauteng Health Department, and our past and present board members for providing the leadership that turned the concept into reality. But, most importantly, we acknowledge every person, family, and institution whose generosity has enabled us to impact the lives of our vulnerable patients. We salute you all.

 

REFERENCES

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Correspondence:
Jerome.loveland@wits.ac.za