For decades, surgical waiting lists in South Africa have largely been invisible outside individual hospitals. Patients waited, clinicians improvised and health system leaders often lacked a real-time picture of who was waiting, for what procedure and for how long.
However, Gauteng’s new Treatment Time Guarantee (TTG) programme changes that, writes a group of leading public healthcare experts.
Professor Martin Brand, Professor Thifhelimbilu Luvhengo and Dr Adiel Chikobvu write:
Early experience suggests that the value of the programme lies not only in reducing waiting times, but in revealing where surgical access is blocked and where health-system capacity is being lost.
A different way of looking at waiting lists
Every public health system has waiting lists but for the patient, waiting is never simply a delay. It may mean prolonged pain, loss of income, progression of disease or avoidable disability. What Gauteng is now implementing is different: it is turning waiting lists into a transparent management system.
The GDoH TTG platform was introduced with Nelson Mandela Day in 2025. It is the first initiative of its kind in South Africa, and one of the first attempts in a low- and middle-income public health system to apply waiting-time guarantees across a whole provincial surgical service.
Rather than leaving patients on opaque lists held separately by individual hospitals, the TTG approach defines when a patient formally enters a treatment pathway, sets a clinically meaningful time expectation, and makes delay visible to clinicians, managers and provincial administrators.
For example, a patient awaiting cataract surgery in one hospital should no longer disappear into a local paper waiting list while another patient elsewhere is fully visible to provincial oversight and receives their surgery in a timely manner.
TTGs are designed not simply to shorten waits, but to ensure that patients with similar clinical urgency are treated, regardless of where they enter the provincial health system.
Why this matters
Hidden demand leads to hidden budgets; invisible patients are invisible to planning. These ideas are simple, but their implications are substantial.
A waiting list is a passive record. A patient waits, a hospital schedules when it can, and the wider system may only see the problem when delays become extreme. A TTG changes the question from “how many people are on the list?” to “which patients require care, by when and which system constraint is preventing treatment?”
In doing so, GDoH has reframed waiting times into patient access, patient safety and health-system performance issues, rather than a purely administrative inconvenience.
The decision-to-treat starting point
The foundation of the programme is the Decision to Treat (DTT). This is the time point at which a specialist has assessed a patient, determined that a procedure is required, and committed that patient to a defined treatment pathway. Anchoring the TTG to DTT is important because it creates a common starting point for measuring delay.
Without this, different hospitals may count waiting times differently. Some may start the clock when a patient is referred, others when the patient is booked, and others, only when theatre time becomes available.
The DTT concept creates a single auditable baseline and allows hospitals to be compared equally.
Province-wide system, not a single hospital project
Gauteng is an appropriate test case for such a reform. The province is South Africa’s smallest by area but the most populous and economically active. It contains some of the largest public hospitals on the African continent and provides district, regional, tertiary and central surgical care. A reform which works in this setting must simultaneously accommodate all these services for both the competing demands of emergency and elective surgery.
What early data show
Early TTG analyses illustrate the scale of the challenge. An early provincial snapshot across all 31 public hospitals recorded 3 091 patients on registration lists, 6 419 patients booked for surgery, 24 437 completed procedures, and 3 237 cancellations.
At the same time, 529 cases were visible as TTG backlog, and almost 30 000 additional backlog cases had not yet been captured on to the TTG platform. A broader consolidation exercise identified more than 30 000 patients awaiting surgical intervention.
These numbers should not be read as a failure of the system; rather, they show what becomes visible once a province starts measuring demand in a standardised, transparent way.
Making hidden demand visible
Thus far, one of the most striking lessons is that a clean dashboard is not the same as a controlled clinical pathway. Several hospitals had little or no registration-list capture while still carrying substantial off-platform backlogs.
In practical terms, this means that some patients existed on waiting lists but were not visible to the provincial prioritisation engine.
TTGs therefore expose a crucial governance problem. A patient cannot be prioritised, escalated or protected from excessive delay if the system has not first captured them.
The first success of TTGs is therefore not immediate backlog reduction; it is the creation of truthful visibility.
From visibility to accountability
Visibility matters because it changes accountability. When demand is invisible delays can be explained vaguely as resource pressure. When demand is captured, hospitals and the province can distinguish between different reasons for delay. Some patients are waiting because theatre capacity is genuinely insufficient. Others are delayed because a booking pathway is weak, because a patient has not been prepared, because a case has been displaced by emergencies, or because a downstream ICU or high-care bed is unavailable.
These are different problems requiring different solutions. TTGs make those distinctions possible.
Capacity is more than the number of theatres
The Gauteng experience has also demonstrated that surgical capacity is not simply determined by the number of operating theatres. In another snapshot, 200 theatres were active and 71 were inactive, meaning that 26.2% of nominal theatre capacity was not functioning.
This is a powerful finding. It suggests that increasing access may not always require building new theatres. Many health systems instinctively respond to long waiting lists by requesting additional infrastructure. The GDoH TTG data suggest that substantial gains may first be achieved by improving utilisation of existing infrastructure. In other words, the fastest gains may come from activating dormant capacity, improving staffing, reducing cancellations, shortening changeover times and linking theatre planning to bed and ICU availability.
In a fiscally constrained public system this distinction matters.
Cancellations as health-system signal
The TTG programme has also changed the way surgical cancellations are understood. Traditionally, cancellations are counted as operational mishaps. Gauteng’s cancellation analyses suggest they are better understood as health-system signals. Province-wide data showed thousands of cancellations after booking, with many occurring on or immediately before the day of surgery.
Same-day cancellation is especially costly because theatre time often cannot be reallocated effectively, the patient has prepared for surgery, staff have been allocated and the backlog remains unresolved. Frequent cancellation is therefore not just an inconvenience; it is an avoidable loss of clinical opportunity.
Clinician-led reform
International experiences suggest that waiting time guarantees fail when they are perceived as external targets imposed on clinical practice. They are more likely to work when clinicians help design the urgency categories and own the prioritisation logic.
A key strength of the GDoH model is that it is not designed as a purely managerial target. TTGs require clinician involvement because the guarantee must be clinically meaningful. Clinicians define what delay is acceptable for a particular condition or procedure, while managers and provincial structures are responsible for making the pathway visible and deliverable. This clinician-manager partnership is essential.
Financial leadership story too
Although TTGs are often described as access tools, they are also financial governance tools. Gauteng’s early results reveal large numbers of cancellations, inactive theatres and hidden backlog. Each of these has financial implications. A cancelled list wastes staff time, theatre time and patient preparation.
An inactive theatre represents underused capital. Hidden backlog undermines planning and budgeting. In a province under fiscal pressure TTGs help leaders ask not only “do we need more money?” but also “are we using existing resources in the right place, at the right time, for the right patients?”
Why this matters for NHI
This is particularly relevant as South Africa moves toward National Health Insurance. Universal healthcare access cannot be delivered through financing reform alone: it also requires systems which can define need, measure access, prioritise fairly and track whether care was delivered.
TTGs provide an early provincial architecture for this. They make access measurable before, during and after broader financing reform. In that sense, Gauteng’s TTG programme may be viewed as a practical bridge between policy aspiration and operational reality.
Beyond surgery
The TTG programme is not merely monitoring. It creates a learning system. Every completed operation, cancellation or delayed case becomes information, which improves future planning.
Although the current work has focused strongly on surgery, the logic is not limited to operating theatres. A treatment time-guarantee approach could be applied to radiology, radiation oncology, medical oncology, endoscopy, rehabilitation, podiatry, and other services where patients wait for time-sensitive care. The architecture is transferable: define the point of entry, define the acceptable delay, capture exceptions, monitor completion and make delays visible.
The result is a pathway rather than a list.
What success should look like
Success should not be judged only by whether every backlog disappears immediately – in a large public health system this is unrealistic. More appropriate early indicators include improved registration completeness, fewer uncoded cancellations, better theatre activation, reduced same-day cancellations, clearer escalation of overdue cases and improved alignment between clinical urgency and available capacity.
Over time, the more important question will be whether TTGs reduce harmful delay, improve equity and help patients receive the right operation at the right level of care.
A South African first
The significance of Gauteng’s programme is that it represents a South African first. It is a deliberate attempt to make waiting time governable across a whole provincial public surgical system. It does not solve every problem by itself. It does not create surgeons, nurses, ICU beds or theatres overnight.
But it changes the information environment in which decisions are made. It exposes hidden demand, highlights underused capacity, identifies avoidable cancellations, and creates a common language for clinicians, managers and policymakers.
Health-system reform often begins not with new buildings or new policies, but with better visibility of the patients already waiting.
GDoH’s TTG programme is a digital clinical governance tool which suggests that when every patient becomes visible, every delay becomes actionable and every theatre becomes accountable, surgical access can begin to move from aspiration into a measurable reality.
In a system preparing for NHI and facing persistent resource constraints, this is a substantial and timely innovation.
Acknowledgements
The authors acknowledge the contributions of clinicians, managers, healthcare workers, academic partners and the leadership structures of the Gauteng Department of Health, in particular Hospital Services, the COO, HoD and MEC. Their support for health-system strengthening and TTG surgical service reform contributed significantly to the advancement of this initiative.
Professor Martin Brand, Surgeon at Steve Biko Academic Hospital (GP)
Professor Thifhelimbilu Luvhengo, Head of the Department of Surgery at Charlotte Maxeke Academic Hospital (GP)
Dr Adiel Chikobvu, Director of Strategic Operations, Department of Health (GP).
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