Most patients do not receive important pain treatment during and after surgery, reports GroundUp, with a recent local study – published in Lancet Africa – providing disturbing insight into how acute pain is managed in South African hospitals.
The authors describe pain as being divided into two broad types: acute and chronic. Acute pain is short and intense, the type you would experience after surgery. Chronic pain lasts more than three to six months, sometimes longer, after an initial injury has healed. This study looked at acute pain.
The researchers considered data from more than 3 500 patients across five surgical disciplines at 10 hospitals. They wanted to know how widely four important aspects of acute pain management were implemented. These are:
• Patients are educated on how to manage their pain.
• Patients receive pain relief for the area around their wound, in addition to the main operation.
• Patients receive pain relief medications during and after the operation.
• Pain is assessed in patients after their operations.
The researchers first used patient records taken from September 2021 to April 2022 to estimate how widely the above bundle of care was implemented. Only 9% of patients received all four interventions.
“It’s the first time that we’ve got big data showing that acute pain is a real problem in this population, and we’re doing a pretty shitty job of dealing with it,” said lead author Professor Romy Parker, director of the Pain Management Unit at the University of Cape Town.
“The good news is that it doesn’t take rocket science or millions of rands to make a difference. It just takes paying attention.”
Researchers at the hospitals from which the data were obtained first met in June 2022. Everyone agreed to implement the four-element bundle. Patients would be given education and receive at least a combination of paracetamol (commonly branded as Panado) and non-steroidal anti-inflammatories (like ibuprofen).
“We found that with these relatively simple things you can make quite a big difference to people’s pain management. Patients’ pain reduced from being moderate, the kind of pain that interferes with your movement, mood and cognition, to mild, the kind of pain which is a bit annoying but doesn’t stop you from doing all the things you need to and want to do,” Parker said.
The researchers then evaluated data taken from January to April 2023.
Care improved a bit: 39% of patients received all four interventions.
Parker said the gold standard in quality improvement studies is to get 80% adherence to the changes.
“We fell way short of that, mostly because getting people to change their behaviour is hard. We think it is promising, though, because the improvement was achieved in just three months, with no resources at all.
“No extra funding, no dedicated training time, no system changes, just teamwork. Imagine what we could do with a structured and supported approach – management support, funding for training and implementation and staff dedicated to supporting the behaviour change,” she pointed out.
Managing acute pain reduces health system load
“Acute pain on its own is a fairly straightforward problem, which typically fades as the injury heals,” said Associate Professor Sean Chetty, a senior author on the paper and head of the Department of Anaesthesiology and Critical Care at Stellenbosch University’s Faculty of Medicine and Health Sciences.
“The problem comes when acute pain is not properly managed. When this happens, acute pain can transition into chronic pain, which is a much more invidious thing. Chronic pain destroys lives, and even impacts the state in the form of increased disability grants and so on.
“If we can approve the management of acute peri-operative pain, we can potentially lessen our burden of chronic pain.”
Study details
Evaluating a perioperative pain management bundle in South Africa: a registry-based quality improvement study
Romy Parker, Philipp Baumbach, Sean Chetty et al.
Published in Lancet Africa in March 2026
Summary
Background
The Lancet Commission on Global Surgery urges expanding surgical services to promote equity. Yet postoperative pain, a core feature of surgical care, remains inadequately managed in many settings, particularly in low- and middle-income countries (LMICs). Consequently, if pain management programmes do not develop alongside surgical expansion, the result may be avoidable suffering, increased morbidity, and mortality. This study evaluated the implementation of a four-element perioperative pain management bundle and examined its association with patient-reported outcomes.
Methods
An observational pre-post study in ten South African hospitals using the PAIN OUT methodology, a standardised approach to capturing postoperative patient-reported outcomes. The ‘Perioperative Pain Management’ bundle had four evidence-based interventions designed for flexible local adaption. We assessed bundle implementation and explored associations between number of elements received and a multidimensional composite pain score (CPS).
Findings
Data from 3522 patients across five surgical disciplines showed significant bundle implementation. Patients receiving all elements had significantly better CPS than those receiving none/one/two/three elements (small-to-medium effect size). Regression analysis (n = 1880) identified patient education as the most effective element for improving CPS.
Interpretation
The bundle approach may help close a critical gap in Global Surgery by demonstrating that context-adapted perioperative pain management bundles can be feasibly implemented in diverse South African hospitals and improve patient-reported outcomes. Diverse clinical disciplines successfully implemented the bundle, enhancing perioperative care. By aligning with international guidelines and emphasising patient engagement, it supports a shift toward holistic, patient-centred surgical care in LMICs. As surgical access expands, pain must become visible, measurable, and manageable through scalable, interdisciplinary strategies.
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