Paediatric surgeon Dr Elliot Motloung, in Mbombela, has a plan – a blueprint – to expand access to quality, equitable paediatric surgery in every province, having already established two public paediatric surgery units in Limpopo and Mpumalanga.
Motloung circles Limpopo, Mpumalanga, North West and Northern Cape on a map. Just five years ago, none of these four provinces had a single paediatric surgeon in either private or public healthcare, a 2018 study by UCT researchers showing this absence left “4.5m children in these predominantly rural areas without specialist paediatric surgical providers”.
Motloung had one question: “All those kids, what happens to them?”
Children in those provinces needing emergency surgery had to travel to hospitals mostly in Gauteng, home to the bulk of the country’s paediatric surgeons. Making arrangements to travel hundreds of kilometres with specialised paramedics can take up to 36 or even 48 hours, he told Daily Maverick.
“That’s how the deaths come about.”
Today, after leading the creation of two public paediatric surgery units in Limpopo and Mpumalanga, Motloung crosses these two provinces off the list of those without paediatric surgery care.
If no one else starts state paediatric surgery wards in the North West and Northern Cape, he said, “I know where I am going.”
From loss to ambition
Motloung’s passion for expanding access to surgery in rural South Africa is rooted in his childhood. He was raised by his grandmother, a domestic worker, in Trompsburg, a tiny rural Free State town with just one doctor.
When he was an adolescent, his grandmother developed breast cancer. Waiting with her for hours outside the doctor’s rooms on icy mornings was how he was introduced to the inequities of healthcare, seeing separate entrances for black and white patients, and how the queues for black patients grew longer while white patients who arrived later were helped first.
Accessing the cancer treatment his grandmother needed in far-away Bloemfontein was impossible.
“She died without her surgery. And I thought, I want to become a surgeon. Why are people dying without an operation? That’s where my love for surgery started.”
Motloung later lived with his uncle, who died a year afterwards of lung cancer, also without getting the quality care he needed.
‘There is no way I’m not going to become a surgeon’
Motloung held on to this dream through school in Trompsburg, where he initially had good teachers. But in grades 10 and 11, when his science and maths teachers left without being replaced, he took on the role of teaching his peers those subjects.
He soon realised that to get into medicine at university, he needed to finish Grade 12 at a better-resourced school. He had his eye on Navalsig, a boarding school in Bloemfontein.
Living with his mother, who was unemployed, he couldn’t afford school fees. But at the start of his matric year, Motloung arrived at Navalsig and persuaded the headmaster to allow him to study and board without paying fees.
“I met fantastic teachers but I was very behind.”
Through ceaseless early-morning study sessions with top-performing classmates, Motloung finished matric close to the top of his class and in the top 100 in the province.
But he had to use the same persuasiveness that got him into Navalsig to convince the University of the Free State administration to enrol him in medical courses.
“I decided to sit outside that office every day.” Eventually, the administrators relented and made an exception for him, vowing never to allow someone else to do the same.
Finding purpose
In his fourth year of medicine, Motloung inadvertently walked into the wrong operating theatre. He saw paediatric surgeon Dr Esme le Grange performing a complex operation to save a child’s life. “I realised, ‘This is it’.”
Paediatric surgery became his passion.
Years later, after finishing community service, Le Grange insisted Motloung specialise with her.
However, he found specialisation in paediatric surgery immensely taxing, and his life began to unravel as he fell into depression and lost his marriage.
“Those were the worst five years … I suddenly hated the one thing I had wanted all my life.”
So close to finishing, but having lost motivation, he took off a year. He travelled South Africa, often living out of his car. To earn an income, he occasionally assisted other surgeons.
During this time, he found direction by researching the history of black medical doctors in South Africa. He discovered how those in the late 19th and early 20th centuries were forced to train outside the country and did not receive recognition once they returned, but still provided quality healthcare to their often rural communities.
Motloung compiled this history into a manuscript, now with a publisher.
“Their stories reminded me of why I wanted to become a doctor in the first place… (they) said, ‘rural health matters’.”
Limpopo’s first paediatric surgery department
As important to Motloung as the histories of black doctors was the mentorship of Professor Nyaweleni Tshifularo, a trailblazing paediatric surgeon. He encouraged and supported Motloung through his training and gave him the impetus necessary to start carrying out his mission of expanding paediatric surgery to rural provinces.
Motloung recalls Tshifularo telling him he had a job for him: to start a paediatric surgery department at the University of Limpopo – one of the four provinces without the specialisation.
He was daunted by the prospect but says Tshifularo’s experience and support were instrumental in working through challenges.
“There was also political will from the Limpopo Department of Health to support this.”
Today, Limpopo has a fully-fledged paediatric surgery unit.
Motloung also worked with other doctors to establish a master’s programme in paediatric surgery at the University of Limpopo, and within several years, the department had “four paediatric surgeons (and) six doctors who were training… more paediatric surgeons than a unit like the University of Pretoria”.
Equitable access in Mpumalanga
With the department in Limpopo running smoothly, Motloung felt it was time to continue his mission of expanding access.
“There was no paediatric surgeon in Mpumalanga, private or public.”
So he moved to Mbombela and set up a private practice.
“I remember sitting here thinking, the kids who don’t have medical aid are still dying.”
After waiting months for approval from the provincial Department of Health, in August 2022, Motloung opened Mpumalanga’s first paediatric surgery ward at Rob Ferreira, Mbombela’s state hospital.
For more than a year, with the help of a team of passionate community service doctors and nurses, the unit has provided life-saving care to hundreds of children.
“It’s not about just providing care, it must be the current cutting-edge surgery,” said Motloung, who specialises in the innovative camera-aided minimal access surgery to reduce pain, recovery time and complications.
“If I don’t know how to do it, I go and train.”
He has received training in surgical leadership at Harvard and is currently working towards an additional master’s at Oxford.
‘Better than the NHI’
Motloung is determined that, at his unit at a public hospital, “patients will have the same state-of-the-art ward and theatre structure as any patient with medical aid”.
To meet his vision for equitable, quality healthcare at Rob Ferreira, he drew on the support of local businesses, non-profit organisations, and the community to renovate and transform a dilapidated ward into a brightly decorated, well-equipped, specialised paediatric surgery unit.
The renovations have improved the environment for nursing and medical staff, in turn, translating to better patient outcomes.
“The state spent nothing,” he said of the upgrades.
Motloung sees this experience in creating the first public paediatric surgery department in Mpumalanga as a model for how shortcomings in the province’s “collapsed” public healthcare system should be addressed.
“Healthcare should not depend on whether you have money or not. That’s why the government, the NGOs and private hospitals – these three parties – should be able to bridge the gap between funding.”
Motloung cites examples of how this has worked in his practice. In a complicated case of conjoined twins on whom he operated last year, a private hospital agreed to provide theatre time and beds for the patients who were without medical aid or funds.
Appeals for community help have secured customised, 3D-printed prosthetics for a patient with severe burns.
“If we get that right, it’s better than the NHI …The NHI doesn’t solve the problem,” he said.
Motloung sees budgets being misspent and staffing shortages as the biggest challenges facing public health system. With the NHI, he believes healthcare in the country will continue to suffer.
“As long as they do not fix the administration, they don’t fix the employment, the human resources and the procurement processes, they can change all the systems…but it will not work.”
More work to do
In winter, there’s a sharp uptick in the number of children arriving at paediatric surgery wards with serious burns. “I get at least 10 children weekly with severe burns, and I have nowhere to put them.”
He is now gathering contributions to establish a specialised paediatric burns ward at Themba Hospital in Kabokweni. He said Mpumalanga needs a centralised place to focus on providing care to children with burns and to host outreach on burns prevention and treatment.
With two paediatric surgery units established and another in the works, Motloung’s mission is far from over.
“One day, when I retire, I want paediatric surgery services to be accessible to every child in South Africa, everywhere.”
See more from MedicalBrief archives:
Mpumalanga Health underspends budget despite chronic staff shortages
Dire state of health services in Mpumalanga and Limpopo
Free State hospitals: patient waits 7 months for surgery, others sleep in chairs