Inside Africa’s Largest Hospital: Five Years of Interventional Radiology Reveal a Service Shaped by Crisis

Deep in Soweto, Johannesburg, stands Chris Hani Baragwanath Academic Hospital, one of the largest hospitals in the world and a lifeline for millions of patients across Gauteng province. Behind its imaging suites, a team of interventional radiologists performs procedures that drain infected fluid collections, unblock obstructed bile ducts and rescue kidneys from obstruction, all through pinhole incisions guided by real-time imaging. A new descriptive service audit, published in BMC Medical Imaging, has for the first time mapped the procedural profile of this body interventional radiology service across selected periods spanning 2018 to 2023, offering a rare quantitative window into how a high-volume public-sector service in South Africa operated before, during and after the COVID-19 pandemic.

The study, led by Anjali R. Magan, Nomasonto N. Mkhize and Maureen M. Ramantsi of the Department of Diagnostic Radiology at the University of the Witwatersrand, was designed as a retrospective, single-centre descriptive audit. Rather than tracking every procedure continuously over five years, the researchers sampled distinct audit windows: one contiguous six-month pre-pandemic sample running from October 2018 to April 2019, three discrete two-month windows nested within the first, second and third pandemic waves of 2020 and 2021, and one contiguous six-month later audit-period sample from October 2022 to April 2023. In total, 1,443 procedure records were analysed. The authors are careful to stress that the intervening periods were not sampled, meaning the audit describes the windows examined rather than providing an unbroken chronicle of the service.

The headline finding is strikingly consistent: drainage and decompression dominate the workload. Pigtail catheter drainage and aspiration, a technique in which a coiled-tip catheter is placed percutaneously into abscesses, effusions or other fluid collections to evacuate their contents, accounted for 566 of the 1,443 records, or 39.2 percent of all recorded activity. Biliary drainage interventions, including percutaneous transhepatic biliary drainage and percutaneous transhepatic cholangiography, formed the second-largest group at 282 records, or 19.5 percent. Percutaneous nephrostomy, the image-guided placement of a tube directly into the kidney to bypass obstruction of the urinary tract, contributed a further 128 records, or 8.9 percent. Together, these three categories illustrate a service whose core business is relieving pressure and removing fluid, often in patients too unwell for surgical intervention.

The workload distribution across the sampled periods tells its own story. The pre-pandemic sample contained 601 records, the pooled pandemic-wave sample 387 records, and the later audit-period sample 455 records. Within the pandemic waves themselves, the three two-month windows contained 105, 115 and 167 records respectively, suggesting a gradual recovery in recorded activity as the waves progressed. The drop from the pre-pandemic sample to the pooled wave sample is consistent with the enormous disruption that COVID-19 imposed on elective and semi-elective procedures worldwide, as theatres were repurposed, staff were redeployed and patients delayed presentation. Yet the authors explicitly caution against causal interpretation: because the audit comprised discrete windows rather than continuous observation, the findings describe the sampled periods and cannot establish that the pandemic itself drove the changes.

To test whether the composition of the procedure mix shifted over time, the researchers turned to exploratory, procedure-record-level Pearson chi-square tests, comparing seven analytical procedure categories across the three broad samples and separately across the three wave windows. For the broad samples, the test yielded a chi-square statistic of 41.13 with 12 degrees of freedom and a p value below 0.001, with Cramér’s V, a standardised measure of association, at 0.119. For the wave windows, the chi-square was 32.08 with 12 degrees of freedom and a p value of 0.0013, with Cramér’s V of 0.204. In plain terms, the procedure mix varied significantly across the sampled intervals, and the effect size was modest for the broad comparison but moderate for the wave-to-wave comparison. These statistics are exploratory by design, and the authors flag an important limitation: because persistent patient identifiers were unavailable, the p values do not account for possible within-patient clustering, meaning the same patient contributing multiple procedures could influence the results.

Why does a single-centre audit from a Johannesburg hospital matter to the wider world? The answer lies in the scarcity of site-specific data on interventional radiology activity in South African public hospitals. Health service planning, whether for imaging capacity, specialist staffing, consumables procurement or training programmes, depends on knowing what procedures are actually performed, in what volumes, and how demand fluctuates under stress. Chris Hani Baragwanath Academic Hospital serves an enormous and diverse population, and its interventional radiology service operates within the resource constraints typical of the public sector, where equipment downtime, contrast shortages and competing clinical priorities can reshape a service overnight. A benchmark derived from 1,443 real procedure records gives planners and clinicians something they have rarely had: an evidence-based picture of demand.

The technical profile of the service also carries implications for training. Pigtail drainage, biliary intervention and nephrostomy are bread-and-butter procedures in many interventional radiology curricula, but the balance of categories observed at CHBAH reflects the specific disease burden of its catchment population, including high rates of infective and obstructive pathology. Trainees rotating through such a service encounter a case mix that differs from private-practice or high-income-country patterns, where oncological embolisation, vascular intervention and tumour ablation often dominate. Understanding this profile helps the University of the Witwatersrand align its fellowship and registrar training with the realities of the service, and helps other institutions in similar settings anticipate the skills and equipment their own services will require.

The pandemic windows add a layer of historical significance. Waves I, II and III of COVID-19 in South Africa, driven in turn by ancestral strains, the Beta variant and the Delta variant, placed unprecedented strain on hospital infrastructure. Imaging departments were central to that response, providing chest radiography and computed tomography at scale while maintaining, where possible, the interventional procedures that patients with abscesses, biliary obstruction and renal colic could not safely defer. The rising record counts across the three wave windows, from 105 to 115 to 167, hint at a service adapting under pressure, though the sampled design means the authors stop short of characterising this as a trend. What the audit does establish is that interventional radiology remained active throughout the pandemic periods examined, a testament to the essential nature of image-guided drainage and decompression.

Methodologically, the study is transparent about its limits. It is a Level 4 retrospective descriptive study, conducted in accordance with the Declaration of Helsinki and approved by the Human Research Ethics Committee of the University of the Witwatersrand, which waived individual informed consent given the retrospective design. The sampling strategy trades comprehensiveness for feasibility, and the absence of patient-level linkage constrains the statistical inference. Yet these constraints are honestly declared, and the descriptive benchmark the audit provides is precisely the kind of foundational data that prospective monitoring programmes can build upon. The authors frame their work as a service-level benchmark for planning imaging capacity, specialist staffing, consumables and training, and for prospective monitoring of demand, access and outcomes, a mandate that extends well beyond a single institution.

As health systems worldwide digest the lessons of the pandemic, studies like this one demonstrate the value of auditing what actually happens at the bedside, or rather at the angiography table. The picture that emerges from Chris Hani Baragwanath Academic Hospital is of an interventional radiology service anchored by drainage and decompression work, responsive to shifting demand across turbulent years, and now equipped with baseline data to argue for the capacity it needs. For a field that often measures itself by technological spectacle, the humble pigtail catheter, placed under imaging guidance to drain an abscess or decompress a blocked kidney, turns out to be the quiet workhorse of one of the world’s largest hospitals, and now one of its best-documented.

Subject of Research: Interventional radiology service audit at a large South African public hospital

Article Title: Body interventional radiology procedure patterns across selected audit periods, 2018–2023, at Chris Hani Baragwanath Academic Hospital, South Africa: a descriptive service audit

Article References: Body interventional radiology procedure patterns across selected audit periods, 2018–2023, at Chris Hani Baragwanath Academic Hospital, South Africa: a descriptive service audit. (n.d.). https://doi.org/10.1186/s12880-026-02904-0

Image Credits: AI Generated

DOI: 10.1186/s12880-026-02904-0

Keywords: interventional radiology, Chris Hani Baragwanath Academic Hospital, South Africa, COVID-19, procedure audit, pigtail catheter drainage, biliary drainage, percutaneous nephrostomy, tertiary hospital, BMC Medical Imaging, service planning, public healthcare