World J Surg
DOI 10.1007/s00268-014-2775-9
ORIGINAL SCIENTIFIC REPORT
The Rate-Limiting Step: The Provision of Safe Anesthesia
in Low-Income Countries
Simon Hendel • Thomas Coonan
Sarah Thomas • Kelly McQueen
•
Ó Société Internationale de Chirurgie 2014
Abstract
Background The importance of safe anesthesia for the best possible surgical outcomes in every patient is not
disputed in high resource settings. Low-income countries lag far behind in the provision of, and training for, safe
anesthesia practice. Too little is known about numbers and types of providers in a majority of low-income countries.
Methods A review of the member societies of the World Federation of Societies of Anaesthesiologists was
undertaken, and membership statistics of national societies were requested. Of the 126 members of the federation,
only 14 represent low-income countries. Many non-federation-member countries are also low-income countries.
Results The anesthesia infrastructure and personnel challenges in low-income countries contribute to poor patient
outcomes and limited access to emergency and essential surgery. The presence of a functional anesthesia society
provides a measure of the numbers of providers and a snapshot of local professional activities.
Conclusion The establishment and maintenance of an anesthesia society is an indicator of respect for the profession
and commitment to standards of practice, quality initiatives, and continuing medical education within the country.
Introduction
S. Hendel
Center for International Health, The Burnet Institute for Medical
Research, 85 Commercial Road, Melbourne, VIC 3004,
Australia
e-mail: [email protected]
T. Coonan
Dalhousie University, Halifax Infirmary, 1796 Summer Street,
Halifax, NS B3H 3A7, Canada
e-mail: [email protected]
S. Thomas
University of Tennessee, Knoxville, USA
e-mail: [email protected]
K. McQueen (&)
Department of Anesthesiology, Affiliate Faculty, Vanderbilt
Institute for Global Health, Vanderbilt University Medical
Center, 1301 Medical Center Drive, #4648 TVC, Nashville,
TN 37232, USA
e-mail: [email protected]
The impact of surgical care on the global burden of disease
is indisputable as the post-2015 Development Goals come
into focus. The global shift from communicable disease to
non-communicable disease during the last 20 years is
reflected in the global burden of disease (GBD) literature,
and the 2010 study estimates that appropriate surgical
intervention has the potential to impact nearly 28 % of the
GBD [1–4].
The potential role of surgical intervention in decreasing
disability and premature death will only be possible when
both safe anesthesia and emergency and essential surgery
are accessible to meet unmet need. The role of safe anesthesia is often neglected in the discussion of safe surgery. A
delay in the development of outcomes collection and
reporting hides the underlying patient safety issue, though
much data do exist [5–24].
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World J Surg
The number of physicians per 10,000 population is a
health indicator collected and reported by the World Health
Organization (WHO) for the 146 member states. Health
indicators at baseline and over time are indicative of the
well-being of the population. They are used to benchmark
improvement in the health system, and to reveal the impact
of strategic interventions on overall health. The WHO does
not capture data on specific medical specialties and specialist physicians. Therefore, the relative number of physicians is best utilized in combination with other health
indicators to assess baseline population health and assess
needs.
A minimum number of anesthesiologists and surgeons
per 10,000 population, geographically positioned, are
required to meet emergency and essential surgical needs.
High-income countries often track the number of physicians in a state, province, or country by medical licensure. While this offers a snapshot of the number of
physicians currently licensed, the number is not specific for
whether the physician is actively practicing in the region
where the license is held, or if the physician holds one or
more licenses simultaneously.
The medical specialty chosen by the physician and the
related credentialing completed is often reported in the
licensing application, but physicians frequently practice
outside the specialty indicated on the application, may no
longer be practicing, or may hold a license with or
without the actual delivery of care in the location where
the license is held. Medical Society membership offers a
similar snapshot into physician numbers. Specialty societies also offer insight into the numbers of specialty
trained physicians. The limitations of the data provided by
societies are similar to those of data provided by licensing
bodies.
The tracking of physicians is equally challenging in lowincome countries (LICs). Physicians are in great demand in
the poorest countries, and therefore many doctors may
practice without the appropriate credentialing. They may,
therefore, be unknown to the Ministry of Health or other
governing bodies. The specialists who choose to belong to
medical societies may represent only a fraction of the
workforce, but in the case of anesthesiology, which is truly
in a state of crisis in LICs, the members of the anesthesia
society undoubtedly represent the specialty leaders.
Anesthesia providers in LICs include physicians, nurses,
and technicians, have varying degrees of education and
training, and may or may not be credentialed or licensed.
These realities further complicate the understanding of
anesthesia practice and provider numbers in each country.
Recently, the literature has begun to report numbers and
types of anesthesia providers in LICs [25–38]. The WHO
Situational Analysis Tool database collected information
on the number and type of anesthesia providers working in
123
the full spectrum of medical facilities in 28 low- and
middle-income countries (LMICs).
A recent report revealed that 30.4 % (n = 344) of all
medical facilities reported having no full- or part-time
anesthesia personnel, including anesthesiologists, general
doctors providing anesthesia, or nurse/clinical/assistant
medical officers providing anesthesia. In these same institutions, only 41 % of the anesthesia providers were certified, registered, or licensed. Further, only 37.1 %
(n = 485) of all medical facilities evaluated employed
physician anesthesiologists, and of those only 50.9 % were
certified, registered, or licensed [25].
The crisis of anesthesia in LICs
The anesthesia crisis in LICs has grown in the last decade.
The number of physician anesthesia providers in LICs is
dwindling, impacted by ‘brain drain’, income disparity
from other specialty physicians, and declining interest
among medical students. Lack of infrastructure, including
safety equipment and unpredictable medical supplies, have
also contributed to the anesthesia crisis [16, 18, 19, 21, 24,
29, 30, 39–45]. The anesthesia-related perioperative mortality rate (POMR) is higher in LMICs and is related to
shortfalls in trained personnel, infrastructure, and anesthesia equipment [32, 44].
In Afghanistan, with a population of 32 million, there
are nine physician anesthetists; in Uganda, with a population of 27 million, there are 13, excluding expatriate providers [31]. In sub-Saharan Africa, anesthesia is provided
by non-physician anesthetic providers in the majority of
cases. Usually these providers work alone, unsupervised,
and with limited training [46] (Table 1).
A recent review of the literature identified 17 studies
that documented surgical and anesthesia capacity from
individual LMICs. This literature, representing 12 LIC and
five middle-income countries (MICs), documented the
anesthesia capacity of 555 facilities, and reported the types
of providers practicing in the country surveyed.
In terms of facilities, 66.3 % (281/424) and 54.3 %
(198/364) had oxygen and electricity all of the time; 47 %
(121/254) and 47 % (145/309) had anesthesia machines
and pulse oximeters. Ketamine anesthesia was available in
72.9 % of hospitals reporting, whereas inhalational anesthesia was only available in 56.2 %. Alternative techniques, such as regional and spinal anesthesia, were
available in 58.9 and 65.9 % of hospitals, respectively.
Adult endotracheal tubes were available in 51 of 109
hospitals (47 %), and pediatric endotracheal tubes in
44/126 (35 %) [17].
Recent and evolving awareness of the role of safe
anesthesia and surgery in improving global health (Disease
Control Priorities [DCP]-3) requires that LICs invest in the
World J Surg
Table 1 Comparing Anesthesia Societies between low-income countries and the USA, Canada, and Australia
Country
Society name
Members
Total population
Physicians per 10,000
population
Longevity M/F
WHO rank (X/191)
Australia
ASA
3,025
23,050,000
38.5
80/84
30
Canada
CAS
1,877
34,838,000
20.7
80/84
32
USA
ASA
30,086
318,000,000
24.2
76/81
37
Bangladesh
BSA
60
155,000,000
3.6
69/70
88
Benin
SARB
32
10,051,000
0.6
56/59
97
Cambodia
CSA
150
14,865,000
2.3
64/66
174
Congo
Ethiopia
SCARU
ESA
20
16
4,337,000
91,729,000
1.0
0.3
57/59
59/62
166
180
Haiti
SHA
45
10,174,000
2.5
61/64
138
Kenya
KSA
120
43,178,000
1.8
58/61
140
Mali
SARMUM
32
14,854,000
0.8
50/53
163
Mozambique
AAM
17
25,203,000
0.3
52/53
184
Myanmar
ASMMA
120
52,797,000
5.0
63/67
190
Nepal
SAN
100
27,474,000
2.1
67/69
150
Rwanda
RSA
15
11,458,000
0.6
58/61
172
Uganda
USA
22
36,346,000
1.2
54/57
149
Zimbabwe
ZAA
50
13,724,000
0.6
53/55
155
Bangladesh: Bangladesh Society of Anesthesiologists; Benin: Societe d’Anesthesie-Reanimation du Benin; Cambodia: Cambodia Society of
Anesthesiologists; Congo: Societe Congolaise d’Anesthesie Reanimation Urgences; Ethiopia: Ethiopian Society of Anesthesiologists; Haiti:
Societe Haitienne d’Anesthesiologie; Kenya: Kenya Society of Anesthesiologists; Mali: Societe d’Anesthesie de Reanimation et de Medicine
d’Urgence du Mali; Mozambique: Associacao de Anesthesiologistas de Mocambique; Myanmar: Anaesthetists Society of Myanmar Medical
Association; Nepal: Society of Anaesthesiologists of Nepal; Rwanda: Rwanda Society of Anesthesiologists; Uganda: Uganda Society of
Anesthesia; Zimbabwe: Zimbabwe Anaesthetic Association
F female, M male, WHO World Health Organization
requisite infrastructure, medicines, equipment, and training. Increasing burdens in trauma and cancer, as well as
unmet surgical needs in terms of obstetric conditions, will
require increasing numbers of trained anesthesia providers.
We sought to evaluate the state of physician anesthesia
resources and the commitment to anesthesia standards and
guidelines, and access to continuing medical education in
LICs, with a novel evaluation of the existing societies of
anesthesia.
Investigation of the society by website and direct contact
was attempted with every society representing an LIC. The
authors emailed the contact for the society listed on the
WFSA website, requesting information on the society,
including membership numbers and frequency of society
meetings. The data received were compared between
sources.
Results
Methods
A review of the 126 member societies of the World Federation of Societies of Anaesthesiologists (WFSA) was
undertaken. Country-specific details were reviewed on the
WFSA website, including member numbers, website
availability, length of membership, and related educational
activities [47]. When available, the society websites were
reviewed. Updated national society membership numbers
were requested and received from the WFSA. Membership
data were also requested directly from the national anesthesia societies in the 14 LICs, using the email provided as
a contact for the society.
A total of 126 national societies were identified as members of the WFSA. Of these, 14 represented LICs. Of the 79
countries without WFSA membership (Fig. 1) 30 are
located in Africa; 18 of those 30 are LICs. There are 36
countries identified as LICs by the World Bank, and
therefore only 39 % of LICs have representative anesthesia
societies. This is in comparison with high-income countries, which all have representative anesthesia societies.
WHO comparative health data from each country and the
World Bank comparative health ranking were reviewed
[48, 49].
Email contact with each of the 14 identified LIC societies was attempted. Of the 14 emails sent, only one was
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World J Surg
Fig. 1 World Federation of Societies of Anesthesia (WFSA) members and non-members
email returned as undeliverable. All other addresses were
therefore assumed to be operational. Every society listed a
representative member or contact with an email address on
the WFSA national member page; however, none of the
remaining 13 contacts responded to the enquiry sent by the
authors. Three societies had a functional website, and
review of these sites allowed comparison of data between
the LIC society and the American, Australian, and Canadian societies (Table 2).
Overall, LICs with representative societies report few
anesthesia physician providers when compared with MIC
and high-income countries (Table 3).
Discussion
Recent assessments of anesthesia infrastructure in LMICs
reveal a crisis in the provision of safe anesthesia care [4,
10, 24, 25, 30, 32, 41, 44, 45]. Contributing to this crisis in
surgical access and patient safety are the limited number of
trained providers, including very few practicing physician
anesthesiologists; the limited access to essential medications; and the few functional patient safety monitors.
123
Simultaneously, as the backdrop to this crisis, noncommunicable diseases (NCDs)—including trauma and
cancer—is increasing and contributing to premature disability and death. Diagnosis, treatment, and palliation of
NCDs frequently require surgical intervention.
Physician anesthesia providers are essential to any
healthcare system. These specialty trained physicians are
needed for patient care and safety, education and training
of other physician and non-physician providers, the establishment of local guidelines and standards, and for leadership with the medical community, government, and
related societies. The dwindling numbers of physician
anesthesia providers in LICs has contributed to poor patient
outcomes and to unacceptably high POMR [10]. The
encouragement and support of physician anesthesia providers must be considered part of any strategy to improve
patient safety and increase the numbers of successful nurse
and technician anesthesia providers [34, 50, 51].
Confirming the presence of national anesthesia societies
and related membership, as well as WFSA membership, is
another measure of the local commitment to anesthesia.
This commitment, reflected in society membership, may be
an useful surrogate for estimating the future of anesthesia
World J Surg
Table 2 Low-income country anesthesia website comparison
Country
Website/last
updated
Contact
information
Society
information
Member
information
Meeting
information
Other
Bangladesh
www.bsabd.com,
2/2014
Mailing
address,
email,
telephone
#, website
Office holders,
history of
society
List of
members
List of future
conference dates
(2014 and 2015),
calendar of events
Information on specialty chapters,
Journal of the Bangladesh Society
of Anesthesiologists, information
for anesthesia education
Congo
www.socaru.net,
5/2013
Mailing
address,
email,
telephone
#, website
Office holders,
mission
statement,
and
constitution
Kenya
www.
anaesthesiakenya.
co.ke, 2/2013
Mailing
address,
email,
telephone
#, website
Office holders,
mission
statement,
and
constitution
Reports of past
conferences
List of
members
education, training, and patient safety efforts in a particular
region.
Even the smallest societies (Congo, Rwanda, Mozambique) improve the stature of anesthesia in their countries
and provide an opportunity to create and publish guidelines
and standards. The established hierarchy of leadership,
contacts, and meetings that societies are required to
develop create opportunities for government dialogue.
These structures may also allow clearer communication of
expectations with schools, programs, and institutions
training non-physician providers.
There will be a shortage of physicians to deliver the
majority of anesthesia in LICs for the foreseeable future.
However, this is also true in many high-income countries
where nurse and technician providers provide safe anesthesia care under the direction of a physician. This reality
does not diminish the critical role of physicians within the
specialty of anesthesia in LICs. Cataloging the shortage of
physicians is a recognized aspect of healthcare system
evaluation, and is recognized by the WHO and governments as a health indicator.
Specialty physicians are not currently included as a
country metric or health indicator. The impact of NCDs
and the related role of surgery and anesthesia may soon
demand that healthcare systems, governments, and perhaps
even the WHO evaluate and report the anesthesiologists,
obstetricians, and surgeons, and their related non-physician
counterparts. This information is critical to planning for
improving access to emergency and essential surgical services, and to expanding surgical care and safe anesthesia to
avert disability and death related to NCD.
Evaluating the non-physician provider base in LICs is a
greater challenge. The surveys and reviews published in the
last decade have improved the understanding of the nurse
and technician providers for surgery and anesthesia at the
Reports of past
conferences,
calendar of events
List of common questions and
answers for patients, discussion
forum
country level [17, 19, 22, 23, 25, 31, 32, 42, 52–56]. But
the information gap remains large due to the arduous and
time consuming nature of surveys, as well as the reality
that most surveys are based on representative samples and
are not a thorough review of the entire system. The gap is
even greater in most countries when considering the credentialing of nurses and technicians.
Integral to the anesthesia provider analysis is patient
safety. In high-income countries, physicians are leaders of
patient safety initiatives and the guidelines that accompany
them. As discussed, reports of excessive mortality in LICs
are very much in the historical and current literature. In
addition, there remains in the vicinity of 70,000 operating
rooms globally without pulse oximetry, [57] and well
documented shortages in personnel, essential medications
and equipment [20, 23, 30, 32, 53, 55, 58–60].
Efforts are underway to encourage collection and
reporting of POMR, at least 24 h post-operatively, as a
baseline and benchmark of patient safety [61]. The spectrum of information, including specialist physician and
non-physician provider numbers, and the POMR, will
greatly inform the country-specific barriers to safe patient
care and access to surgery. Even before these data are
available, the global health community, focusing on the
provision of emergency and essential interventions for the
growing surgical burden of disease, must demand safe
anesthesia in every operating location.
The reality of the global anesthesia crisis has long been
recognized. The flight of anesthesiologists to other medical
specialties and higher income countries has been noted in
LICs for decades. Simultaneously, fewer and fewer medical students are choosing anesthesia as a specialty.
For those physicians remaining in anesthesia, their
remuneration has not kept pace with that of their surgical
counterparts, their professional development has lapsed,
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Table 3 Anesthesia providers, training programs, and working conditions by country reported in recent international publications
Country,
study
Anesthesiologists
Number
Afghanistan,
Dubowitz
et al. [32]
Per 10,000
populationa
0.03
Anesthesia
residency
programs
Anesthetic officers/
nurse anesthetists
Available types of anesthesiab
0
Afghanistan,
Iddriss
et al. [20]
Bangladesh,
Lebrun
et al. [23]
30 % of facilities have limited
oxygen delivery systems,
40 % have unreliable
running water sources, and
only 34 % have reliable
electrical power
850
Congo,
Dubowitz
et al. [32]
0.56
Yes
Oxygen cylinders are available
at all hospitals. 71 % of
facilities have pulse
oximeters in each OR and
100 % of facilities have an
anesthesia machine in each
OR. Limited number of
anesthesiologists, which
limits the ability to perform
surgery
Occasional lack of electricity
and water supply. All
hospitals have access to
oxygen. Only 63 % of
hospitals have a pulse
oximeter for each OR
0.02
Ethiopia,
Chao et al.
[30]
19
0.022
Yes, in all but 3
hospitals, anesthesia
is provided by nonphysician personnel
Gambia,
Iddriss
et al. [20]
8
0.45
Yes, anesthesiologists
deliver anesthesia in
only 22.2 % of
facilities
Kenya,
Dubowitz
et al. [32]
120
0.37
Yes, up to 300
Liberia,
Sherman
et al. [58]
0
0
0
Rwanda,
Notrica
et al. [55]
9
0.082
1 PG
123
Working conditionsc
82.4 % of facilities are capable
of ketamine anesthesia,
76.5 % are capable of
regional. Spinal anesthesia
and general inhalational are
available in 72.2 % of
facilities
77.8 % of facilities have
consistent oxygen supplies,
50 % have consistent water
supplies, and 44.4 % have
consistent electricity. 70.6 %
have working anesthesia
machines
Yes, 19 nurse
anesthetists and 1
non-anesthesiologist
physician delivering
anesthesia
81.2 % of facilities can
provide spinal or ketamine
anesthesia. 25 % can provide
general anesthesia, and
12.5 % are capable of
regional blocks
31.3 % of facilities have fulltime oxygen cylinders, 25 %
have full-time electricity.
18.8 % have a functional
anesthesia machine
Yes, average of 3
anesthesia
technicians per
hospital. Some
uncertified nurses
also practice
anesthesia
Routine shortages of essential
anesthesia medications such
as diazepam
Backup generators are
frequently used due to
recurrent power outages.
Access to clean running
water is not a problem.
Oxygen is hard to attain, but
all facilities report access to
oxygen concentrators when
oxygen cylinders are not
available. Pulse oximeters
are scarce
World J Surg
Table 3 continued
Country,
study
Anesthesiologists
Number
Per 10,000
populationa
Anesthesia
residency
programs
Anesthetic officers/
nurse anesthetists
Available types of anesthesiab
Sierra
Leone,
Iddriss
et al. [20]
Sierra
Leone,
Groen
et al. [53]
20 % of facilities have
functioning anesthesia
machines
1
Tanzania,
Dubowitz
et al. [32]
Yes, 23 nonphysician
anesthesia staff
0.04
2, 4
residents
in
training
Tanzania,
Penoyar
et al. [59]
Uganda,
Dubowitz
et al. [32]
Uganda,
Hodges
et al. [60]
Working conditionsc
0.04
15
Zimbabwe,
Dubowitz
et al. [32]
2, 10
residents
in
training
0.047
0.3
Broken system: health workers
spend 50–60 % of their time
on productive tasks
Yes, 87 % of
anesthesia
providers are nonphysicians
42 % of facilities have
consistent access to oxygen.
Pulse oximeters are scarce.
32 % have no access to an
anesthesia machine. 37.5 %
have both consistent running
water and electricity
Yes, up to 300
Lack of infrastructure: 23 % of
hospitals have capacity and
equipment for safe delivery of
anesthesia for adults, 13 % for
children, \6 % for cesarean
section
Yes, anesthesia is
mainly provided
by non-medical
anesthetists, most
with little training
Anesthesia for children consists
of IM or IV ketamine or drawover anesthesia with
halothane, but sometimes only
ether is available. Local
anesthesia is also common
Only 13 % of facilities are able
to provide anesthesia for a
child. Oxygen concentrators
are used. Tracheal tubes are
used and re-used
1, 150
residents/
year
IM intramuscular, IV intravenous, OR operating room, PG post-graduate
a
Physicians are reported per 10,000 population by the WHO. Comparison from the USA is approximately 2 anesthesiologists per 10,000
population
b
Ketamine, spinal, general
c
Clean water and electricity, access to oxygen, pulse oximetry, and anesthesia machines
and the opportunities for leadership have dwindled. Only
recently did LICs begin training nurse anesthesia providers
to begin to fill the professional gap, [56] and, in many of
the poorest countries, technicians, some with official
training, and others without, have provided anesthesia
without supervision, without monitors and, frequently,
without oxygen.
Conclusions
The global anesthesia crisis represents the largest barrier to
access to safe surgery. Appreciating the gap in physician
anesthesiologists and other providers, as well as the POMR
as a measure of patient safety, is required for the provision
of emergency and essential surgery. Pivotal to the discussion around effective and sustainable provision of essential
and emergency surgery is understanding and prioritizing
the anesthesia workforce. Strategies to assess the anesthesia gap, equipment, and medicine needs must evolve from
the static survey model if the growing surgical demands are
to be met.
Solutions for increasing the availability and safety of
providers can only be found once the levels of training and
credentials of existing providers have been assessed, and
projections for future health service requirements have
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World J Surg
been estimated. Anesthesia societies and their physician
leaders have an essential role in this process. The creation
of guidelines, minimum training requirements, and examinations must be part of a successful credentialing program.
Monitoring and benchmarking outcomes, and driving
improvements, must also be physician led. In the absence
of a physician leader at every hospital, a national society
will need the authority to initiate change and ensure patient
safety.
Equally important as the challenge of preparing and
training a cadre of professional independent anesthesia
providers is the collection and analysis of anesthesia outcome data. Reliable data are essential in order to truly
characterize the nature of the crisis, both to motivate policy
makers and to inform pragmatic solutions as we move
forward.
National Physician Societies offer a snapshot into
patient care and the healthcare system. Tracking and
encouraging the progress of anesthesia societies, combined
with following POMR over time, will allow for further
analysis of country-based systems, patient safety, and
opportunities for quality improvement.
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