Anesthetists wanted: addressing the disparity of care providers in surgery in low resource settings
by Jake Mathewson MSc and Olga Knaven MD
As appears in the January 2021 Global Surgery edition of MTb
Over the past decades there have been numerous approaches and attempts to increase surgical capacity in low resource settings. Many have unfortunately overlooked a fundamental tenet without which most surgeries cannot occur: for a patient to undergo a surgical procedure, they must first be properly anesthetized. In most low and middle-income countries (LMICs) across the world, the extreme shortage of well-trained anesthetists is not only shocking but is in many ways compounding systemic challenges that already leave hundreds of millions of people without access to basic lifesaving and life altering surgical procedures.[1]
Shortage of anesthesiology providers
The SURG-Africa project, funded by the European Union’s Horizon 2020 Programme started in 2017 with the aim of assessing and implementing surgical systems that deliver safe, affordable and sustainable essential surgical services to rural populations in LMICs. At the beginning of this project, the research team examined the current state of surgical care in the three countries involved: Tanzania, Malawi and Zambia, in order to improve understanding of systemic challenges and limitations. From the results, Dr. Gajewski, the lead researcher for the SURG Africa project, and his team found that in these areas, many of the shortages and gaps in surgery could be attributed to the limitations in the capacity of anesthesia. There was not a single anesthesiologist present in any of the surveyed hospitals at the district level, and even in national level hospitals the number of MD anesthetists was shockingly low. “In Zambia, there are only 26 MD anesthetists in the entire country serving a population of 18.7 million people, whereas in Malawi that number is even more shockingly 4 MD anesthetists to the 19.4 million people,” according to Gajewski. Upon further examination, Gajewski confirmed that the extreme lack of anesthesia providers in the three countries taking part in the study was not an anomaly, but rather evidence of an issue seen throughout many LMIC’s in the world — particularly across Sub-Saharan Africa.
Challenges in creating an adequate workforce of Anesthetists
The lack of qualified anesthetists has created an uneven balance between anesthesia and surgical providers, the latter being comparatively much better staffed in these regions. This mismatch has a detrimental effect on surgical capacity and limits the types of procedures that can be performed in many health care facilities, accounting for significant morbidity and mortality when insufficiently trained health workers are tasked with administering anesthetic agents. “There are far more people who can do an operation than who can anesthetize the patient. That means that if you have only one person as part of the operating team who can anesthetize, they would need to work all the time, which is impossible,” Gajewski explains.
Dr. Ntambwe, an anesthesiologist working in Livingstone Central Hospital in Zambia, offers a local insight on why so many more physicians turn to surgery and away from anesthesia, explaining that there is a lack of incentive to work in anesthesiology. As the constant demand placed upon anesthetists would require them to work significantly more hours than numerous other specialties in medicine, “a Clinical Officer Anesthetist (COA) has to work 8 hours a day, whereas a Clinical Officer Psychiatry works 4–6 hours a day, but they end up getting the same salary.”
Dr. Gajewski adds that many physicians are propelled into surgery by the perceived social benefits that come with the role, stating that “in the northern hemisphere, surgical care is more of a teamwork approach, whereas in these settings, the surgeon is the dominant figure. He gets power and influence over the whole team, therefore people strive for that.”
Of these very few MD Anesthesiologists that are working within these countries, many can end up being the only person with their specialty in a certain facility or institution. Without a network of well-trained colleagues to continue learning and get supervision from, it is hard for many workers to maintain levels of skills and knowledge. Gajewski refers to this phenomenon as “professional isolation,” where anesthetists who may have been initially well trained may end up lacking skills they would acquire with more access to training, resources, and mentorship. This can account for a significant reduction in the skill and ability of an already limited workforce, further hindering surgical capacity.
This limited workforce exists on top of shortages and extensive gaps in equipment and supply. These range from disruptions in water and electricity, limited, counterfeit and low-quality medications, shortages in supplies that extend from gloves to oxygen, obsolete equipment and machines, and insufficient sterilization techniques, to name a few. Such challenges to an already resource-deprived health system increases the importance and value of having capable and well-trained providers in every specialty, including anesthesia.
Solutions and efforts to improve workforce
Recognition of the severe shortages of anesthesia providers has put emphasis on the need to improve the capacity of the workforce going forward. While shortage of anesthesia providers varies from country to country, many nations are implementing parallel programmes and strategies to create a larger, more skilled and interconnected workforce of anesthetists.
An example of this effort to improve the capacity of the workforce on a local level is seen in one of SURG-Africa’s projects, which brings mentorship and supervision to isolated providers in district level hospitals. Such interventions aim to address professional isolation and increase the capacity of existing providers by reinforcing a more cohesive team approach. “There was a surgeon, an anesthesiologist and a nursing specialist to supervise, train and mentor local teams providing them the latest knowledge within the discipline. The idea was to do better within existing skills, rather than just to expand,” states Dr. Gajewski.
On a regional level, an initiative has been started by CANECSA (the College of Anesthesiologists of East, Central and Southern Africa, www.canecsa.com) training new MD Anesthesiologists through an Irish Aid supported collaboration programme. The constituent member countries of this initiative are Eswatini, Kenya, Malawi, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe. Training provided in institutions accredited by CANESCA are aimed not only at expanding the workforce but also at improving the quality of care.
Merely increasing the number of MD Anesthesiologists, however, is not feasible as a standalone strategy to fill what is an immense gap. Zambia offers a 2-year training of registered nurses to become anesthesia providers, part of an effort to train a capable workforce of non-physician clinicians (NPCs) to become non-physician anesthesia providers (NPAPs). This strategy of increasing the NPAP workforce is seen as the only way in the short term to supply the necessary number of anesthetists to keep up with surgical demand. The usage of NPAPs is becoming increasingly prevalent in many forms throughout numerous countries in the world, including in high income countries.
There is some doubt, however, that a two-year training course is sufficient to train NPCs to work autonomously in a role so challenging and with such dire consequences when not performed properly. According to Dr. Ntambwe, it has been a challenge in Zambia. “After the two-year training, it takes time for these nurses to be able to work autonomously in terms of providing anesthesia. Therefore, they go for an internship in the big centers for another year. But still, in the end, they will only be able to provide anesthesia for the basic emergency surgeries which are performed in the district hospitals. For the other surgeries they will need to refer.” To this, Dr. Gajewski added a positive note: “Despite these challenges, growing research evidence does show comparable surgical or anesthesiologic outcomes between non-physician and physicians, as long as you put a clear ceiling on their tasks and qualifications, and provide periodic supervision.”
Going forward
Global health programmes are continuing to work to improve the capacity of the existing anesthesia workforce through research and advising on training programmes, but many experts like Dr. Gajewski are adamant that change will have to come from initiatives within the health ministries. “In order to achieve sustainable improvements in manpower, as well as equipment and supplies, the leading role should be with the ministry,” Dr. Gajewski explains. “The Global Health community should step away a bit to allow local empowerment. Running just on projects is not the way to go. The results of the projects are presented to the ministry, but eventually they need to take over and be in charge, be responsible and accountable towards their own clinicians and patients who are the voters in how to make the system better.”
For now, Zambia and other countries in the area grapple with the added burden of the pandemic and its associated surgical disruptions. Dr. Ntambwe informs us that presently (January), the country has suspended elective surgeries to accommodate the heightened demand on health systems created by the COVID-19 pandemic.