For many years, the healthcare systems of high-income countries have prioritized safe practices in both surgery and anesthesia. However, with the global burden of disease (GBD) continuously worsening for non-communicable diseases (NCDs), low- and middle-income countries (LICs and LMICs) are in great need of prioritized surgical and anesthetic services. For many of these countries, safe and adoptable practices are critical to improving health outcomes for leading causes of mortality, including cardiovascular disease, trauma, cancer, and obstetrics.
Every year, 32 million people are administered anesthesia without sufficient monitoring, while the poorest 33% of the world population receives only 3.5% of all surgical operations. In an effort to explain this disparity and ensuing crisis, multiple organizations, including the World Health Organization (WHO) and the Harvard Humanitarian Initiative (HHI) have surveyed and assessed the healthcare systems of LICs and LMICs across Africa, Southeast Asia, and Central and South America. The findings suggest that, in many rural areas, deficient infrastructure, a lack of human resources, and a shortage of essential instruments, equipment, and medicines are major contributors to the issue.[1]
The Lancet Commission on Global Surgery recently pointed to the lack of access to safe surgical and anesthetic services for 5 billion people around the world and the projected investment necessary to equalize the imbalance between high and low resource environments.[2] It referenced the World Federation of Societies of Anesthesiologists (WFSA), which consists of 135 member societies representing 150 countries. From 2015 to 2016, WFSA conducted a survey to capture an up-to-date, comprehensive snapshot of access to surgical and anesthetic care for 97.5% of the world’s population, which included non-physician anesthesia providers (NPAPs). Today, only 50% of all countries meet the sufficient ratio of 5 anesthesiologists per 100,000 population. In fact, high income countries have nearly 95 times the density of anesthesiologists compared to low-income countries.[3] This imbalance and the projected need for 136,000 additional anesthesiologists necessitates novel approaches and models for care delivery, especially in low-income and rural areas. So where can we start?
First, it is necessary to recognize that the availabilities of both human resources and infrastructure vary across low-income and rural regions, and together, they should dictate which model is most appropriate for improved anesthesia care delivery.
Second, specialist anesthesiologists from high-, middle-, and low-income countries must lead the specialty towards adopting a broader, global perspective. Safe anesthesia administration begins with education, and the number and quality of academic training programs across countries, especially in low-income and rural areas, needs to substantially increase. It is equally imperative for this growth to be coupled with additional anesthesia educators and resources. While the Ministries of Health in many LICs and LMICs have already recognized the need for continued development of NPAP training programs, anesthesiologists should assist governments in developing country-specific roadmaps, consisting of a standardized curriculum and training duration, an accreditation process, and clear delineation of scope of practice across provider levels.
Finally, anesthesiologists and organizations in LICs and LMICs can help providers in remote or rural areas by both establishing support networks and offering opportunities for continued medical education. ‘Quick-fix’ solutions that are often proposed by non-anesthesiologists are not the answer. An example is a 5-day course teaching non-physician healthcare workers how to administer ketamine for surgery. This is not safe, jeopardizes the health of many patients, and endangers the continuation of formal training programs and care delivery standards.
Despite the major challenges that anesthesia faces in low-income and rural areas, the silver lining lies in the fact that we now have a more complete, global picture that highlights the discrepancies in the access to and administration of care. The global anesthesia community now has the opportunity to work cohesively to provide safe, affordable, and accessible care for 5 billion people across the world.
References
[1] Martin, J., Tau, G., Cherian, M. N., de Dios, J. V., Mills, D., Fitzpatrick, J., … & Cheng, D. (2015). Survey of the capacity for essential surgery and anaesthesia services in Papua New Guinea. BMJ open, 5(12), e009841.
[2] Enright, A., & Newton, M. (2017). Human Resources in Anesthesia: The Road to 2030.
[3] Kempthorne, P., Morriss, W. W., Mellin-Olsen, J., & Gore-Booth, J. (2017). The WFSA global anesthesia workforce survey. Anesthesia & Analgesia, 125(3), 981-990.
