Secondary Logo

Journal Logo

Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia

A Mixed-Methods Study

Gajewski, Jakub PhD*; Pittalis, Chiara MS; Lavy, Chris MD; Borgstein, Eric MD§; Bijlmakers, Leon PhD; Mwapasa, Gerald MS§; Cheelo, Mweene MS; Le, Grace MS; Juma, Adinan MD#; Kachimba, John MD; Marealle, Paul MD**; Mkandawire, Nyengo MD§; Chilonga, Kondo MD††; Brugha, Ruairi MD

doi: 10.1213/ANE.0000000000004363
Global Health: PDF Only

BACKGROUND: District-level hospitals (DLHs) are the main providers of surgical services for rural populations in Sub-Saharan Africa (SSA). Skilled teams are essential for surgical care, and gaps in anesthesia impact negatively on surgical capacity and outcomes. This study, from a baseline of a project scaling-up access to safe surgical and anesthesia care in Malawi, Tanzania, and Zambia, illustrates the deficit of anesthesia care in DLHs.

METHODS: We undertook an in-depth investigation of anesthesia capacity in 76 DLHs across the 3 countries, July to November 2017, using a mixed-methods approach. The quantitative component assessed district-level anesthesia capacity using a standardized scoring system based on an adapted and extended Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) Index. The qualitative component involved semistructured interviews with providers from 33 DLHs, exploring how weaknesses in anesthesia impacted district surgical team practices and quality, volume, and scope of service provision.

RESULTS: Anesthesia care at the district level in these countries is provided only by nonphysician anesthetists, some of whom have no formal training. Ketamine anesthesia is widely used in all hospitals, compensating for shortages of other forms of anesthesia. Pediatric size supplies/equipment were frequently missing. Anesthesia PIPES index scores in Malawi (M = 8.0), Zambia (M = 8.3), and Tanzania (M = 8.4) were similar (P = .59), but an analysis of individual PIPES components revealed important cross-country differences. Irregular availability of reliable equipment and supply is a particular priority in Malawi, where only 29% of facilities have uninterrupted access to electricity and 23% have constant access to water, among other challenges. Zambia is mostly affected by staffing shortages, with 30% of surveyed hospitals lacking an anesthesia provider. The challenge that stood out in Tanzania was nonavailability of functioning anesthesia machines among frequent shortages of staff and other equipment.

CONCLUSIONS: Tanzania, Malawi, and Zambia are falling far short of ensuring universal access to safe and affordable surgical and anesthesia care for district and rural populations. Mixed-methods situation analyses, undertaken in collaboration with anesthesia specialists—measuring and understanding deficits in district hospital anesthetic staff, equipment, and supplies—are needed to address the critical neglect of anesthesia that is essential to providing surgical responses to the needs of rural populations in SSA.

From the *Institute of Global Surgery, Royal College of Surgeons in Ireland, Beaux Lane House, Dublin 2, Ireland

Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Beaux Lane House, Dublin 2, Ireland

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom

§Department of Surgery, University of Malawi, College of Medicine Malawi, Mahatma Gandhi, Blantyre, Malawi

Radboud University Medical Center, Nijmegen, the Netherlands

Department of Surgery, Surgical Society of Zambia, University Teaching Hospital, Lusaka, Zambia

#East Central and Southern Africa Health Community, Arusha, Tanzania

**Tanzania Surgical Association, Muhimbili Orthopaedic Institute, Dar Es Salaam, Tanzania

††Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.

Accepted for publication July 1, 2019.

Funding: The Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) project is funded by the European Union Horizon 2020 Programme for Research and Innovation, under grant agreement No. 733391.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Reprints will not be available from the authors.

Address correspondence to Jakub Gajewski, PhD, Institute of Global Surgery, Royal College of Surgeons in Ireland, Lower Mercer St, Dublin 2, Ireland. Address e-mail to

© 2019 International Anesthesia Research Society