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Anesthetic Care in Mozambique

Lyon, Camila B. MD*; Merchant, Amina I. MD; Schwalbach, Teresa MBBS; Pinto, Emilia F. V. MBBS§; Jeque, Emilia C. MBBS; McQueen, K. A. Kelly MD*

doi: 10.1213/ANE.0000000000001223
General Articles: Research Report
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BACKGROUND: The World Bank and Lancet Commission in 2015 have prioritized surgery in Low-Income Countries (LIC) and Lower-Middle Income Countries (LMICs). This is consistent with the shift in the global burden of disease from communicable to noncommunicable diseases over the past 20 years. Essential surgery must be performed safely, with adequate anesthesia monitoring and intervention. Unfortunately, a huge barrier to providing safe surgery includes the paucity of an anesthesia workforce.1 In this study, we qualitatively evaluated the anesthesia capacity of Mozambique, a LIC in Africa with limited access to anesthesia and safe surgical care. Country-based solutions are suggested that can expand to other LIC and LMICs.

METHODS: A comprehensive review of the Mozambique anesthesia system was conducted through interviews with personnel in the Ministry of Health (MOH), a school of medicine, a public central referral hospital, a general first referral hospital, a private care hospital, and leaders in the physician anesthesia community. Personnel databases were acquired from the MOH and Maputo Central Hospital.

RESULTS: Quantitative results reveal minimal anesthesia capacity (290 anesthesia providers for a population of >25 million or 0.01:10,000). The majority of physician anesthesiologists practice in urban settings, and many work in the private sector. There is minimal capacity for growth given only 1 Mozambique anesthesia residency with inadequate resources. The most commonly perceived barriers to safe anesthesia in this critical shortage are lack of teachers, lack of medical student interest in and exposure to anesthesia, need for more schools, low allocation to anesthesia from the list of available specialist prospects by MOH, and low public payments to anesthesiologists. Qualitative results show assets of a good health system design, a supportive environment for learning in the residency, improvement in anesthetic care in past decades, and a desire for more educational opportunities and teachers.

CONCLUSIONS: Mozambique has a strong health system design but few resources for surgery and safe anesthesia. At present, similar to other LICs, human resources, access to essential medicines, and safety monitoring limit safe anesthesia in Mozambique.

From the *Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee; Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University, Nashville, Tennessee; Universidade Eduardo Mondlane, Maputo, Mozambique; §Department of Anesthesiology, Maputo Central Hospital, Maputo, Mozambique; and Department of Anesthesiology, Maputo Central Hospital and Ministry of Health, Maputo, Mozambique.

Accepted for publication January 20, 2016.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Camila B. Lyon, MD, Vanderbilt University, 2200 Children’s Way, Suite 3115, Nashville, TN 37232. Address e-mail to camila.lyon@vanderbilt.edu.

In 2015, Disease Control Priorities 3 (DCP3) and the Lancet Commission on Global Surgery have prioritized essential surgery for low-income countries (LICs) and lower middle-income countries (LMICs). The Essential Surgery Volume of DCP3 supports 44 cost-effective surgical interventions and basic anesthesia capacity for every first referral hospital in LICs and LIMCs. Implementation of these recommendations together with the consistent provision of emergency surgery and anesthesia is expected to impact 28% of the global burden of disease including 25% of trauma and 35% of obstetric burdens.1–3 Anesthesia capacity is the rate-limiting step for the development of essential surgical capacity.4

The neglect of surgical systems in most LMICs for decades has resulted in 5 billion people worldwide annually without access to safe surgical care, and 32 million anesthetics performed without adequate monitoring.5,6 This has resulted in limited access to emergency and essential surgery and in unacceptably high perioperative mortality rates in most LMICs. It is estimated that 143 million surgeries are needed in LICs6 but provision of the necessary interventions is limited by too few surgical, anesthesia, and obstetric providers; essential medicines; and equipment including safety monitoring. At current rates, lack of surgery will decrease the gross domestic product (GDP) of LMICs by 1.7% over the next 15 years, dragging down the economies of these countries. In addition, an estimated 60,000 unnecessary maternal deaths occur yearly, and the maternal mortality rate will only improve another 15% if necessary, surgical procedures are actually performed.6 Thus, safe surgery and anesthesia should be an essential component in the Sustainable Development Goals of Universal Health Coverage.6 The cost of lost GDP over 15 years is $12 trillion, whereas the cost of scaling up surgery is estimated at 300 to $500 billion and therefore is cost effective.3

Anesthesia capacity limits the provision of safe surgery in LICs. Contributors to the anesthesia crisis and poor anesthesia-related outcomes include workforce shortages,2,7 unpredictable access to essential medicines including oxygen, and limited safety monitors to provide appropriate anesthetic care. Minimal outcomes tracking and quality improvement exist in most LMICs.8 The World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO) have outlined the minimal standards for safe surgery, but most are not met in most LMICs.8 Recent surveys of LMICs reveal that 30% of medical facilities have no full or part-time anesthesia personnel, and only 41% of anesthesia personnel were certified in LMICs.4 The lack of trained anesthesia providers limits access to surgery and contributes to unacceptable perioperative mortality rates, estimated at 35,000 deaths from anesthetics among 35 million operations in LICs. As an example of 1 LIC in Africa, we qualitatively reviewed the anesthesia capacity of Mozambique.

Mozambique is located in Southeast Africa bordered by the Indian Ocean, Tanzania, Malawi, Zimbabwe, Swaziland, and South Africa. The country’s population is 25,727,911 with 45.3% younger than 14 years.9,10 The 2014 United Nations Human Development Report ranked Mozambique 178 of 187 countries with a life expectancy of 50.3 years, an infant mortality ratio of 63 of 1000 live births, <5 years mortality rate of 90 of 1000 live births, and a maternal mortality ratio of 490 of 100,000 live births.11

After independence from Portugal in 1975, Mozambique suffered from large-scale emigration, dependence on South Africa, severe droughts, and a prolonged civil war that hindered the country’s development through the 1990s, when the human immunodeficiency virus crisis worsened.9 According to the WHO, Mozambique had 8 hospital beds per 10,000 people in 2009, with the average for the African region being 9.12 First referral hospitals are designated by the WHO as having a capacity for emergency and some essential surgery.13 Mozambique had 40 hospitals with surgical services in 2005. Forty-seven percent of the distribution of the health workforce is composed of management and support staff. Only 2.6% are physicians, with 30.7% nurses and midwives.12 The health care expenditure is 6.6% of GDP, with only 0.3 physicians per 10,000 population.9,14 Because of this physician shortage, Mozambique trained technicians with specific skills including cesarean delivery, appendectomy, and anesthetic administration to fill the gap.15 Even with trained midlevel providers, anesthesia capacity is at a critical shortage.

With new input from DCP3 and the Lancet Commission on Global Surgery for cost-effective surgery and safe anesthesia for all LMICs, Mozambique is uniquely positioned to increase surgical care and patient safety.

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METHODS

An assessment of anesthesia capacity in Mozambique was conducted through unstructured interviews of key Mozambique personnel. Personnel interviews were conducted in a public central referral hospital, a general (first referral) hospital, a private care hospital, a rural hospital, and with anesthesia and health leaders in Mozambique. The central hospital is 1 of only 3 tertiary care hospitals in the country and contains the only anesthesia residency program. Interviews were conducted with Ministry of Health personnel, the Central Maputo Hospital Anesthesia Chairman and Residency Director, Dean of the University of Eduardo Mondlane medical school, a district hospital Anesthesia Chairman, a rural hospital medical director, Director of the Mozambican Association of Anesthesiologists, Director of the College of Anesthesia, the Director of the only Mozambique anesthesia pain clinic, and President of the Mozambican Pain Association. Other anesthesiologists, residents, and anesthesia technicians were interviewed if available when visiting hospital sites. Personnel databases were acquired from the Ministry of Health and Maputo Central Hospital. The health care metrics and personnel information obtained were verified with the Director of the National Program of Anesthesia and Resuscitation under the Ministry of Health and Chairman of Anesthesia at the Maputo Central Hospital, and the President of the Mozambican Pain Association.

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RESULTS

Ten anesthesia practitioners at 5 Mozambican institutions were interviewed (Tables 1–5 and Fig. 1). Maputo, the capital of Mozambique, has 4.5% of the population and 77% of the physician anesthesiologists. The only anesthesia residency program in the country is located in Maputo, and a majority of the physician anesthesiologists live and work in Maputo.

Table 1.

Table 1.

Table 2.

Table 2.

Table 3.

Table 3.

Table 4.

Table 4.

Table 5.

Table 5.

Figure 1.

Figure 1.

Mozambique has 33 practicing anesthesiologists and 257 anesthesia technicians for 25.8 million people.17 Anesthesia technicians practice independently and without physician supervision. Physician anesthesiologists are found only in the central (level 4) and provincial (level 3) hospitals. The first referral hospitals that should have capacity to perform emergency surgery according to the WHO are staffed by technicians only. In addition to the Mozambican workforce, 19 foreign anesthesiologists (Table 2) are also contracted by the government to work in the country. Mozambique has a national anesthesia society recognized by the WFSA; it includes 11 anesthesiologists and 60 technicians.

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Medical School and Residency

There is no formal anesthesiology exposure in the medical school curriculum. To reach the US anesthesia capacity, Mozambique needs 5166 anesthesia providers. Mozambique has 1 anesthesia residency with 4 training spots yearly. However, these spots are not always filled; last year’s class recruited no residents. Reasons for this include lack of medical student interest, lack of exposure to the specialty, and paucity of anesthesia teachers (Table 6).

Table 6.

Table 6.

Physician training in Mozambique involves 6 years of medical school, of which 1 year serves as an internship with multiple specialty rotations. Immediately after graduation, the majority of students must complete 2 years of paid general medicine public service. They are assigned any location throughout Mozambique from central to rural for practicing general medicine. After this commitment, postgraduate training begins, and residents must complete 4 years of anesthesia residency. The only anesthesia fellowship offered is Pain, which must be completed in Spain and Portugal, only 1 anesthesiologist has completed this training since 1975. After residency, anesthesia providers may choose to specialize in a field such as obstetrics or cardiovascular by performing more cases in that area as consultants. In the Maputo Central Hospital, anesthesiologists rotate through the operating room, intensive care units, radiology suites, and chronic pain clinic, and they are currently expanding to provide pediatric sedation. Even if physicians develop areas of interest, all are required to rotate through the urgent care service in the Central Hospital.

There are entrance and exit examinations for the anesthesiology residency; licenses are provided by both the Ministry of Health and the Order of Doctors. Anesthesia residency diplomas include certification to deliver anesthetics and intensive care. There is no formal resuscitation training in the country (such as the American Heart Association Advanced Life Support), and certification is not required. Several practitioners reported travel to South Africa to seek certification in Advanced Trauma Life Support, Advanced Adult Life Support, and Pediatric Advanced Life Support. No continuing medical education is required nor does it exist for anesthesiologists.

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Anesthesiology Technician Training

There are 2 anesthesia technician schools: a medium-level training program (Instituicao para a Sciencia e Saude [ICSM]) and a superior-level training program (Instituicao Superior de Sciencias e Saude [ISCISA]). The medium-level school graduates 20 to 30 people each year. The superior school graduates 33 students this year and offers advanced training to medium-trained anesthesia technicians. These superior technicians are trained as teachers, and 10 have been assigned to the 3-level 4 hospitals in the country. Many medium-level technicians aspire to be superior-level trained, but barriers include the fact that time away from their current posts has significant impact on anesthesia capacity. Therefore, hospitals wait for 1 superior technician to graduate before sending another away for training.

Anesthesia technicians work as practicing nurses before training. Nursing school is 1.5 years; medium-level studies take 2.5 years; superior studies take an additional 4 years, and all levels of training require tuition. Entrance and exit examinations are required. The Ministry of Health provides licenses to practice anesthesia. No continuing medical education is required or provided; no formal resuscitation training is provided.

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Access to Essential Medicines and Safety Monitoring

The Mozambique pharmacopeia supported by the Ministry of Health includes every medication in the WHO Model List of Essential Medicines for anesthesia, pain, and palliative care.18 In the capital city of Maputo, anesthesiologists report access to all of these medications, but there are frequent medication shortages. Outside of the capital, however, access to essential medicines is not as predictable.19 Opioids for acute pain management are frequently unavailable outside of urban areas. The Maputo hospitals visited are equipped with anesthesia machines, fresh etco2 absorber, and standard American Society of Anesthesiologists monitors including pulse oximetry in the operating rooms, blood pressure, and electrocardiogram.

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Pain Management

The Maputo pain unit located in Maputo Central Hospital is the only chronic pain clinic in Mozambique. The clinic is staffed with 1 full-time fellowship trained anesthesiologist and 2 part-time physician anesthesiologists, 1 general physician, 4 nurses, and 1 full-time and 1 part-time psychologists. Medications available for chronic pain management include morphine, tramadol, paracetamol, ibuprofen, lidocaine, bupivacaine, and methylprednisolone. Opioid shortages are common, and extended-release transdermal formulations are not available. A wide range of pain-alleviating procedures are performed including neuraxial and regional nerve blocks, as well as local trigger point injections.

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DISCUSSION

The anesthesia crisis in Mozambique is similar to other LICs in Africa. Inadequate numbers of physician providers have been compensated for by task shifting to technicians to fill the gap in anesthesia delivery. Although training physician and technician providers is ongoing, the graduation rate lags behind the need for both emergency and essential surgery. The Lancet Commission on Global Surgery recommends surgical, anesthesia, and obstetrical ratios to be 20:100,000 providers. Additional barriers to safe anesthesia in Mozambique include lack of safety monitors such as pulse oximetry and commonly unpredictable supplies of essential medicines18 including oxygen, emergency resuscitation medicines, and pain medicines.

The predicted improvement of surgical capacity in LICs after the cost-effectiveness reports from the World Bank1 and Lancet Commission Report3 are likely to increase available funding for surgical care in LICs and encourage the Ministries of Health to invest in essential surgical care and safe anesthesia over the next 20 to 30 years. These goals will only be realized in Mozambique if the current barriers to safe anesthesia are addressed throughout each province.

The Mozambican Ministry of Health plans to expand anesthesia technician training and the anesthesia residency programs. Anesthesiology residency programs will be available in each of the 3 central referral hospitals, with the first class in Nampula starting in Autumn 2015 and the first class in Beira in July 2015.

Perioperative mortality rates in Mozambique are not known; however, collection of the perioperative mortality rate is underway. Safe surgery and anesthesia are dependent on evaluation of process and quality improvement, and for LICs, the perioperative mortality rate is an initial evaluation of current patient safety and will benchmark surgical system improvements.

The survey assessed anesthesiologists’, residents’, and technicians’ perceptions of barriers to increasing the workforce capacity. The most common challenge cited was the lack of educators to train the number of anesthesia residents and technicians. External assistance has periodically assisted in training, but a sustainable program is greatly needed. Teaching capacity can increase by using foreign anesthesiologists for training, not just providing care, as in their current roles. In addition, the residency program appreciated international training previously offered by the French government for postgraduates. Residents were exposed to new techniques and experiences, as well as received training and support from mentors. In addition to a shortage of educators, there is a shortage of allocated residency positions to anesthesia by the Ministry of Health from a pool of specialty physicians. This problem will improve as the number of physicians in the country increases over time.

Lack of interest in anesthesia is a challenge in Mozambique as well. Medical students are not currently exposed to the specialty, and there is no formal curriculum to include anesthesia as a clinical rotation. However, there is considerable interest in anesthesia technician careers, and many current technicians are seeking to advance in their careers by becoming superior technicians.

Anesthesia compensation in Mozambique is inadequate and usually lower than compensation for other medical specialties. This reality combined with overall shortages in many public hospitals often lead anesthesiologists to seek private hospital alternatives. A 2015 initiative addresses the issues of duel appointments through monetary incentives. Now, providers who agree to work solely for public institutions will receive a 40% increase in salary, although this initiative does not address the lack of resources in public hospitals.

There are many challenges for medical school graduates to seek specialty training such as anesthesia, including the 2-year general medicine requirement that students owe the government. After 2 years, many doctors are unwilling to return to Maputo city for further training because of high living expenses and family relocation. The anesthesia residents interviewed would prefer to repay this time after postgraduate training. Some exceptional students have this option, although recently the Ministry of Health has not approved it.

To meet the Lancet Commission on Global Surgery goal of 20 anesthesia providers per 100,000 population and the DCP3 recommendations for anesthesia and perioperative care, the Mozambique health care system must increase the number of physician providers, advance the training of current and future technician providers, and work to meet the minimum anesthesia guidelines of the WFSA and WHO. Consistent access to essential medicines, especially oxygen, and availability of safety monitors are essential to improve patient safety and anesthesia outcomes.

Mozambique sets an example on progress of the WHO essential medication availability. Access to medications increased from 10% of the population in 1975 to 80% in 2007. In 2006, 465 medications were tested for regulatory purposes with only 7.4% failing identity or assay.20 In 1999, Mozambique started a Common Fund for Medicines and Medical Supplies to finance medicine procurement and pharmaceutical support to prevent shortages; this was found to be very effective.

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CONCLUSIONS

Anesthesia in Mozambique, similar to other LICs, is limited by too few providers and safety monitors. This reality limits access to emergency and essential surgery and patient safety. As surgery increases with the support of the DCP3, Lancet Commission, and the new resolution on safe surgery, and anesthesia, practical, country-based solutions are imperative. Mozambique’s health system model holds promise for success and is ready for expansion, including for surgical and anesthesia components, and may provide an example for similar LICs in Africa.

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DISCLOSURES

Name: Camila B. Lyon, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Camila B. Lyon approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript and is the archival author.

Name: Amina I. Merchant, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Amina I. Merchant approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript.

Name: Teresa Schwalbach, MBBS.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Teresa Schwalbach approved the final manuscript.

Name: Emilia F. V. Pinto, MBBS.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Emilia F. V. Pinto approved the final manuscript.

Name: Emilia C. Jeque, MBBS.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Emilia C. Jeque approved the final manuscript.

Name: K. A. Kelly McQueen, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: K. A. Kelly McQueen approved the final manuscript.

This manuscript was handled by: Hugo Van Aken, PhD, FRCA, FANZCA.

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