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An Observational Assessment of Anesthesia Capacity in Madagascar as a Prerequisite to the Development of a National Surgical Plan

Baxter, Linden S. MBBS*; Ravelojaona, Vaonandianina A. MD*; Rakotoarison, Hasiniaina N. MD*; Herbert, Alison RN*; Bruno, Emily BS*†‡; Close, Kristin L. BAS*; Andean, Vanessa MBBS; Andriamanjato, Hery H. MD; Shrime, Mark G. MD, PhD‡¶#; White, Michelle C. MBChB*

doi: 10.1213/ANE.0000000000002049
Global Health: Original Clinical Research Report
Free
SDC

BACKGROUND: The global lack of anesthesia capacity is well described, but country-specific data are needed to provide country-specific solutions. We aimed to assess anesthesia capacity in Madagascar as part of the development of a Ministry of Health national surgical plan.

METHODS: As part of a nationwide surgical safety quality improvement project, we surveyed 19 of 22 regional hospitals, representing surgical facilities caring for 75% of the total population. The assessment was divided into 3 areas: anesthesia workforce density, infrastructure and equipment, and medications. Data were obtained by semistructured interviews with Ministry of Health officials, hospital directors, technical directors, statisticians, pharmacists, and anesthesia providers and through on-site observations. Interview questions were adapted from the World Health Organization Situational Analysis Tool and the World Federation of Societies of Anaesthesiologists International Standards for Safe Practice of Anaesthesia. Additional data on workforce density were collected from the 3 remaining regions so that workforce density data are representative of all 22 regions.

RESULTS: Anesthesia physician workforce density is 0.26 per 100,000 population and 0.19 per 100,000 outside of the capital region. Less than 50% of hospitals surveyed reported having a reliable electricity and oxygen supply. The majority of anesthesia providers work without pulse oximetry (52%) or a functioning vaporizer (52%). All the hospitals surveyed had very basic pediatric supplies, and none had a pediatric pulse oximetry probe. Ketamine is universally available but more than 50% of hospitals lack access to opioids. None of the 19 regional hospitals surveyed was able to completely meet the World Federation of Societies of Anaesthesiologists’ standards for monitoring.

CONCLUSIONS: Improving anesthesia care is complex. Capacity assessment is a first step that would enable progress to be tracked against specific targets. In Madagascar, scale-up of the anesthesia workforce, investment in infrastructure and equipment, and improvement in medication supply-chain management are needed to attain minimal international standards. Data from this study were presented to the Ministry of Health for inclusion in the development of a national surgical plan, together with recommendations for the needed improvements in the delivery of anesthesia.

From the *Mercy Ships, Port of Toamasina, Madagascar; College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; §Department of Anesthesia, The Austin Hospital, Melbourne, Australia; Ministère de la Santé Publique, Madagascar; Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts; and #Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.

Accepted for publication January 6, 2017.

Funding: L.S. Baxter received a travel and education grant from the National Institute for Academic Anaesthesia, United Kingdom. E. Bruno received funding for international travel from Boston Children’s Hospital, Boston, Massachusetts, and funding from the Mark Allen McConkey, MD, Medical Student Public Service Fund.

Conflicts of Interest: See Disclosures at the end of the article.

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.

Interim data were presented previously at European Society of Anesthesia Meeting, London, May 2016.

Reprints will not be available from the authors.

Address correspondence to Michelle C. White, MBChB, M/V Africa Mercy, Mercy Ships, Port au Cotonou, Benin. Address e-mail to doctormcw@gmail.com.

In low- and middle-income countries (LMICs), the need for surgical and anesthesia care is growing.1,2 Since surgery was first described in 2008 as “the neglected step child of global public health,”3 little has changed. Today, 5 billion people lack access to surgical care, causing an estimated cumulative loss in economic productivity of US $12.3 trillion by 2030,1 and 16.9 million lives are lost to diseases requiring surgical care.1,4 Despite surgical procedures ranking among cost-effective health interventions,5,6 surgical and anesthesia services remain disproportionately underfunded in LMICs.7 Solutions have been proposed but are challenging to implement due to the cross-cutting nature of surgery and anesthesia.1,8–11 Recent reductions in mortality from general anesthesia have occurred predominantly in high-income countries; LMICs continue to endure mortality rates 100–1000 times higher.12,13 The safe practice of anesthesia depends on multiple factors, including adequate numbers of trained staff, reliable infrastructure, functioning equipment, and the availability of essential drugs. Published reviews of anesthesia care capacity in low-income countries consistently describe widespread, ongoing serious deficits in these areas.9,14,15

In 2015, the World Health Assembly urged member states to address surgical and anesthesia services as part of universal health coverage,16 and the Lancet Commission on Global Surgery published a template for a national surgical plan to guide how this may be achieved.1 Since each country has unique problems, a one-size-fits-all approach is inappropriate. Therefore, country-specific data are still needed if national surgical plans are to have the desired effect. However, progress in action and policy making is impeded by a recognized paucity of published data on anesthetic capacity, especially in low-income countries. Madagascar has an estimated population of 24 million people and is one of the poorest nations in the world.17 There are no reports in the literature on Madagascar surgical or anesthesia capacity.

From April 2015 to June 2016, Mercy Ships, a surgical nongovernmental organization (NGO) providing free surgeries, training, and quality improvement projects, collaborated with the Malagasy Ministry of Health to provide nationwide surgical safety quality improvement training. We proposed that assessment of anesthesia capacity in regional hospitals, conducted during this training, could provide data to aid national surgical plan development.1 This article describes a collaborative approach with the Ministry of Health to assess the anesthesia capacity in Madagascar and discusses how these data will be used to develop a national surgical plan.

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METHODS

This study was approved by the Mercy Ships Institutional Review Board (MS-2015-00), and the Madagascar Ministry of Health gave permission for the study. This article adheres to the applicable Equator guidelines (STROBE statement).

There are 22 regions in Madagascar, each with a regional referral hospital, which, in 6 regions, is classified as a university hospital; the next level comprises the district hospitals (divided into levels 1 and 2); and then the primary care facilities. Surgery is only performed at district level 2 hospitals and regional referral hospitals. The timetable for this anesthesia capacity assessment was designed so it could be conducted at the same time as a separate nationwide quality improvement project implementing the World Health Organization (WHO) Surgical Safety Checklist throughout all the regional hospitals in Madagascar. Of the 22 regional hospitals, those in Antsinanana and Beony were involved in piloting the WHO checklist training in October 2014 and February 2015, and the hospital in Anamalanga (containing the capital city Antananarivo) was being used as part of a separate WHO checklist implementation program in collaboration with another NGO. Therefore, these 3 hospitals were excluded from this anesthesia capacity assessment, leaving data to be collected in 19 of 22 regional referral hospitals and 2 district hospitals suggested by the Ministry of Health. The district hospitals were suggested because one (Antalaha) was very large and functioned much like a regional referral hospital, and the other (Nosy Be) was on an island that is one of the most popular tourist destinations in the country and therefore has a large, albeit transient, population. The regional referral hospitals in Anamalanga, Antsinanana, and Beony, which were excluded, serve a combined population of 5.8 million (24.8% of the total population) as shown in Table 1, which means the anesthesia capacity assessment is representative for 75% of the population. However, workforce density data are representative for 100% of the population because, using baseline data collected during the pilot WHO checklist implementation and verified by personal contact with the hospitals, we were able to calculate workforce density for all 22 regions.

Table 1.

Table 1.

The assessment was divided into 3 areas: anesthesia workforce, infrastructure and equipment, and medications. Equipment was subdivided into adult and pediatric where appropriate. Assessment dates were preagreed with the Ministry of Health, which sent letters informing each regional minister of health and hospital director. A team of 3–5 people, including 2 Malagasy physicians, visited each hospital for 2–3 days between September 2015 and April 2016. On arrival, the team visited the regional ministers of health and hospital directors to confirm understanding of the nature of the visit and the permission to interview hospital staff.

In Madagascar, the anesthesia workforce consists only of fully qualified and registered physician and nurse anesthetists. Physicians after 5 years at medical school must apply during their final sixth year for a national competition for 4 further years of postgraduate anesthesia training at the Faculty of Medicine in Antananarivo. One of the 4 years must take place outside Madagascar, usually in France or the French territory, Reunion Island. For nurses, there are 3 methods of qualification: 1 for high school graduates, and 2 for those already holding a bachelor’s degree in general nursing. High school graduates can apply by national competition for a 3-year bachelor’s degree in nurse anesthesia offered at the Faculty of Medicine in Antananarivo. Qualified general nurses who wish to specialize in anesthesia can either apply for a national competition for a 2-year master’s level program at the National Institute of Nursing in Antananarivo or apply to 1 of the 3 private nurse anesthesia schools in Antananarivo, all of which are authorized by the government and offer a 3-year bachelor’s qualification.

Workforce and infrastructure data were obtained during semistructured interviews with hospital directors, technical directors, statisticians, and Regional Ministry of Health officials. Data on functioning equipment and the availability of essential medications were collected in semistructured interviews with anesthesia providers and pharmacy staff and through on-site observations. All data were recorded in real time using 3 electronic questionnaires representing each area (Supplemental Digital Content, Appendix, http://links.lww.com/AA/B712). Questions were adapted from the WHO Situational Analysis tool18 and the World Federation of Societies of Anaesthesiologists (WFSA) International Standards for Safe Practice of Anaesthesia.19 The WFSA19 classifies anesthesia equipment as highly recommended, recommended, and suggested. Highly recommended is defined as the functional equivalent of a mandatory standard for the practice of safe anesthesia without which only procedures absolutely necessary for the urgent saving of life or limb should be undertaken. The WFSA also classifies small hospitals/health centers, district hospitals, and referral hospitals as level 1, 2, and 3 health care facilities, respectively. Each level of health care facility has prescribed standards for infrastructure and medication availability. We used the WFSA classification to report infrastructure and medication availability. Responses were recorded either as numerical values or using a 3-point Likert scale (“always,” “sometimes,” “never”).

All interviewees were adults over 18 years of age who gave verbal consent to participate. Interviews were conducted by L.S.B. and E.B. either in French or in English, with translation into French or Malagasy by V.R., and H.R. V.A., K.L.C., and M.C.W. also assisted with interviews. Interviews took place at either the interviewee’s own hospital or in the offices of the Regional Ministry of Health and lasted 15–60 minutes. Budget constraints did not allow for recording and transcribing of interviews. Data were recorded contemporaneously using electronic data capture.

In September 2015, when the assessment started, the template for a national surgical plan was published1 but the process not defined. Therefore, we planned 2 meetings with the Ministry of Health. The first occurred at the midway point of the capacity assessment, in December 2015, to review interim results and discuss potential next steps; the second occurred after the completion of the survey to discuss the results and their implications for the role of anesthesia in a national surgical plan.

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Statistical Analysis

Responses from the electronic data collection tool were transferred directly into Excel and were analyzed using simple descriptive statistics. For calculation of workforce density, we used World Bank 2014 population estimates20 for total and regional populations, giving a total population of 23.57 million. The 19 regions surveyed have a combined population size of 17.72 million, representing more than 75% of the total population.

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RESULTS

Data were collected from all 21 predetermined hospitals for infrastructure and equipment and medication surveys, and from 27 hospitals in all 22 regions for workforce density.

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Anesthesia Workforce

Table 2.

Table 2.

The anesthesia workforce in each region surveyed is shown in Table 1. Every hospital performing general anesthesia had at least 1 trained nurse anesthetist, but only 6 regions had physician supervision. The anesthesia physician and nurse workforce densities are 0.26 and 0.53 per 100,000 population, respectively; outside the capital city, the anesthesia workforce densities fall to 0.19 physicians and 0.46 nurses per 100,000 population. In the capital city, physician workforce density is more than 3 times that of the rural areas (0.66 per 100,000 population). A comparison with reported anesthesia workforce density in other LMICs is shown in Table 2.

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Reliable Infrastructure and Functioning Anesthesia Equipment

Availability of essential infrastructure and equipment for administration of safe anesthesia is shown in Table 3. Less than half of the hospitals had electricity and oxygen always available, and 53% of the hospitals always had running water. Ten percent of the hospitals never had oxygen, and 6% never had running water.

Table 3.

Table 3.

Table 4.

Table 4.

The majority of anesthetists (52%) work without pulse oximetry, 24% without reliable blood pressure monitoring, and 52% without a reliable vaporizer (Table 3). None of the hospitals had end-tidal capnography or nerve stimulators, but tracheal tubes, difficult airway equipment (defined as bougie and/or stylet), oropharyngeal airways, self-inflating bags, intravenous administration sets, nasogastric tubes, and personal protective equipment were available for adults in more than three quarters of the hospitals surveyed (Table 3). Pediatric-specific equipment was present in less than half of the hospitals surveyed, and no hospital had pediatric pulse oximetry probes (Table 4).

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Availability of Essential Medication

Table 5.

Table 5.

All surveyed hospitals were level 3 referral hospitals as defined by the WFSA International Standards,19 but none had the full range of recommended medications for a level 1 basic health care facility (Table 5). This is largely explained by the lack of availability of opioids. Suxamethonium was entirely absent; however, other muscle relaxants were available, although none were suitable for rapid sequence induction. Ketamine and thiopentone are widely available and were the mainstay of general anesthesia. Where inhaled anesthesia was used, halothane was the only available agent. Despite spinal needles being available all the time in only 71% of hospitals, spinal anesthesia was widely reported. Intrathecal bupivacaine was always available at 86% of the sites.

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DISCUSSION

Specialist anesthesia physician workforce density is low (0.26 per 100,000 population), and nurse anesthetists provide the majority of general anesthesia in Madagascar. Many hospitals lack reliable oxygen (58%), electricity (59%), and running water (47%); most do not have a pulse oximetry (52%) or a functioning vaporizer (52%); and none have pediatric pulse oximeter probes. No hospital surveyed meets the WFSA “highly recommended” (functional equivalent of “mandatory” standard) for safe practice of anesthesia,19 and the availability of opioid analgesics is very low (<40%).

Like other LMICs,14,15 the shortage of physician anesthesia providers in Madagascar means nurse providers are working without physician anesthetist supervision in 66% of the centers, which is significant since anesthesia services suffer when there are few physicians to advocate for resources and training.21 “Task shifting” of anesthesia duties to nonphysician providers is relied upon in many resource-constrained settings. While the long-term role of task shifting remains controversial,22–24 there remains a clear need for increased numbers of anesthesia providers of all levels. Our data also highlight the workforce shortage in rural regions (anesthesia physician workforce density in the capital region versus rural areas is 0.66 vs 0.19 per 100,000 population). This is relevant because 65%–75% of the population of Madagascar live in rural areas,20 and rural areas face particular challenges in recruiting and retaining specialist medical workforce compared with urban centers.25

Availability of anesthetic equipment is the most commonly identified priority by anesthetists for improving anesthetic safety in other LMIC settings.26 Intraoperative monitoring and the availability of oxygen are also crucial26 and play a critical role in safety. The WFSA describes supplemental oxygen for general anesthesia, pulse oximetry, and temperature monitoring as the “functional equivalent of a mandatory standard” for any center undertaking elective surgery.19 More than half of the surveyed Malagasy hospitals performing general anesthesia (52%) did not have pulse oximetry, none had pediatric pulse oximetry probes, and 67% did not have a thermometer. Other basic pediatric airway and cardiovascular equipment were lacking in more than 50% of the hospitals, similar to other LMIC studies.27,28 This is clinically significant since 42% of the Madagascar population is below 15 years of age, and 85% of children in LMICs are likely to require treatment for a surgical condition by 15 years of age.29 Definitions of a “functioning anesthesia machine” vary and hinder comparisons between studies. A draw-over vaporizer with tubing, present in 43% of the hospitals, could constitute a “functioning anesthesia machine,” but if a functioning anesthesia machine is defined as a vaporizer with reliable oxygen supply and functioning ventilator, then this was only found in 2 of the 21 (10%) hospitals.

McQueen et al10 argue that the WFSA19 and WHO30 standards are unachievable in some very poor countries that cannot provide for consistent oxygen, water, electricity, and the most basic medications. Therefore, they propose a simpler approach: that safe anesthesia founded on vigilance (using pulse oximetry, precordial stethoscope, and clinical signs) should be the “bare minimal” standard. This argument is consistent with our results that Madagascar is a long way from attaining WFSA standards. One major difference between the bare minimal standards10 and the WFSA highly recommended standards19 is that the former place a higher emphasis on temperature, blood pressure, and precordial stethoscope monitoring compared with pulse oximetry. In response to this survey, Mercy Ships supplied pulse oximeters for the operating room and recovery, manual blood pressure cuffs, stethoscopes, and self-inflating bags to all hospitals that needed them. With the exception of a thermometer, all the regional hospitals in our survey can now meet McQueen et al’s10 bare minimal standards for a rural hospital. Thermometers are small and cheap to procure and priority should be given to supplying them to hospitals performing surgery.

The lack of opioids in Madagascar is similar to other studies: one study estimates that worldwide, 5.5 billion people live in countries with low to nonexistent access to analgesic medication;31 another study estimates that 94% of the world’s morphine supplies are used by only 20% of the world’s population.32 We are unable to explain the complete lack of suxamethonium in Madagascar, given its availability in other LMICs. The only alternative to suxamethonium was pancuronium, which was used for nearly all intubations despite the universal absence of peripheral nerve stimulators. Similar to other studies, ketamine was widely available and its use widespread.26 Our results reinforce the view that ketamine is a necessity in LMICs, and any attempt to restrict its use should be resisted and met with simultaneous efforts to improve access to other medications and equipment so as to decrease overreliance on one medication.33 Benzodiazepines and atropine were also widely available to mitigate the common side effects of ketamine.33

The Lancet Commission on Global Surgery described the lack of access to safe, affordable, and timely surgical and anesthesia care. It proposed a series of 6 indicators, time-bound targets, and a template for a national surgical plan. At the time of writing, all data had been shared with the Malagasy Ministry of Health. The Ministry of Health, 2 government representatives, and one of the authors (M.W.), attended a consultative symposium on the implementation process for national surgical plans in March 2016; a working party of surgical specialists was then created and support obtained from other stakeholders for a preliminary planning meeting in September 2016. Five technical work groups are now creating roadmaps for workforce planning, service delivery, infrastructure, finance, and information and technology. At the time of writing, data and recommendations from this survey were being considered by the workforce planning, service delivery, and infrastructure workgroups. Of particular relevance is a Ministry of Health–sponsored anesthesia recruitment campaign beginning in January 2017.

Our study has limitations. We only surveyed government referral hospitals and 2 large district hospitals; smaller district hospitals and private or mission-based hospitals were excluded. However, since the majority of surgeries take place in the hospitals surveyed, and our aim was to inform a national surgical plan with a focus on big-picture strategy, the impact of the omission of other surgical facilities from the survey is minimized. Three out of a total of 22 regional hospitals in Madagascar were excluded, including the largest hospital in the capital region, but nonetheless our survey still covered 75% of the population of Madagascar, which we considered sufficient to inform the national surgical planning process, and workforce density was calculated for all regions. Answers were given face-to-face by structured interview rather than anonymous questionnaire. This could have introduced both positive or negative responder bias, with interviewees feeling the urge to give more positive answers to “impress” or more negative answers in the hope of acquiring a donation. Despite these limitations, we believe our study has a number of strengths. The main strength is that our survey is a comprehensive assessment of anesthesia capacity in Madagascar, covering more than 85% of regional hospitals where the majority of major surgeries take place. It was conducted in collaboration with the Ministry of Health, with the results being shared and used constructively as part of the ongoing development of a national surgical plan. All our data and key recommendations (Table 6) were shared with the Ministry of Health for consideration in the first national surgical plan forum in September 2016.

Table 6.

Table 6.

Improving surgical and anesthesia care in LMICs is complex, and capacity assessment is the first step. At a country level, this information is crucial to target infrastructure improvements, equipment donations, and pharmaceutical supply-chain management. We have described our experience of anesthesia capacity assessment in Madagascar and recommend that all data are made available to governmental authorities, with recommendations to inform national surgical plan development.

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ACKNOWLEDGMENTS

The authors thank Mr Jim Callahan for his help with logistics and translation.

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DISCLOSURES

Name: Linden S. Baxter, MBBS.

Contribution: This author helped conceive the study design, acquire the data, analyze the data, interpret the data, review the literature, and prepare the manuscript.

Conflicts of Interest: None.

Name: Vaonandianina A. Ravelojaona, MD.

Contribution: This author helped acquire the data.

Conflicts of Interest: None.

Name: Hasiniaina N. Rakotoarison, MD.

Contribution: This author helped acquire the data.

Conflicts of Interest: None.

Name: Alison Herbert, RN.

Contribution: This author helped acquire the data.

Conflicts of Interest: None.

Name: Emily Bruno, BS.

Contribution: This author helped acquire, analyze, and interpret the data.

Conflicts of Interest: None.

Name: Kristin L. Close, BAS.

Contribution: This author helped conceive the study design, acquire the data, analyze the data, and interpret the data.

Conflictsof Interest: None.

Name: Vanessa Andean, MBBS.

Contribution: This author helped acquire the data.

Conflicts of Interest: None.

Name: Hery H. Andriamanjato, MD.

Contribution: This author helped acquire, analyze, and interpret the data.

Conflicts of Interest: None.

Name: Mark G. Shrime, MD, PhD.

Contribution: This author helped analyze and interpret the data.

Conflicts of Interest: Mark G. Shrime receives funding from the GE Foundation for its Safe Surgery 2020 initiative.

Name: Michelle C. White, MBChB.

Contribution: This author helped conceive and design the study, acquire the data, analyze the data, interpret the data, review the literature, and prepare the manuscript.

Conflicts of Interest: None.

This manuscript was handled by: Angela Enright, MB, FRCPC.

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