Zambia has a population of approximately 14.5 million1 and is ranked 141 out of 187 countries on the Human Development Index.2 It is classified as one of the least developed countries by the United Nations3 and has a gross national income per capita of $2898 (US) with 74% of the population living on less than $1.25 (US) a day.1 The University Teaching Hospital (UTH) is a referral center for Zambia as well as serving the entire Lusaka area with an estimated population of 1.7 million.4 It has an inpatient capacity of approximately 1655 beds, but demand often outstrips capacity. UTH is also the main teaching site for the University of Zambia School of Medicine (UNZASoM) and serves as the clinical training hospital for undergraduate and postgraduate specialties.
The Lancet Commission on Global Surgery has defined the challenges facing resource-poor countries if they are to improve their perioperative outcomes in the next decade.5 One of these challenges is the consistent provision of safe anesthesia services to underpin a robust “surgical ecosystem.” Data from 2006 indicate that anesthesia services at the largest referral hospital in Lusaka, Zambia, the UTH, suffered from poor infrastructure, inadequate staffing, poor access to equipment to support anesthesia practice, absence of a postgraduate anesthetic teaching program, and no research activity within the specialty in the previous 5 years.6
The situation in anesthesia has changed significantly over the past 9 years, mainly owing to investment in the specialty by the UK Department for International Development (DFID) and the Zambian Ministry of Health, and the development of effective partnerships to support postgraduate training in anesthesia by the Tropical Health and Education Trust (THET).7 , 8 The primary aim of this study was to evaluate precisely what progress has been made over the past 9 years and the current state of anesthesia in Lusaka, Zambia, which will inform efforts to further develop the specialty in support of the aspirations of the Lancet Commission on Global Surgery. A secondary aim of the study was to assess the extent to which international health partnerships have contributed to the successful growth.
This study was granted ethics approval from the ERES Converge Research Ethics Board. Data were collected at the UTH, Lusaka, Zambia between April 11 and May 15, 2015. The data collection form was based on the previous study by Jochberger et al6 so that the current status of clinical practice, education, and research in anesthesia at UTH could be directly compared with findings from 9 years ago.
Purposive sampling was used to recruit participants who could authoritatively represent key professions and specialties in perioperative care. We aimed to include participants who had been at UTH throughout the 9-year period covered in the study. Eight participants were identified and all of them have consented to participate in the study (2 consultant anesthesiologists, 2 Master of Medicine [MMed] anesthesia trainees, consultant radiologist, consultant hematologist, consultant pathologist, and an intensive care nurse). Qualitative data collection was by semistructured interviews lasting between 10 and 40 minutes conducted by 2 of the authors (A.J. and T.K.). The same questionnaire was used for all the participants (see Supplemental Digital Content, Data Collection Form, http://links.lww.com/AA/B711). Notes were taken during the interviews and all information was subsequently entered into the data collection form. Supporting data were collected from a document review that included departmental and hospital records and documents from relevant training programs. Hospital statistics were obtained with permission from the hospital superintendent who granted permission to access all data sources, covering the years from 2012 to 2015. Cross verification was used whenever possible during data collection process. All data were analyzed thematically using the framework described in the 2006 study so that the historical situation could be directly compared with the current state. The themes were based on what was proposed by Jochberger et al to be the 3 major functions of a major teaching hospital: patient care, undergraduate and postgraduation education, and research. Patient care was further divided into anesthesia, intensive care, and supporting disciplines.
The workload of the Department of Anaesthesia has increased only slightly since 2006. There are still 17 operating theaters, of which 15 are now in regular use compared with 13 in 2006. A little fewer than 20,000 procedures are performed every year, up from 16,000 in 2006, with a substantial increase in the number of major cases performed (Table 1). There have been significant changes to anesthetic techniques most commonly used since 2006, in particular, techniques for airway management and the use of neuraxial (spinal) anesthesia. Whereas previously most general anesthesia (GA) cases were managed with endotracheal tubes (ETT) or mask anesthesia, now laryngeal mask airway is the predominant method owing to its ubiquitous availability. This is aligned with practice in high-resource environments.
The rate of spinal anesthesia for cesarean deliveries has risen from 20% to 86.2%, which represents a significant advance toward safer anesthesia for pregnant women, and this appears to be due to better education of anesthesia providers. There is a wider choice of anesthetic and analgesic agents available compared with 2006 (Table 2), with propofol and fentanyl, previously unavailable, now standard agents for GA. Although halothane remains the most commonly used inhalational agent, isoflurane has also become available.
In 2006, there was no electronic or automated monitoring, with a reliance on clinical skills known to be inaccurate (eg, estimation of cyanosis) or distracting (eg, manual blood pressure measurement). In 2015, there is automated electronic monitoring that more closely reflects the standards considered to be mandatory in modern practice (electrocardiogram, noninvasive blood pressure, oximetry), with the exception of respiratory CO2 and anesthetic gas measurement, which are still unavailable. Although the postoperative recovery room is now equipped with pulse oximeters (Lifebox, from http://www.lifebox.org/), noninvasive blood pressure machines and occasional availability of electrocardiogram (ECG) monitors, regular staffing by nurses with specific recovery training remains an issue.
There are no 2006 data on oxygen availability, but we present data about the current status here for any future comparisons. As in 2006, oxygen is provided by a central oxygen unit, provided by in-house oxygen concentrators, but both concentration (70%–80%) and pipeline pressure (less than 4 Bar) are erratic. However, supply by oxygen cylinder provides more predictable pressures, notwithstanding at low oxygen concentrations (50%–60%). The oxygen cylinders are also filled from in-house oxygen concentrators. Air conditioning that was nonexistent in 2006 is now available in all theaters, but the use is intermittent due to the lack of patient-warming devices. The electricity supply appears to be the same quality as in 2006, with occasional unexpected (usually up to 15 minutes) and planned (up to 6 hours) power cuts. Availability of water is also unchanged at around 16 hours a day with only stored water being used overnight.
Drugs and Consumables
Data from 2006 are limited and no direct comparison can be made. However, there is a good supply of dressing materials and basic airway equipment, but supply of consumables for the intensive care unit (ICU) is donor driven and is erratic. In 2014, ETTs were available in a wide variety of sizes, but UTH is still very much reliant on reuse of ETTs designed to be single use, after cleaning with 0.5% chlorine. Laryngeal masks were also reused and available in a wide variety of sizes. Intravenous cannulae, needles, and syringes were available and single use in 2014. This situation seems to be essentially unchanged from 2006.
For anesthesia, there is a broader range of induction agents, muscle relaxants, benzodiazepines, analgesic agents, antibiotics, and emergency drugs available and commonly used (Table 2). Inotropic agents such as epinephrine are now readily available, with norepinephrine frequently available from donations. However, invasive arterial monitoring is only available in exceptional cases.
In 2006, all anesthetic machines were over 20 years old, had no facilities for positive pressure ventilation or any monitoring. There has been a significant improvement in the quality of anesthetic machines and monitoring for theaters, which are modern and of adequate standard. Twenty new Aeon 8300A (Aeonmed, Beijing) anesthetic machines (Figure) have recently been supplied by the Ministry of Health and are equipped with volume/pressure-controlled ventilators and integrated monitoring. The availability of maintenance provided by the hospital-based engineering department remains variable.
Intensive Care Unit.
The ICU has remained a 10-bed mixed medical/surgical unit and continues to be run by the Department of Anaesthesia. In contrast to the 354 admissions in 2005, there were 793 in 2015, but poor records make it impossible to provide a breakdown of the most common diagnoses. Surgical causes accounted for 62% of admissions and medical for 38%. Of the surgical admissions, 36% were following trauma and around 10% were obstetric. Mortality rate based on the best available data was 46.2% in 2014, compared with 55.9% in 2006, but there are not enough robust data to explain the improvement. Nursing provision has improved in terms of both number (35 vs 28) and skill (Table 3), with a critical care nursing training program, implemented by THET, being a major contributor.
The ICU is currently equipped with 10 ventilators, 8 infusion pumps, and 8 IntelliVue MP20 monitors (Philips, Amsterdam), which provide integrated monitoring of patient’s ECG, heart rate, oxygen saturation, and blood pressure. Not all of the above were functional at the time of data collection. Availability of transducers for central venous pressure monitoring is very limited and there is only facility for invasive arterial blood pressure monitoring in ICU in exceptional cases. This is a distinct improvement on the situation with monitoring in 2006 when there were 3 pulse oximeters and 9 ECG monitors (with no information on how many of them were functional). The current range of routine nursing observations remains much the same as 2006 and includes noninvasive blood pressure, oxygen saturation, heart rate, respiratory rate, Glasgow Coma Scale, and urine output measurement if requested.
There has been a substantial increase from the 5 physician and 8 clinical officer anesthetists (COA) available in 2006. The Department of Anaesthesia has a current complement of 30 physician anesthetists comprising 7 consultants and 23 residents (postgraduate anesthesia trainees), with only 6 COAs (Figure). Staffing is such that all elective theaters now have assigned physician anesthesiologists, and the ICU is covered by anesthesia residents for 24 hours per day. The ICU is further staffed by 5 consultants (including 3 physicians not counted above) who provide daytime cover 4 days of the week.
In addition to local staff, the anesthetic department has also been supported by visiting clinicians from the UK and Canada who are attached as honorary consultants (attendings) or visiting residents. This is the main form of support provided by the global health partnership. These visiting faculty are supported by THET’s grant through DFID, and their primary role is to deliver all the classroom teaching for the MMed anesthesia program7 as well as most of the clinical supervision. These visiting faculty also conduct specified quality improvement initiatives including working with local trainees to support audits, improvement in the organization and storage of anesthesia equipment, the introduction of the World Health Organization surgical safety Checklist, the development of clinical protocols, and the institution of mortality and morbidity meetings. In 2014, these additional visiting faculty included 9 consultants on short-term visits of between 2 weeks and 3 months each. Since 2013, there has also been 1 consultant anesthetist employed full time by UNZASoM as a lecturer and academic lead for the postgraduate training program who remained in country for 2 years. There were also 5 visiting senior residents (with 4–5 years of anesthesia training in the UK or Canada) and 3 junior residents (with 2–3 years of postgraduate anesthesia training in the UK) in Zambia for between 1 and 6 months. Consultant short-term visiting faculty were funded by the UK Department of International Development, via a grant administered by THET. Trainees have had funding from a variety of sources including grants from THET, the Association of Anaesthetists of Great Britain and Ireland and the Beit Trust, but in many cases these visits have been largely or entirely self-funded.
A more comprehensive range of blood tests was routinely available in 2014 (full blood count, electrolytes, renal function, liver function, clotting profile, arterial blood gases, and cardiac enzymes) than in 2006 (full blood count, electrolytes, and serum glucose), but, as then, reagents are not always available and the service is only available during daytime hours. There is also no efficient system for delivering blood samples to the laboratory, with delays in obtaining results. There are a limited number of devices for bedside hemoglobin measurement in cases of acute hemorrhage.
As in 2006, the blood transfusion service was able to issue a range of products including whole blood, packed red blood cells, platelets, fresh frozen plasma, and cryoprecipitate, which were all routinely tested for infectious diseases and transfusion compatibility. Blood product shortages did occur and occasionally emergency Group O blood was out of stock. Recent developments have been the formation of a Hospital Transfusion Committee and the implementation of a massive hemorrhage protocol, these being examples of quality improvement initiatives by a THET supported volunteer and clinical faculty.
Limited data from 2006 indicate very poor radiological support for ICU, with no x-ray or sonography available in the ICU, which has improved considerably. Routine x-rays are available at any time, but are not always achieved on the same day due to organizational delays. There is a dedicated portable x-ray machine situated on the ICU, and radiographers are on site for 24 hours a day. Ultrasound examinations are available up to 4:00 PM and both computed tomography and magnetic resonance imaging scans are available on the hospital site. However, when the hospital computed tomography scanner is not functional, critically ill patients may need be transferred to other hospitals for investigations.
Anesthesiologists or COAs (nonphysician anesthesia providers) are regularly requested to attend critically ill patients in the Emergency Department, in sharp contrast to the situation in 2006 when the anesthesia department did not undertake any patient management outside theaters and ICU. The Emergency Department now has a dedicated defibrillator. Anesthesiologists also occasionally provide urgent treatment to critically ill patients on the wards where they have access to emergency trolleys with a limited supply of epinephrine, atropine, and occasionally a self-inflating bag. A surgical emergency department also provides basic monitoring, airway equipment, and emergency drugs for use by anesthesiologists.
Although there is a growing awareness of the importance of postoperative pain control, anesthesiologists are not yet formally responsible for pain management outside theaters and ICU. This situation has not changed since 2006, possibly owing to the still limited number of anesthesiologists available to provide such a service.
EDUCATION AND TRAINING
In 2006, undergraduate anesthesia was taught as a subspecialty of surgery, but there is no report of the curriculum content. Structured teaching now exists for anesthesia and medical students to complete a 2-week module in the specialty. This includes tutorials comprising the history of anesthesia, pharmacology of anesthetic agents, neuraxial anesthesia, obstetric anesthesia, pediatric anesthesia, and anesthesia for a shocked patient. Informal teaching is also delivered on a daily basis in the operating theaters by residents and consultants.
There was a complete absence of any postgraduate training program for anesthesia in 2006, although programs existed for the specialties of surgery, obstetrics, internal medicine, and pediatrics. In 2011, the UNZASoM MMed anesthesia Program was initiated, with support from THET, and by 2015 the course had 23 residents over 4 years of training.7 The syllabus is delivered by a combination of formal small group teaching sessions, simulation, and workplace-based supervision delivered by visiting faculty from the UK and Canada. Direct clinical supervision is also provided by local consultants, with distant supervision out of hours. Curriculum delivery and assessment are based on the UK model of postgraduate anesthetic training, with residents participating in annual reviews for training progress at the end of each year and compulsory examinations at the end of the first and fourth years. The structure of the examinations is aligned to those of the UK Royal College of Anaesthetists, although there is no formal link between the 2. The program had its first graduates in October 2015, the first physician anesthetists to complete training in Zambia since independence in 1964. At the time of this study, a proposal was submitted and under consideration by UNZA to recognize an independent academic Department of Anaesthesia.
Nonphysician anesthetic training was not mentioned in the previous study, but a clinical officer training program has been in place since the 1960s, with an Advanced Diploma program since 1996. This is a 2-year program based in Lusaka and comprises practical experience in the hospital and structured teaching in the classrooms. This program is run by clinical officers at the Chainama College of Health Sciences, a public institution under the Ministry of Health.
In 2006, the only continuing professional development provided for anesthetists was through a biennial anesthesia conference held in Lusaka. This conference is still held, but there are now several other opportunities for professional development that have been initiated to support the postgraduate anesthesia training program. These include the Safe Obstetric Anesthesia course (3 courses to date including 70 anesthesia clinical officers)9 and Primary Trauma Care course (one course to date including 7 clinical officers),10 supported by THET and the Lifebox course (which provides oximeters and teaching on the World Health Organization surgical safety checklist),11 supported by the Lifebox Foundation. All these courses are supported by the MMed trainees, and the reach is beyond Lusaka, to include COAs stationed in rural districts and includes a “train the trainers” element that aims to embed training capacity locally.
The report by Jochberger et al noted that in 2006 there had been no research activities by the division of anesthesia for the previous 5 years. Since 2011 every postgraduate anesthesia trainee has been expected to lead their own research project for the dissertation required to pass the MMed anesthesia degree. To date, 3 of these projects have been completed, 7 have been granted research ethics approval, with the other proposals at earlier stages of development. The completed projects were on (1) anesthetic-related perioperative complications during cesarean deliveries at UTH, (2) a validation of pain assessment tools for the patient population at UTH, and (3) a comparative study of diclofenac with wound infiltration to additional ilioinguinal/hypogastric nerve block for pain relief in children undergoing groin surgery. These research dissertations have been supervised by visiting faculty from the UK and Canada through a combination of in-person visits and remote research mentorship using electronic communication. Other scholarly activities from 2011 to 2015 include collaborative research undertaken by local and visiting residents, and visiting faculty of the Department of Anaesthesia, as well as co-investigators in the Departments of Surgery and Obstetrics.12–15
There have been significant positive changes in anesthesia at UTH in the past 9 years. Progress has been marked in the 3 areas of patient care, education, and research as defined by Jochberger’s study. Although these areas are interdependent, our study suggests that the primary driver for development has been the initiation of the postgraduate training program in anesthesia and intensive care which has had the multiple effects of increasing the number of capable anesthesia providers, increasing advocacy for an undervalued profession, strengthening processes for procuring drugs and equipment, embedding quality improvement as an expected professional activity and driving scholarship through mandated research activity.
The Department of Anaesthesia at UTH is no longer a subdivision of the Department of Surgery and has expanded its zone of activity beyond the operating theater to encompass care of critically ill patients in the ICU and across the hospital. This is in keeping with the international recognition of the anesthesiologist as “perioperative physician” rather than theater technician. The ICU is now covered by anesthesia for 24 hours per day, with significantly increased consultant input during the day. However, Zambian anesthesiologists have yet to assume responsibility for pain management, which is an integral function of the anesthetist’s extended role.
Although evaluating patient safety and better operative outcome was not the direct aim of this study, it is likely that the observed improvements in the processes, equipment, and drugs for anesthesia have had a beneficial effect on surgical outcomes. The strongest indicator for such improvement is the huge increase in the number of spinal anesthetics for cesarean delivery since 2006, rising from 20% to 86%. This is a major achievement in obstetric anesthesia because it is well recognized that spinal anesthesia is a safer alternative to GA and has been advocated as a first choice for the conduct of cesarean deliveries worldwide. Further enhancement in this high risk area has been the successful delivery of several SAFE Obstetric courses, which not only train anesthetists to better manage acute problems for pregnant women, but also embed the capacity for further training locally. Additionally, the Lifebox and Primary Trauma Care courses provide important sources for continuing professional development, and adopt the same philosophy of embedding training capacity locally so that the courses become self-sustaining over time.
The growth in educational and research activities in the department has been of sufficient quality for the university to consider forming a self-standing Academic Department of Anaesthesia within UNZASoM. If this development comes about, it will likely give greater impetus to further growth to the specialty and raise its profile which in turn will promote recruitment and retention in this undervalued discipline.
If, as our study suggests, the observed improvements since 2006 are directly attributable to the development of a postgraduate training program in anesthesia with an increased number of physician anesthetists, it begs the question of how the program has been successfully implemented. The answer may offer a solution to other countries facing similar challenges. In the case of Zambia, the central vehicle for development has been through global health partnerships enabled by THET. A full description of how this partnership was put together can be found elsewhere,7 but the necessity to train specialist physician anesthesiologists was identified by the Zambian Ministry of Health, which has had a previous formal partnership with the UK government. THET has sourced funding from the UK DFID to support the initial requirement for overseas faculty. It is difficult to give a precise amount for start-up costs as they included the anesthesia program as 1 of 3 MMed programs that were started at the same time, and included support of nursing training and biomedical engineer training in Zambia, which were all supported by THET. There were some shared costs between these programs, but we estimate that start-up and ongoing costs for the anesthesia program were around £100,000 ($123,000 USD) per year. THET also leveraged cooperation and support from high-level stakeholders such as the Ministry of Health. Without such high-level buy-in, it would have been difficult to negotiate the many hurdles presented when instituting a major change from afar. In addition, the ties to institutions in the UK have helped to develop a base of expertise to support all aspects of program development; curriculum design and review, research, and quality improvement.
Funding has since been renewed by DFID for the anesthesia program on the basis of 3-year funding cycles. The current funding cycle ends in late 2017, and it is not yet clear if there will be ongoing funding from the DFID or other funding agencies. We are now in the second phase of the partnership. Phase 1 (2010–2015) was called “building capacity” and phase 2 (2016–2020) is called “embedding the program locally.” The goals of the current phase are to mentor graduates of the program into leadership roles in administration, education, research, and quality improvement both at the University of Zambia/UTH, where the training program is situated, but also nationally. The goal is to have the program entirely run by Zambian anesthesiologists and to be self-sustaining by the end of this phase of the partnership as well as to broaden support to all anesthesia providers to ensure adequate supply of trained providers across Zambia.
This study has limitations; in particular, we did not collect data, or have previous data for comparison, on many factors relating to anesthesia care that are likely to affect the outcome of perioperative care. Areas for future evaluation should include surgical and nursing factors such as the number and subspecialty availability of surgeons, constraints in nursing staffing, sterilization processes, and available surgical equipment.
Jochberger et al made several recommendations for improving anesthesia in Zambia. We would concur with their recommendations for “Improved staff training … promotion of anesthesia to improve its image as a postgraduate specialty, and… the creation of a local postgraduate training scheme.”6 We believe that these elements have been critical to the observed growth of anesthesia at UTH in the past 9 years. Their other recommendations for reliable supply of basic amenities and drugs, functional medical equipment, improved anesthesia systems (such as procurement), and introduction of clinical audit and governance procedures naturally follow because the primary interventions create a “pull” on the rest of the system through enhanced advocacy, influence, and understanding. However, their recommendations offer no guidance as to how the necessary changes were to be achieved, and our study has offered insights into how major change has been facilitated. Global health partnerships and the concept of codevelopment16 have been key enablers to progress and have demonstrated how effectively this model of support can work. This advance in anesthesia capability has coincided with the recent launch of the Lancet Commission on Global Surgery, which has placed surgical outcomes and development of the surgical care environment at center stage internationally.5 Central to achieving the Commission’s goals are developing anesthetic capacity in countries with high perioperative mortality to support safe surgery.
There needs to be continuing investment in infrastructure, equipment, and drugs, but these are likely to continue to be driven by further developing training and research capacity to create an established profession of anesthesia in Zambia who can advocate for patient safety. Although the profiles of anesthesia and perioperative care are rapidly evolving, subspecialty areas will require significant enhancement of expertise. For Zambian anesthetists to develop these skills, it will be essential for them to be exposed to practice in a high-resource environment so that they can return with the expertise. This can be achieved by supporting fellowship schemes in neighboring and overseas countries. Some examples already exist in Uganda, Malawi, Zimbabwe, Namibia, Tanzania, who access fellowships in South Africa, Canada, America, and Asia. Furthermore, regional collaboration will be important in setting uniform standards for anesthesia practice and training and the anesthesia community has followed the example of the College of Surgeons of East, Central and Southern Africa (COSESCA) collaborative17 by founding the College of Anaesthesia of East, Central and Southern Africa (CANECSA) in 2014.
Name: Anna Janowicz, MD.
Contribution: This author helped collect and analyze the data, and write the manuscript.
Name: Tuma Kasole, MBChB.
Contribution: This author helped collect and analyze the data.
Name: Emily Measures, MA.
Contribution: This author helped write the manuscript.
Name: Meg Langley, MPH.
Contribution: This author helped write the manuscript.
Name: Fastone M. Goma.
Contribution: This author helped review the manuscript.
Name: Feruza Ismailova, MD.
Contribution: This author helped collect the data and review the manuscript.
Name: John A. Kinnear, MBBCh.
Contribution: This author helped write the manuscript.
Name: M. Dylan Bould, MBChB.
Contribution: This author helped supervise data collection and analysis, and write the manuscript.
This manuscript was handled by: Angela Enright, MB, FRCPC.