The Lancet Commission on Global Surgery shone a spotlight on many issues related to the dire need for improvement in access to essential surgical services throughout the world, but especially in low-income areas.1 The report’s 5 Key Messages focus on the following: surgery as an essential part of universal health care; the lack of access to safe surgical and anesthetic services for 5 of the world’s 7 billion people; the catastrophic costs which many people encounter in obtaining surgical care; the increased number of surgeries necessary to meet the need; and the projected economic investment which is required in anesthesia and surgery to equalize the imbalance between high and low resource health care environments.
In addition, the Lancet Commission emphasizes the need to have sufficient numbers of well-trained anesthesia, surgery, and obstetric specialist medical providers to meet the need for basic, essential surgical services.1 These numbers were derived from a World Health Organization (WHO) database and when information was not available, numbers were estimated based on national health system indicators.2 While this is a start in assessing the numbers of anesthesiologists, the exclusion of the non-physician anesthesia providers (NPAP) limits the comprehensiveness of the report regarding the global picture of anesthesia care. In the first of 2 articles in this edition of Anesthesia & Analgesia, the World Federation of Societies of Anaesthesiologists (WFSA) helps establish a baseline of where we are globally in regard to the current total anesthesia workforce and the human resource expansion necessary to satisfy a minimal standard.3 The second article by Lipnick et al4 discusses the need for a flexible model of practice which takes into account the human resource challenges in areas of the world which have the most dramatically insufficient anesthesia workforce capacity.
The WFSA has 135 member societies representing 150 countries. In the WFSA Global Anesthesia Workforce Survey,3 we are presented with results from 153 countries, representing 97.5% of the world’s population. The survey was undertaken in 2015 and 2016 and is therefore the most current information available. The WFSA recognized the need to include NPAP numbers and, although these country-specific numbers are much less complete when compared with those for the anesthesiologists, the survey is 1 step closer to capturing the total global anesthesia workforce, both anesthesiologists and NPAPs.
The survey results demonstrate that there are marked disparities in the numbers and distribution of anesthesiologists throughout the world, with the WHO African and South East Asian regions having alarmingly few. Projecting a country-specific, physician provider ratio of 5 anesthesiologists per 100,000 population, only 76 or roughly 50% of all of the countries surveyed meet this goal. Looking specifically at these 2 WHO regions, both demonstrate a ratio closer to 1.3/100,000 population. In comparison, using the World Bank income numbers as a guide, high-income countries have almost 95 times the density of anesthesiologists compared with low-income countries.3 This current anesthesiologist imbalance between high- and low-income countries and the projected need for 136,000 more anesthesiologists immediately should prompt a global response which searches for new approaches and models for care delivery, specifically targeting those areas of greatest need.
So, if there are so few anesthesiologists, who provides anesthesia care in these low- and middle-income countries (LMICs)? There is a variety of NPAP education programs, with diverse entry levels and training durations, which tend to be country or region specific.5–8 It is difficult to obtain exact numbers for NPAPs because they may not be organized into national societies, they tend to work in rural areas and they may not be recognized by the national anesthesiologists’ organizations or even by government licensing bodies. Nevertheless, many LMICs have a long history of utilizing NPAPs, both documented and undocumented, to provide clinical anesthesia care. In rural populations in most countries, more than 50% of anesthesia care is provided by some level of NPAP.
This brings us to the second article of interest in this edition of Anesthesia & Analgesia—by Lipnick et al.4 The Lancet Commission prefers the term task sharing with “shared responsibility” to task shifting.1 The shared tasks are performed directly by someone with less training, preferably under the supervision of a specialist provider, in this case an anesthesiologist. Task sharing has long been practiced in sub-Saharan Africa in medicine, surgery, obstetrics, and anesthesia.9–11 For example, task sharing has been achieved with significant success in addressing the human immunodeficiency virus epidemic in many low resource settings and these country-specific urban and rural delivery models may be quite different.9 Lipnick et al4 emphasize that it is not always possible to have the presence of a supervising anesthesiologist especially in poorly resourced, rural environments. There is a great need for flexibility of approach if anesthesia is to meet the global surgery and anesthesia need by 2030. We must recognize that available resources, both infrastructure and human, will dictate which model is appropriate for safe anesthesia care delivery in our world’s economically diverse environments.
Both of these articles, on merging paths, bring us to a place which highlights the glaring imbalance in the global delivery capacity of anesthesia care while prompting us to seek solutions to meet the anesthesia needs of the 5 billion people without access to safe and affordable surgery. Specialist anesthesiologists from high-, middle-, and low-income countries are needed to lead the specialty, utilizing a global lens and not just a country centric perspective. As a cohesive voice, we must first exponentially increase the number and quality of academic training programs. Second, we should seek to expand the role of anesthesia outside of the operating room environment including, but not limited to, perioperative services, pain management teams, and intensive care units. Finally, and equally important, we must stand as advocates for change with our LMIC colleagues, for infrastructure-appropriate resources and the consistent supply chains necessary to provide safe anesthesia. Although the numbers and quality of specialist anesthesia training programs in LMICs are growing,12,13 the trainee numbers are small in comparison to the tremendous needs. The WHO regions with very low numbers of anesthesiologists will need additional anesthesia educators, an often overlooked necessity, to match the growing government demand to establish additional training programs.
Ministries of Health in many LMICs recognize the need for further development of non-physician anesthesia training programs. While this is appropriate, anesthesiologists should assist their governments in developing an anesthesia roadmap. This would include a standardized curriculum and training duration, an accreditation process, and clear delineation of scope of practice for the various provider levels, in an effort to increase numbers while also improving competency. The WHO Surgical Safety Checklist14 emphasizes the importance of teamwork in the operating room and it is now time for all members of the anesthesia community to work together and to teach this team approach within training programs.
Together, these 2 articles have highlighted the profound deficiency in global anesthesia provision capability, proposed an interim target for levels of anesthesia providers while working toward the Lancet goal,1 and suggested possible solutions for improving team clinical care capacity. Now, we must mobilize and implement a suitable response. What is certainly not appropriate, and may be potentially dangerous, are “quick-fix” solutions sometimes proposed by non-anesthesiologists. A recent example is a 5-day course teaching non-physician health care workers how to administer ketamine for surgery (cesarean deliveries and more) and then calling this “safe anesthesia.”15,16 This alarming example is counterproductive and endangers the development and continuation of proper anesthesia training programs and care delivery standards in LMICs. Anesthesiologists and their organizations in LMICs can help anesthesia providers who work in remote areas by developing support networks17 and by providing opportunities for continuing medical education both centrally and through distance education.18 Anesthesiologists must take a leadership role in the development of anesthesia and surgical services in their countries. Anesthesia societies must be active participants in national surgical and anesthesia action plans as their input is crucial to achieving the desired human resource, educational, and clinical goals.
Anesthesia faces major challenges if it is to attain the stated Lancet Commission 2030 target.1 We must build anesthesia bridges and networks across geographical and economic borders while keeping our efforts focused on correcting the anesthesia care imbalance. For the sake of those 5 billion patients who have great need of surgical and obstetric care, the global anesthesia community must strategize effectively, and work cohesively, to provide “safe, affordable surgical, and anesthetic care when needed.”
Name: Angela Enright, MB, FRCPC.
Contribution: This author helped write the manuscript.
Conflicts of Interest: Dr Enright is a former President of WFSA.
Name: Mark Newton, MD.
Contribution: This author helped write the manuscript.
Conflicts of Interest: None.
This manuscript was handled by: Thomas R. Vetter, MD, MPH.
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