We obtained information about the availability of specialist PAP training from 125 countries. Training was offered in 106 of these countries but not in the other 19.
Information on the minimum duration of training that was considered acceptable in order to qualify as a specialist PAP was provided by 134 countries. This training could be within the country or in another country. There was a wide range of training durations—from <1 year to >5 years.
Numbers of NPAPs
We attempted to collect data on 2 types of NPAPs—nurse providers (those with a nursing qualification) and non-physician/non-nurse providers (other health workers). These providers could be working under anesthesiologist supervision or working independently when providing anesthesia care. The survey allowed respondents to add explanatory comments.
Unfortunately, analysis of these data proved problematic owing to differences in terminology and interpretation. For example, in some countries, the term anesthesia assistant refers to a health worker who provides supervised anesthesia care; in other countries, the term refers to a health worker who provides assistance to the main anesthesia provider but does not personally provide direct anesthesia care. Some respondents, especially those in higher income countries, included the latter type of assistant, and this made direct comparisons difficult.
The United States reported 49,000 nurse anesthesia providers and 1960 non-physician/non-nurse providers (compared to 67,000 PAPs). A number of other high-income countries, including Sweden, Switzerland, the Netherlands, and Taiwan, reported relatively high numbers of non-physician providers. In Europe, nurse anesthetists work only under anesthesiologist supervision as part of a team.17 This is the case for countries like Norway, Sweden, and France, whereas for other European countries, such as Germany and Spain, the nurses do not provide direct anesthesia care.
Analysis of comments suggests that NPAPs working in less well-resourced countries were highly likely to be providing direct anesthesia care, either supervised or unsupervised. Given the difficulties of comparing the NPAP data from higher income countries with that of lower income countries, we have tabulated NPAP numbers for countries with a PAP density of <5 per 100,000 population (Table 4). More complete survey data are available on the WFSA website (www.wfsahq.org/workforce-map).
In Table 4, the reported proportions of NPAPs to total providers range from 0% to 100%. A number of countries reported zero NPAPs (see Discussion).
Even when NPAPs are included, the total anesthesia provider density was still very low in many countries. A PAP density of <5 per 100,000 population was reported by 77 countries—36 in AFR, 11 in AMR, 9 in SEAR, 8 in EMR, and 13 in WPR. There were no EUR countries with a density of <5. With NPAPs included, 70 countries reported a total anesthesia provider number of <5 per 100,000 population—34 in AFR, 9 in AMR, 9 in SEAR, 8 in EMR, and 11 in WPR.
Forty countries in this group reported that NPAPs were providing anesthesia care without supervision from a PAP.
Data on NPAP training were incomplete and therefore not included in this article.
Changes Between 2006 to 2010 and 2015 to 2016
We were able to compare PAP numbers for 101 countries that had provided information for both surveys.
Twenty-four countries reported a reduction in PAP density. Eritrea, with a population of over 5 million people, had 2 PAPs at the time of the first survey but no PAPs at the time of the second survey. The other countries reporting a reduction were Benin, China, Colombia, Cook Islands, Cuba, Ecuador, France, Greece, Guatemala, Hungary, India, Japan, Lithuania, Malaysia, Mexico, Peru, Romania, Serbia, United Kingdom, Uzbekistan, Venezuela, and Zimbabwe.
The United Kingdom and Zimbabwe reported an increase in PAP numbers but a decrease in the number per 100,000 population.
The remaining 77 countries reported an increase in the number of PAPs per 100,000 population.
This survey is an important step in comprehensively quantifying the global anesthesia workforce. We obtained workforce data from 153 countries representing 97.5% of the global population. Most countries not represented in the survey have relatively small populations, but it will be important to continue to attempt to obtain workforce data from them.
The WFSA Workforce Survey is available online at www.wfsahq.org/workforce-map and will be updated frequently to reflect new information and corrections.
It will be necessary to continue to collect workforce information and to improve the quality of the data to define the magnitude and distribution of workforce deficits and to monitor progress in addressing shortages in the anesthesia workforce.
Summary of the Main Findings
There was a total of 436,596 PAPs in 153 countries, representing an overall workforce density of 6.09 PAPs per 100,000 population. Seventy-seven countries reported a density of <5 per 100,000. The average workforce densities in the WHO AFR and WHO SEAR were very low (1.36 and 1.20, respectively), but there were also marked disparities between countries in the other WHO regions. There was a 90-fold difference between the average PAP workforce density in high-income countries and low-income countries.
NPAPs accounted for a large proportion of the anesthesia workforce in many countries with limited resources, as well as some high-income countries. The reported ratios of NPAPs to PAPs were very variable, ranging from 0% to 100%. In countries with a PAP density of <5 per 100,000 population, NPAPs made up almost one-quarter of the total anesthesia workforce, but this number is likely to be an underestimate. Even when NPAP numbers are included, the total anesthesia provider density in 70 countries was <5 per 100 000.
Limitations of This Survey
Some of the numbers in this survey should be interpreted with caution. We used WFSA member societies as our primary source of information, and some numbers are necessarily estimates, especially those for large countries without a centralized register of providers. Information is likely to be less accurate for some resource-poor countries and countries suffering from conflict. Other sources, for example, Ministries of Health and the WHO,18 may provide additional important information. We hope that the collection of accurate anesthesia workforce data, along with other core surgical indicators, will become routine as a result of the World Health Assembly resolution.3
As mentioned earlier, data collection relating to NPAPs was problematic because of differences in terminology and interpretation. We attempted to obtain data on health workers directly providing anesthesia care but analysis of comments (especially from some higher income countries) suggested that some health workers not providing direct anesthesia care were also included. However, NPAP numbers from lower income countries are likely to include more health workers who are providing direct anesthesia care. Further work is required to clarify the numbers of NPAPs in all countries.
It is likely that some survey respondents underreported provider numbers, especially NPAP numbers. There may be several reasons for this—the society may have limited information about nonanesthesiologist providers, there may be limited information about rural or remote parts of the country, or there may be political reasons or bias that lead to underreporting. In some countries with NPAPs, only physicians may legally provide anesthesia, resulting in reluctance to report the true number of NPAPs.
Countries were defined using the WHO list of 194 member states, and this created interesting anomalies. Some WFSA member societies, for example, Taiwan, are not WHO member states. Nonindependent territories, for example, Greenland (Denmark) and French Guiana, are not considered separate states by the WHO despite different health and resourcing issues from their governing countries. Where possible, the WFSA is collecting information on nonindependent territories and presenting it on the online map.
We were only able to obtain limited information on training and supervision of anesthesia providers. This will be the subject of ongoing work.
Physician Anesthesia Providers
The WFSA workforce survey reveals critically low numbers of PAPs in many countries around the world. There are marked disparities in the distribution of the anesthesia workforce between regions and between countries.
Overall, the reported number of PAPs was 436,596 in 153 countries. A 2015 article7 estimated that there were 550,134 anesthesiologists worldwide. The reason for this discrepancy is unclear, but this earlier article used a variety of sources to obtain numbers for 167 countries representing 92% of the world’s population. Some of their numbers dated back to 1998, and various methods were used to estimate the total global number of anesthesiologists. Our number relates to 153 countries representing 97.5% of the world’s population, and we have not extrapolated this number to all countries.
The WFSA workforce survey shows marked differences between WHO regions. The density of PAPs is particularly low in the AFR and the SEAR. There is also considerable variation within regions.
Similarly, there are marked differences based on per capita income. The overall PAP density in high-income countries (17.96 per 100,000 population) is 95 times the overall PAP density in low-income countries (0.19 per 100,000 population).
We only collected data for countries as a whole, and our survey therefore will not give an indication of the variability of the workforce within a country. In many countries, it is likely that rural and remote areas will be underserved compared to the large cities.
Availability and minimum duration of specialist PAP (anesthesiologist) training is very variable, with a few countries recognizing a training time of <1 year, but the majority of countries recognizing a training time of 4 years or greater. More information is required in this area.
Non-Physician Anesthesia Provider Numbers
Information on the NPAP workforce (both nurse providers and non-physician/non-nurse providers) is incomplete, but it is clear that non-physicians account for a large proportion of the anesthesia workforce, especially in countries with limited resources.
We have presented data from 77 countries with a PAP density of <5. Fifty of 77 countries reported the use of NPAPs. We are aware that the numbers of NPAPs are likely to have been underreported in a number of countries and clarification of this information will be part of ongoing work by the WFSA.
Even when NPAPs are taken into account, the total number of anesthesia providers is desperately low in some countries. For example, Uganda reported 72 PAPs and 430 NPAPs for a population of 38 million, giving a total provider density of only 1.29 per 100,000. Many other countries with significant NPAP numbers still had a total provider density of <1 per 100,000.
NPAPs are also an important part of the anesthesia workforce in some highly resourced countries, for example, the United States and some countries in Europe. Our data suggest that approximately 43% of the total provider workforce (50,960 of 117, 960) in the United States are non-physician providers.
The NPAP workforce is a heterogeneous group, ranging from highly trained nurse anesthesia providers and clinical officers to some health workers with very brief on-the-job training. Further work is required to define and map the global NPAP workforce.
Expansion of the Anesthesia Workforce
The Lancet Commission on Global Surgery1 has set a target date of 2030 to achieve the goal of “universal access to safe, affordable surgical and anesthesia care when needed.” A massive scale-up of the anesthesia workforce in LMICs will be required if this goal is to be achieved.
The Lancet Commission recommended that all countries scale up their specialist surgical workforce (surgeons, anesthesiologists, obstetricians) to at least 20 per 100,000 population by 2030. This recommendation is based on obstetric data, which showed a dramatic improvement in patient safety with increasing specialist surgical density from 0 to 20 per 100,000 population.
The Lancet Commission did not give a recommendation regarding the proportions of surgeons, anesthesiologists, and obstetricians within the specialist surgical workforce, and we are not aware of any other specific recommendations regarding anesthesiologist (specialist PAP) workforce density. In our opinion, a specific minimum recommendation is necessary to highlight disparities and to stimulate debate and action, but we also acknowledge the arbitrary nature of such a recommendation.
Arguably, the number of specialist anesthesia providers should match the combined number of specialist surgical providers (surgeons and obstetricians) to ensure effective leadership of anesthesia services and delivery of emergency and essential patient care. This equates to at least 10 anesthesiologists per 100,000 population (half the total workforce target of 20 per 100,000 population). The authors acknowledge that such a target is unlikely to be achievable in many countries and therefore recommend an interim goal of at least 5 anesthesiologists per 100,000 population, even in countries with very limited resources. This target maintains some relativity between specialist surgeons, anesthesiologists, and obstetricians and provides a starting point for discussions regarding workforce planning. We emphasize that a target of 5 anesthesiologists per 100,000 population is still very low, and countries with more resources should work toward a higher workforce density.
The Lancet Commission workforce recommendation of 20 per 100,000 population applies to only the specialist surgical workforce. In many countries with limited resources, training of nonspecialist surgical, anesthetic, and obstetric providers will also be required. The Commission recommended the use of task sharing as a means of addressing workforce deficits. Task sharing was defined as the “specialist provider and the provider with less training sharing the responsibility for a high-quality outcome of the task” (eg, delivery of an anesthetic). The specialist provider should always be available to give assistance, either locally or remotely.
Our data show that NPAPs are a vital part of the global anesthesia workforce, especially in LMICs. In many of these countries, it will not be possible to achieve the required scale-up of the anesthesia workforce by training only PAPs; training of both PAPs and NPAPs will be required. The ratio of PAPs to NPAPs will be determined by models of care, surgical demands, financial resources, and other factors. More work is required to determine the correct ratio of PAPs to NPAPs and how this might affect patient safety.
How many anesthesia providers are required to correct workforce deficits? Using the survey results, Table 5 summarizes the PAP workforce densities in our survey population and shows the maldistribution of PAPs, as well as the numbers required to increase the density of providers. The calculations for upscaling the workforce are based on an immediate increase in numbers with no allowance made for changes in population and surgical need. The table does not include countries with PAP densities of greater than 20 per 100,000. There are 18 countries in this category, accounting for a population of 698,059,000 (9.7% of the total survey population) and a PAP number of 162,952 (37.3% of the total PAP number).
Table 5 specifies different “target” densities, the numbers of countries below these targets, and the numbers of PAPs required to reach the targets. For example, 43 countries reported a PAP density below 1 per 100,000 population. These countries accounted for 19.8% of the survey population but had only 1.3% of the PAPs. Eight thousand four hundred sixty-eight additional PAPs would be required to reach a target density of 1 per 100,000 population (14,165 PAPs).
Many more PAPs will be required to achieve a target of 5 per 100,000 population. The 77 countries that had <5 PAPs per 100,000 population accounted for approximately 50% of the survey population but had only 10.3% of the PAPs. These countries would currently need 181,083 PAPs to achieve a workforce density of at least 5 per 100,000. This equates to an additional 136,124 PAPs based on the current country populations.
It is important to note that many of the countries that reported a PAP density of <5 per 100,000 have very limited resources. The 77 countries comprise 26 low-income countries, 34 lower middle-income countries, 16 upper middle-income countries, and 1 high-income country (Saudi Arabia).
DCP-32 and the Lancet Commission on Global Surgery1 both outlined the economic arguments for investing in surgical and anesthesia services. DCP-3 estimated that a global investment of just US$3 billion per year at the first-level hospital would achieve universal coverage of emergency and essential surgery and a return on investment of 10 to 1. The Lancet Commission estimated that US$420 billion may be required by 2030, but the cost of lost output because of untreated surgical conditions in LMICs could be 30 times as much (US$12.3 trillion) during the same period if countries do not invest in surgical and anesthesia services.
Significance of This Survey
The WFSA Global Anesthesia Workforce Survey will continue to collect and refine data on the numbers and distribution of the anesthesia workforce worldwide. The survey will provide vital data that will allow us to monitor progress toward the goal of universal access to safe, affordable surgical, and anesthesia care when needed.
Development of surgical services has fallen behind the development of other areas of medicine, especially in LMICs. While the importance of surgery is becoming better understood from a global health point of view, the role of anesthesia and the development of anesthesia services are at risk of not keeping up with development of surgery because of the relatively low profile of anesthesia. There cannot be safe surgery without safe anesthesia. Given the close relationship between anesthesia and patient safety, it is particularly important to specifically document and monitor the global anesthesia workforce rather than bundle it into a larger package of surgical workforce providers.
A lot more information is required. We will continue to attempt to obtain information from countries that have not responded to date and to improve the quality of information from others. More information on training is required, as well as more accurate data on NPAPs and different models of care. This will be particularly important in LMICs where large increases in both PAP and NPAP numbers will be needed to achieve even modest anesthesia provider workforce densities.
Professional societies, including national anesthesia societies and the WFSA, are in an excellent position to lead the development of anesthesia services around the world. It is therefore vital that these organizations are involved with documenting and monitoring the anesthesia workforce. The online map allows users to zoom in on different areas of the world and to hover over individual countries to see more detailed information (see Supplemental Digital Content 14, Figure 7, http://links.lww.com/AA/B840).
Looking further ahead, the WFSA plans to survey and map not just workforce, but other key elements of safe anesthesia provision, such as infrastructure, equipment, and medicines. This kind of work has been performed at country level,19–21 or even within subsets of several countries,22,23 but must be completed globally if we are to truly understand what is required of health systems and be able to monitor progress against WHA Resolution 68.15 and the target of Universal Health Coverage by 2030.
The WFSA Global Anesthesia Workforce Survey is the most comprehensive study of the global anesthesia workforce to date. It is the first step in a process of ongoing data collection and longitudinal follow-up. Accurate anesthesia workforce data are a vital component of the core indicators recommended by the Lancet Commission.1
The survey shows marked disparities in the distribution of the anesthesia workforce between countries, between regions, and between income groups. Workforce densities were very low in many countries, with 77 countries reporting a PAP density of <5 per 100,000, and 43 countries reporting a PAP density of <1 per 100,000. NPAPs make up a large part of the global anesthesia workforce. Even when NPAPs are included, the total anesthesia density is critically low in many of the world’s poorest countries.
The authors recommend an interim goal of at least 5 PAPs per 100,000 population, even in countries with limited resources, to ensure effective leadership of anesthesia services and delivery of emergency and essential patient care. The implications for country-level and global-level health decision making are significant—over 136,000 additional PAPs would be needed now to achieve a minimum density of 5 per 100,000 in all countries. Substantial investment in the education of all anesthesia providers is required, and the WFSA is well placed to work with the WHO, its own member societies, other specialist medical organizations, governments, nongovernmental organizations, and country-level health systems to correct the workforce gap and achieve safe anesthesia for all by 2030.
We acknowledge the members of the original WFSA Manpower Working Group (2004–2010): Dr Peter Kempthorne (Chair), Dr James Cottrell, Dr Maria Janecskó, Dr Christina Lundgren-Steele, Dr Jannicke Mellin-Olsen, the late Dr Ali Salama, Dr Iain Wilson, Dr Ming Tian, and Dr Manuel Galindo.
We also thank the WFSA Secretariat, especially Aaliya Ahmed and Niki O’Brien, and Dr Eugène Zoumenou, Dr Mark Newton, and many other individuals who have helped to collect these data.
Name: Peter Kempthorne, MBChB, FANZCA.
This author helped design the survey, collect the data, analyze the data, and prepare the manuscript.
Name: Wayne W. Morriss, MBChB, FANZCA.
Contribution: This author helped design the survey, collect the data, analyze the data, prepare the manuscript.
Name: Jannicke Mellin-Olsen, MD, DPH.
Contribution: This author helped design the survey, collect the data, analyze the data, and prepare the manuscript.
Name: Julian Gore-Booth, MA.
Contribution: This author helped design the survey, collect the data, analyze the data, and prepare the manuscript.
This manuscript was handled by: Angela Enright, MB, FRCPC.
a The boundaries and names shown in the maps and tables do not imply the expression of any opinion whatsoever on the part of the WFSA or the authors concerning the legal status of any country, territory, city or area of its authorities, or concerning the delimitation of its frontiers or boundaries (adapted from the WHO).
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© 2017 International Anesthesia Research Society
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