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Improving Anesthesia Safety in Low-Resource Settings

Khan, Fauzia A. FRCA*; Merry, Alan F. FANZCA†,‡

doi: 10.1213/ANE.0000000000002728
Global Health
Free

The safety of anesthesia characteristic of high-income countries today is not matched in low-resource settings with poor infrastructure, shortages of anesthesia providers, essential drugs, equipment, and supplies. Health care is delivered through complex systems. Achieving sustainable widespread improvement globally will require an understanding of how to influence such systems. Health outcomes depend not only on a country’s income, but also on how resources are allocated, and both vary substantially, between and within countries. Safety is particularly important in anesthesia because anesthesia is intrinsically hazardous and not intrinsically therapeutic. Nevertheless, other elements of the quality of health care, notably access, must also be considered. More generally, there are certain prerequisites within society for health, captured in the Jakarta declaration. It is necessary to have adequate infrastructure (notably for transport and primary health care) and hospitals capable of safely carrying out the “Bellwether Procedures” (cesarean delivery, laparotomy, and the treatment of compound fractures). Surgery, supported by safe anesthesia, is critical to the health of populations, but avoidable harm from health care (including very high mortality rates from anesthesia in many parts of the world) is a major global problem. Thus, surgical and anesthesia services must not only be provided, they must be safe. The global anesthesia workforce crisis is a major barrier to achieving this. Many anesthetics today are administered by nonphysicians with limited training and little access to supervision or support, often working in very challenging circumstances. Many organizations, notably the World Health Organization and the World Federation of Societies of Anaesthesiologists, are working to improve access to and safety of anesthesia and surgery around the world. Challenges include collaboration with local stakeholders, coordination of effort between agencies, and the need to influence national health policy makers to achieve sustainable improvement. It is conceivable that safe anesthesia and perioperative care could be provided for essential surgical services today by clinicians with moderate levels of training using relatively simple (but appropriately designed and maintained) equipment and a limited number of inexpensive generic medications. However, there is a minimum standard for these resources, below which reasonable safety cannot be assured. This minimum (at least) should be available to all. Not only more resources, but also more equitable distribution of existing resources is required. Thus, the starting point for global access to safe anesthesia is acceptance that access to health care in general should be a basic human right everywhere.

From the *Department of Anaesthesiology, Faculty of Health Sciences, Medical College, Aga Khan University, Karachi, Pakistan

Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand

Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand.

Accepted for publication November 2, 2017.

Funding: None.

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

Reprints will not be available from the authors.

Address correspondence to Alan F. Merry, FANZCA, Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand. Address e-mail to a.merry@auckland.ac.nz.

The safety of anesthesia in high-income regions of the world has improved steadily over the last century through advances in training, medications, and technology, and through the introduction of minimum standards, guidelines, and checklists.1 Unfortunately, similar gains have not occurred in low-resource settings with poor infrastructure, shortages of anesthesia providers, essential drugs, equipment and supplies, and consequently an inability to adhere to the contemporary standards of high-income countries (HICs). Mortality attributable to anesthesia in some parts of the world is orders of magnitude higher than in high-income settings.2

There is a large global gap in access to adequate health care, in general, and in relation to safe anesthesia. This gap is not confined to low-income countries (LICs). A growing body of literature describes the widespread deficiencies of health care systems and the limitations of many proposed remedies to global health care problems.3 In most parts of the world, there is substantial variation in the provision of health care and, in many countries, the problem is one of maldistribution of resources rather than an absolute shortage.4

There seems to be no absolute global shortage of equipment or medications—simply a shortage of funding for these in many regions. However, there is a large deficit in infrastructure, including (but not confined to) operating rooms (ORs), and there is a substantial global shortage of adequately trained health professionals.5

We take as given that access to essential health care should be seen as a basic human right.6 In this article, we argue that the key to achieving this access for everyone lies not only in increasing global capacity, but also in more equitable distribution of the capacity we already have. Continued disregard of collective responsibility for the global anesthesia and surgery crisis could result in serious failure to achieve the full potential of populations, not only for LICs but ultimately for many more affluent countries as well.

Calls for the advances in global equity required to ensure safe anesthesia for all may seem unrealistic and unattainable. We live in a world where an urge to help others is strongly seen in many individuals, but in which the failure of governments is often a major factor in contributing to the need for such help. At the present time, it is difficult to see how local aid by individuals and nongovernmental organizations can bring about the sustainable transformation needed to bring the health care of the 5 billion people currently living in low-resourced areas of the world to the level of the 2 billion who have more than adequate resources. However, great things often come from small beginnings. Each man, woman, and child in the world matters. Even small gains in the provision of safe anesthesia and surgery in places in which these services are not presently available could make a life-changing difference to individuals, and who knows what some of those individuals may go on to contribute to the future welfare of the planet?

What then is the way forward? What can and should be done to improve patient safety in low-resource settings? In this article, we will provide a high-level overview of some of the relevant challenges and discuss some of the initiatives that are being, or could be, introduced at global, regional, national, and local levels to address these challenges.

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VARIATION IN HEALTH CARE

There is no standardized international definition for the term “low-resource setting.” According to the World Bank in 2015, low-income economies are those with a Gross National Income (GNI) per capita of US $1005 or less.7 However, not only GNI but also the proportion of GNI that is spent on health care (and on the indirect determinants of health) varies, and so does the effectiveness of this expenditure. The term “low-resource setting,” although less precise, is probably preferable in that it captures the idea of a lack of adequate funding for health care on an individual, local, or societal basis. It implies (among other things) inadequate access to medicines, equipment, supplies, devices, infrastructure, and suitably trained health care personnel.8

Regional variation within countries is typical. Some LICs have well-resourced hospitals in major cities.9 Conversely, there are many HICs and middle-income countries with areas or subpopulations that have inadequate access to health care.4 The global variation in access to surgery was starkly demonstrated in 2004 by an estimation that 73.6% of operations worldwide were performed on the 30.2% of the world’s population living in countries that spent more than US $400 per capita per annum on health care, whereas only 3.5% were performed on the 34.8% living in countries that spent less than US $100 (Table 1).

Table 1.

Table 1.

Fisher and Wennberg4 described 3 categories of medical services: effective care, preference-sensitive care, and supply-sensitive care. Supply-sensitive care is the least satisfactory, and is driven by the availability, or lack of availability, of investigatory and therapeutic resources. In some HICs, oversupply often leads to overtreatment, and it is likely that the data in Table 1 reflect at least some element of overtreatment in HICs. By contrast, in many low-resource settings, the supply is grossly inadequate. This was made starkly clear by the 5 key messages of the report of the Lancet Commission in 2015 (Table 2).11

Table 2.

Table 2.

A lack of access to health care may reflect deeper societal problems than simply a lack of hospital services. For those who need surgery it may be difficult to find a primary health care professional (often a nurse) able to assess their condition. Transport to a facility able to provide surgery may then be expensive and slow. Even after a hospital has been reached, further barriers (notably cost) and delays may occur. These delays may impact seriously on the outcome of surgery. Furthermore, the costs may totally prohibit access to surgery, or be financially catastrophic to patients and their families.11

For those that overcome all of these barriers, the standard and safety of the services they finally receive may then turn out to be inadequate, and even unsafe. This is particularly true for anesthesia—and safe anesthesia is clearly essential for safe surgery.

It warrants emphasis that the imperative, for such people, is access to just the simple surgery and anesthesia that can save lives or limbs. Meara et al11 adopted the term “Bellwether Procedures” to capture the idea that “laparotomy, caesarean delivery, and treatment of open fracture are bellwethers (or indicators) of a system functioning at a level of complexity advanced enough to do most other surgical procedures.13 The Bellwether Procedures are cesarean delivery, laparotomy, and the treatment of compound fractures. A lack of capacity in a region to undertake these procedures safely will obviously result in substantial and easily preventable loss of life.

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THE ROLE OF HEALTH SYSTEMS IN IMPROVING SAFETY IN ANESTHESIA

Health care is delivered through complex systems. Going beyond local (and often transient) aid to achieve sustainable widespread improvement globally will require an understanding of how such systems work, and how to influence change within them. This understanding is essential at every level, from the interface between clinicians and patients through the institutional level to that of national governments and global organizations. The national prerequisites for health care are probably the most important, and were articulated as long ago as 1997 in the Jakarta declaration (Table 3).6 Implicit in this declaration was the importance of an absence of corruption, war, and natural disasters.

Table 3.

Table 3.

In any country, the quality of a health care system can be described in relation to several dimensions or elements. The Institute of Medicine defined these by stating that health care should be safe, timely, effective, efficient, equitable, and patient-centered3 (Figure) (these elements are captured by the acronym STEEEP). The element of safety is particularly important in anesthesia because anesthesia is not in itself therapeutic and it is intrinsically hazardous. This point was captured in the original mission statement of the Anesthesia Patient Safety Foundation—that “No patient shall be harmed from anesthesia.”16 However, there is a tension between access and safety—a lack of access to anesthesia, and therefore to essential surgery, is itself unsafe. In reality, it is not meaningful to consider any service or any element of quality in isolation: timely access to safe and effective anesthesia, surgery, other clinical services, primary health care, and social infrastructure are all relevant to the functioning of the health care system. Finally, the provided care must align with the needs of the patients, which implies that it must be affordable, both to individuals and to the nation. Hence, in the Figure, the patient is shown at the center of the global health care system. This figure shows the elements of quality and safety in health care across the various levels at which health care is organized and delivered. Alignment in pursuing these elements is clearly highly desirable between the patient and the clinicians directly involved with their care, but this is not always present. Even when it is, continuing this alignment across every successive level of health care delivery, notably the national and global levels, is very challenging. In less abstract terms, for an initiative such as the surgical safety checklist of the (global) World Health Organization (WHO) to be truly effective, it needs to be embraced by national governments, implemented in institutions, supported by the leadership of surgical units, used by individual clinicians and relevant to 1 or more objectives valued by the patient (in this case the avoidance of harm).

Figure.

Figure.

We suggest that safe anesthesia and perioperative care can be provided for essential surgical services today by (1) clinicians with moderate levels of appropriate training using, (2) relatively simple equipment, and (3) a limited number of inexpensive generic medications. However, there is a minimum requirement in relation to all 3 of these resources, below which reasonable safety cannot be assured, and this minimum (at least) should be available to all. Gains from state-of-the-art resources in politically visible central hospitals will not offset losses in health outcomes from neglecting substantial, usually peripheral, parts of the population. In many countries, even many HICs, considerable improvement could be achieved nationally by strategically redeploying currently available health care resources, but such initiatives presuppose a political will and a relatively sophisticated understanding of population health by those in government.

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IMPORTANCE OF SAFE ANESTHESIA IN POPULATION HEALTH

The reality is, that even highly functioning and well-motivated governments find it difficult to prioritize spending optimally between conflicting needs such as education, employment, houses, roads, and defense—and, of course, these factors are themselves indirect but important determinants of health. There are regions in the world where access to safe drinking water is limited, let alone resources within hospitals.17 Furthermore, infrastructure has a profound influence on the attractiveness of rural and remote regions to health professionals, and (as we have outlined) on the ability of patients to reach the surgical and anesthesia services they need.

Nevertheless, surgery is critical to the health of populations. The understanding has been slow in coming that essential surgery is not an expensive and complex luxury that is less important for the health of populations than infectious diseases or obstetrical services.18,19 The study cited in Table 1 contributed to a change in this perception, by showing that the global volume of major surgery, at 234.2 million operations per year, was almost twice the number of babies born.10 By 2012, this volume had increased by an estimated 33.6%, primarily in countries that spent less than US $400 per capita on health care.20 The authors of this study also noted a correlation between increased life expectancy and increased rates of surgery.21

At the same time, there has been a growing appreciation of the avoidable harm arising from health care, and this harm is itself increasingly recognized as an important population health problem in all countries.22 We have already alluded to the very high levels of mortality from anesthesia in some regions of the world. Thus, it is not enough to provide surgical and anesthesia services—these services must be provided with an adequate level of safety.

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THE ANESTHETIC WORKFORCE

The global anesthesia workforce crisis, especially in resource-limited countries, has been identified as the largest single barrier to provision of safe anesthesia.20 More detailed information is needed on the magnitude of the workforce gap in each region and country and the workforce survey results recently published by The World Federation of Societies of Anaesthesiologists (WFSA) are a useful step in this direction.23 However, we already know that, in LICs, many anesthetics are provided by nonphysicians with limited training and limited (if any) access to supervision, support, or oversight by more highly qualified providers. Many of these anesthesia providers are highly dedicated, but often they are asked to work in circumstances that would challenge even the most highly qualified of specialist anesthesiologists. This situation is not helped by brain drain of the trained workforce to HICs and the reducing numbers of medical students entering the specialty of anesthesia in some countries.24

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MEDICATIONS

A shortage of perioperative medications is a critical issue affecting patient safety in low-resource settings.25 In fact, this has become a worldwide phenomenon, but the reasons for shortages of drugs may differ,26 and may include problems with supply, government policies on manufacturing and pricing, hoarding, smuggling to other countries, and corruption. In some countries, patients (or their families) have to purchase their own drugs before anesthesia can be provided. This constitutes a major barrier to access to surgery and anesthesia, and is moreover a highly inefficient way of funding health care. Dealing with these issues, globally, will be a major challenge for a long time to come.

Even in HICs, drug shortages have contributed to medication errors due to lack of familiarity with alternatives, and in the use of single ampoules on multiple patients with increased transmission of disease and use of expired medications. One approach taken by some HICs in this respect has been the publication of national lists of essential drugs.27 Such lists can be easily compiled in low- to middle-income countries (LMICs) and can be used to drive discussions with governments and act as a resource for pharmacists to keep adequate stocks. The WHO also publishes a list of essential medicines, which includes anesthetic drugs.28

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EQUIPMENT AND INFRASTRUCTURE

We have already alluded to serious deficiencies in infrastructure in many parts of the world. There is clearly a substantial shortage of ORs in much of the world, but there are also often serious deficiencies in a such things as reliable electricity, clean water, roads, transportation, sterilization facilities, communications, and imaging capability that are taken for granted in HICs today and impact substantially (if indirectly) on surgical and anesthetic services.

More specifically, there has been a long-standing and ongoing lack of investment in the development and distribution of appropriately designed, robust, and functional equipment for ORs in resource-poor environments.29 Examples include pulse oximeters, capnographs, oxygen concentrators, anesthesia machines, suction apparatus, resuscitation equipment, airway-related equipment, vaporizers, and many other items of essential equipment.30 Vo et al31 surveyed a total of 590 facilities in 22 LMICs; 35% of hospitals had no access to oxygen and 40% had no anesthesia machines. In a survey of 78 district hospitals in 7 LMICs, there was <1 OR/100,000 people in 5 of the countries.32 Maintenance of equipment is also critical. In many hospitals, trained staffs are not available to repair equipment locally, and breakdown of equipment is frequent and disruptive to services. The well-intentioned, but poorly conceived, donation of equipment (often obsolete in the donor’s country) ill-suited for local needs has created “graveyards” of broken or simply unused devices in many low-resourced regions of the world.

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The Global Oximetry Project and Lifebox

Table 4.

Table 4.

An example of a more systematic attempt to address one aspect of the need for better equipment arose from The Safety and Quality of Practice committee of the WFSA. In 2004, the committee identified the importance of a lack of pulse oximetry to the safety of anesthesia for many patients in the world.33 This led to measurement work by Funk et al34 which demonstrated that there were 77,000 ORs in the world where anesthesia and surgery are delivered without the use of pulse oximeters. In a parallel line of work, pulse oximetry was endorsed in the Standards for a Safe Practice of Anesthesia and included in the Checklist (both discussed above). Proof of concept studies were run in 4 regions of the world.35 A formal specification and tender process led to the manufacture of an oximeter of a standard applicable to HICs, but at the same time, affordable, robust, and suitable for use in environments with unreliable electricity and many other challenges.36–38 To build on this momentum, the Lifebox Foundation (Table 4) was founded in 2011 through an ongoing collaboration between the WFSA, the Association of Anaesthetists of Great Britain and Ireland, the Brigham and Women’s Hospital, and the Harvard TH Chan School of Public Health. Lifebox has now facilitated the distribution of nearly 15,000 pulse oximeters in over 100 countries in low-resource settings.39 From the outset, the objective has been to achieve sustainable improvement in the standard of anesthesia care in low-resource settings, and the approach has been in line with the WHO “Guidelines for Health Care Equipment Donations.”40,41

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ADVOCACY

One of the greatest barriers to improving safety in low-resource settings is the limited ability of the medical profession to influence health policy makers. This is particularly true for anesthesia providers in resource-poor settings, who often have too many clinical responsibilities to find the time for advocacy, or to take up administrative roles. Insecurity of employment may also be a factor. Typically, they become invisible to those making policy decisions at the institutional, regional, and national level. This is perhaps one of the areas where international nongovernmental organizations such as the WFSA can influence the system as a whole.

To be effective, advocacy must focus on the needs of patients, and be realistic. Advocacy for the unattainable, or advocacy that is seen as primarily advancing the cause of the advocates, is likely to fail. On the other hand, patients need well-trained health professionals working with adequate resources, and using such professionals will require the provision of reasonable conditions of employment, at least in the context of each region and country. Thus advocacy of patients can, at the same time, support providers. However, this raises the question of the level of training required to provide anesthesia services safely. A recent position statement on this point, by the WFSA,42 is as follows:

In some countries, the anaesthesia need will be met by training anaesthesiologists. In other countries, especially those with limited resources, the need may, in part, be met by training nonanaesthesiologist providers.

Anaesthesia is complex and potentially hazardous, and optimal patient care depends on anaesthesia being provided, led, or overseen by an anaesthesiologist. The WFSA recognises that effective teamwork is a vital component of patient safety.

More work is clearly needed to define the training needed for either anesthesiologists or nonanesthesiologist providers, but the statement is grounded in the shared appreciation emerging from the work of the Lancet Commission that the global gap in capacity for surgery, anesthesia, and obstetrics will not be closed in any reasonable time frame by focusing only on training more specialist doctors. This position statement underpinned a credible contribution to the Seventieth World Health Assembly of the WHO by the WFSA.42 The critical importance of safe anesthesia needs to be reiterated repeatedly, reasonably, and authoritatively at the global, national, institutional, and departmental levels of the system (Figure).

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TRAINING

Training Anesthesiologists

Currently much training in HICs and LMICs takes place in large urban centers. In many programs, the trainees are not exposed to anesthesia in rural or cost-restrained environments. Even in HICs, there is a maldistribution of workforce and a shortage of anesthesiologists willing to work in rural areas. All countries should be reviewing their anesthesia training programs and curricula with a focus on meeting the true needs of their nations, affordably. Provided adequate supervision and support are in place, spending some training time in more remote areas, both as medical students and as specialist trainees, will expose them to the challenges faced in such areas and may increase their interest in global health and in returning to these areas after graduation or specialization.43

Increasing investment in training raises the complex question of the subsequent migration of well-qualified doctors and nurses between countries. This question encompasses individual rights as well as national priorities and the need for countries to ensure a return on their investment in training.44 Reducing standards of training with a view to limiting the international mobility of graduates is not in anyone’s interest. In fact, few people leave their homeland lightly, and the factors listed in Table 3 probably have more influence to the migration of health professionals than any form of regulation.

Curriculum designs in LMICs should not simply mimic those of HICs but should have stronger elements of training in regional techniques (which are still underutilized in many LMICs45) and in how best to work in resource-restrained environments. Training should also emphasize teamwork and the roles of other health professionals.

To properly equip anesthesiologists to deliver their full potential as physicians, all anesthesiology training curricula today (in any country) should include a grounding in the principles of safety and quality in health care and in the basic elements of population and global health, including the principles of measurement of outcomes of care.46

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Training Nonphysician Anesthetists

This important issue has been severely neglected by anesthesiologists in many parts of the world. Agreed minimum standards are needed, differentiating the requirements for independent practice (which should, ideally, have the foundations of a medical degree) from those of practice within an anesthesiologist-led team.

In the medium term, leadership, oversight, and support by anesthesiologists for clinicians with less training may often need to be provided remotely. The increasing availability of electronic technology, even in many LMICs, makes this possible through video conferencing and other technological methods of communication. Smart phone and Internet technology is now widely available in many LMICs and can also facilitate “self-help” groups to support each other in problem solving or to assist with advice in acute crises. Larger teaching hospitals could pair with peripheral hospitals to give such support.

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THE ROLE OF THE WHO

The WHO is a major contributor to improving access to safe surgery internationally, through setting standards, advocacy and global initiatives, notably the Safe Surgery Saves Lives Global Challenge47 which led to the WHO Surgical Safety Checklist (the Checklist).16,48 An interesting aspect of the Checklist is that it was designed as a tool to make surgery and anesthesia safer everywhere, not just in either HICs or LICs.49 Since its introduction in 2006, the Checklist has been widely implemented in both low- and high-resource settings, often in conjunction with pulse oximetry in the former.50,51 Unfortunately, although there are real difficulties in implementing the Checklist in any setting, these difficulties have been greater in low-resource settings. In some hospitals, the primary value of the Checklist may lie in assisting local clinicians to articulate important deficiencies in basic equipment, such as sterilizers and pulse oximetry or basic drugs such as antibiotics (all of which are items on the Checklist). In all settings, local ownership of the process of introduction and training of staff in the use of the Checklist in the context of each particular setting is essential.51,52

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THE ROLE OF AID AND OF NONGOVERNMENTAL ORGANIZATIONS

Many nongovernmental (often charitable) organizations have been established to meet particular aspects of the global gap in world anesthetic and surgical services (Table 4).

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The WFSA

The WFSA was founded in 1955 and is currently composed of over 134 societies representing over 150 countries. Its mission is “To improve patient care, and access to safe anesthesia, by uniting anesthesiologists around the world.”53 Among other things, this mission implies advocacy, education and training, innovation and research, and a commitment to advancing the quality and safety of health care. Current priorities for the WFSA include workforce mapping and analysis, developing appropriate standards for equipment for low-resource settings, and the promotion of collaboration between its member societies and related organizations. The WFSA supports a wide range of educational activities, including the “Fund a Fellow” initiative,54 SAFE Pediatric and Obstetric courses, subspecialty training in centers of excellence within LMIC regions, teach the teachers courses, and support for the postgraduate diploma of regional anesthesia. These efforts are supported by publications including Anaesthesia Tutorial of the Week and Update in Anaesthesia.55

The International Standards for a Safe Practice of Anesthesia were developed by an independent group of anesthesiologists and adopted by the General Assembly of the WFSA in June 1992. They were revised in 2010 as part of the WHO Safe Surgery Saves Lives initiative, and again adopted by the General Assembly of the WFSA (which has affiliations with the WHO56). Another review is in its final stages and will be published soon.2 These standards are tiered to reflect different levels of facility and service, but even at the most basic level they are still unachievable in many low-resource settings. Importantly, they make it clear that, if surgery is needed to save life or limb, this should proceed in the best way possible, but at the same time they send a very strong message to funders on what is and is not acceptable anesthesia care.

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Other Nongovernmental Organizations

Various other organizations follow different paradigms of aid, often providing different types of specialized surgery to local people that would otherwise not be available to them. The organizations listed in Table 4 all include a commitment to working with local people to achieve sustainable improvement, through training, or even (in the case of The Chain of Hope, for example), through establishing new local hospitals with specialized capabilities.

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National Societies and Colleges of Anesthesia

National anesthesia societies and colleges have been pivotal in advancing the cause of safe anesthesia for all. They have developed and implemented curricula for training and standards for safe and ethical practice. They have standardized anesthesia incomes or fee structures, enhanced recruitment to the specialty, gathered relevant data about outcomes from anesthesia nationally, and provided continuing medical education. Importantly, they have enhanced the standing of all anesthesia providers and increased the attractiveness of the specialty to the next generation of physicians.57

There are important differences within and between countries and no universal model for the optimal provision of anesthesia care. Thus, national societies and colleges should be, and often are, the prime source of advocacy with their own governments and other funders of health care.32,58 Anesthesiologists, as much as any other doctors, can and do inform policy on health care in general, as well as in their own specialty, thereby increasing their influence and ability to provide leadership in working toward universal access to safe anesthesia.

Unfortunately, in LMICs, many societies are small and under-resourced, and manage to do little more than provide an annual continuing education activity in the form of a national meeting to their members. This is an area where stronger societies may be able to assist weaker ones, ideally under the umbrella of their parent organization, the WFSA.

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COORDINATION OF EFFORTS

Currently, there is often a marked lack of goal-oriented coordination42 between the numerous external nongovernmental and charitable organizations working toward improving access to safe anesthesia and surgery within a region (and sometimes even between different organizations representing anesthesiologists within the same country). Collaboration with local stakeholders (Table 5) is even more important, but also variable. The many reasons for this have been articulated by Fisher and Fisher.59 They include interagency competition for donor funds and for reputation. Sometimes pragmatism is a factor: it may be very difficult to gain access to or traction with government departments in host countries, and it may be easier to concentrate on regional or local coordination. However, sustainable change is unlikely to be achieved with models that fail to engage key local stakeholders, and particularly local governments.

Table 5.

Table 5.

Fisher and Fisher59 also list various organizations that could facilitate interagency coordination, including (as 1 example) the WFSA. The constitution of WFSA provides for member societies located in the same geographical region to join together on a voluntary basis to form a regional section.60 Each of these geographical regions contains a unique distribution of HICs and LMICs, and shares its own issues pertaining to the safety of anesthesia. This structure has the potential to facilitate collaboration at a regional level, develop common regional guidelines, and set collaborative objectives. The Helsinki Declaration and the Guidelines for Safety and Quality in Anesthesia practice in the European Union1,12 are excellent examples of a regional initiatives.

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MEASURES OF PATIENT SAFETY IN LOW-RESOURCE SETTINGS

Measurement is integral to quality improvement, but there is a cost to measurement, and, with limited resources, measurement is often seen as unaffordable. Measures possible in LMICs may be seen as too crude to be meaningful for HICs, but common metrics are needed.

The Safe Surgery Saves Lives initiative of the WHO Patient Safety Program recommended 6 measures for assessing surgical services at national level to be used globally. These are number of ORs, number of operations, number of accredited surgeons, number of accredited anesthesia professionals, day of surgery death ratio, and postoperative in-hospital death ratio. When piloted in different countries with different economic capacities, it was feasible to collect data without additional staffing.21 Unfortunately, few if any countries report these measures today.

Perioperative cardiac arrest and/or anesthesia-related cardiac arrest rate has also been used as a safety indicator.37 A recent systematic review with meta-regression and proportional meta-analysis reviewed global data on anesthesia related and perioperative arrest, comparing LICs and HICs. Between 2 time periods, with 11.9 million anesthetics, a significant decrease in these rates was seen in HICs but not in LICs.61

The perioperative mortality rate has the advantage of integrating the risks of anesthetic and surgical interventions, and has been recommended for death occurring either during surgery, before discharge, or at 30 days, depending on the capacity of the reporting health services.62 Ariyaratnam et al63 evaluated the value of the perioperative mortality rate in a large mixed database from both HICs and LMICs and concluded that its use was feasible in different health systems; they recommended standardized reporting. More generally, there should be an expectation for all governments to publish data demonstrating an adequate level of surgical and anesthesia care for all their patients, or in some cases, progress toward that goal. In fact, many countries already publish suites of quality indicators and other metrics to monitor the overall quality of their health services, including various aspects of surgery and anesthesia (see for example Hamblin et al64).

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CONCLUSIONS

There is an increasing realization that surgical conditions represent an important part of the global burden of disease, and that safe anesthesia is essential for safe surgery. There is a massive gap in access to such services today. Many governments and nongovernmental organizations are engaged in various ways in addressing this gap. Voluntary missions and well-conceived aid programs can make a big difference to individual patients, but sustainable progress globally depends on sustainable improvement locally. The effectiveness of international aid is likely to be increased when it is directed to support initiatives driven by local people, but there is a lack of appropriate measurement to demonstrate progress or identify which approaches are indeed the most effective. There is an imperative for increased coordination of effort in the pursuit of agreed global goals and for greater advocacy with national governments for sustainable improvement.

Anesthesia services cannot be thought of in isolation, and inadequate access to safe anesthesia and surgery is not unique to LICs. Sustainable improvement requires a system-based approach, the prerequisite for which is a functioning health care system within a functioning society. The starting point for global access to safe anesthesia is acceptance that access to health care, in general, should be a basic human right everywhere.

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ACKNOWLEDGMENTS

The authors acknowledge Matthew R. Moore who compiled and formatted the manuscript for publication.

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DISCLOSURES

Name: Fauzia A. Khan, FRCA.

Contribution: This author helped prepare the manuscript.

Conflicts of Interest: None.

Name: Alan F. Merry, FANZCA, PhD.

Contribution: This author helped prepare the manuscript.

Conflicts of Interest: A. F. Merry has financial interests in and is a director or Safer Sleep LLC, is Chair of the Board of the Health Quality and Safety Commission in New Zealand, is a Board Member of the World Federation of Societies of Anaesthesiologists, and is a Board Member of Lifebox.

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

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REFERENCES

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