The year 2015 saw a landmark for surgery and anesthesia. The 68th World Health Assembly (WHA) unanimously passed Resolution 68.15 on strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage.1 The Lancet Commission on Global Surgery (LCoGS) delivered the comprehensive report “Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development” which contained 5 key messages relating to access to safe and affordable surgery and anesthesia.2 The LCoGS also presented targets for the upscaling of surgical and anesthesia services with metrics to monitor the journey. At WHA 2017, on a motion presented by Zambia, the Director General of the World Health Organization (WHO) agreed to report every 3 years on the progress being made on Resolution 68.15.3
It is only 12 years until 2030. How will safe anesthesia care be scaled up, and what might anesthesia look like in 2030? This special global health–themed edition of Anesthesia & Analgesia examines many aspects of the challenges faced in meeting the goals described by the LCoGS.
We currently face a tremendous discrepancy between the provision of safe anesthesia care in low- and middle-income countries (LMICs) and that in high-income states. We need to tackle not only the education and training of new practitioners but also the maintenance and support of the existing workforce. Safety standards must be practical and achievable; equipment must be robust and affordable; and a reliable supply of high-quality medications must be ensured. We must also prepare for the pain management challenges that will inevitably accompany the increased volume of surgery.
Together with our colleagues—surgical, obstetric, and nursing—and our partners in the government and in nongovernmental and commercial organizations, we must develop a road map to successfully attain these goals by 2030. That is a challenge of enormous proportions. There is no single solution for even one of these problems which will apply across all countries and all regions.
EDUCATION AND TRAINING
The recent Global Anesthesia Workforce Survey of the World Federation of Societies of Anaesthesiologists (WFSA) argued that 10 anesthesia providers per 100,000 population are required “to ensure effective leadership of anesthesia services and delivery of emergency and essential patient care” but acknowledged that this is unlikely to be achievable in the next 12 years. Their suggested interim target of 5 providers per 100,000 population would still require an additional 136,000 anesthesia providers worldwide.4
Three models of very successful training programs are presented in this issue. The examples of Fiji,5 Mongolia,6 and Benin7 demonstrate the importance of training a critical mass of local and regional anesthesiologists who can not only provide safe anesthesia and educational leadership but also be role models for future anesthesiologists. All 3 programs have relied heavily on external assistance (funding, educational expertise), and they vary in many respects, not only in the length of their training. However, they all have local ownership and local leadership, which are key to their success. Mongolia now has over 6 anesthesiologists per 100,000 people but, even so, due to the sparse population, many districts do not have access to a trained anesthesia provider. Planning is under way for a diploma in anesthesia for nonspecialist physician providers, similar to the 1-year program run in Fiji—this will ensure that rural areas have access to anesthesia and is an example of the task sharing proposed by the LCoGS. Benin has only 0.56 anesthesiologists per 100,000 population and, in spite of the success of its training program, will need to significantly increase the numbers of anesthesia providers. Zoumenou and colleagues7 acknowledge that nonphysician anesthesia providers (NPAPs) are crucial to the future of anesthesia in Africa. The authors suggest that anesthesiologists should work together with small, structured teams of NPAPs to provide complete coverage of countries in Sub-Saharan Africa. This echoes the suggestion, in this issue, of Kudsk-Iversen et al,8 who call for formalization of training and the development of defined career structures for NPAPs.
The role of task sharing has been controversial in the anesthesia community, but we believe that it is an essential part of the solution to the shortage of anesthesia providers.9,10 The success of the Pacific model, training specialist anesthesiologists alongside nonspecialist physician providers, illustrates that task sharing can work. The integration of NPAP training into existing education programs should also be considered as the growth required of the anesthesia workforce is not possible without NPAPs. Each region or country must find its own solution in a combination of specialist anesthesiologists, trained nonspecialist physician anesthetists, and trained NPAPs.
Establishing new training programs is challenging. Morriss et al5 suggest that training guidelines could be very useful in assisting the development of new programs, and this may be a task for the WFSA to undertake.
In the video, “The Checklist Effect,” Atul Gawande commented that while the volume of surgery expands after the economic development of a country, safety does not necessarily follow.11 It is vital that the upscaling in anesthesia and surgery is qualitative and quantitative. Improving and maintaining safety in anesthesia is complex and requires attention to training, continuing education of the existing workforce, and provision of appropriate equipment, as outlined by Khan and Merry.12 It also includes overcoming the barriers to access to reliable and affordable anesthesia medications described by Nickerson and Chikumba.13 This cannot be ignored and will require continued advocacy from individual anesthesia providers, national societies, governments, and nongovernmental organizations. The recent threat to the ketamine supply may have been temporarily addressed but will likely reappear.14 The lack of access to morphine and other essential opioids for treatment of acute and cancer pain continues to be a major barrier to providing basic pain management in many countries.
The WFSA has recognized the vital importance of advocacy and the role that this has played in improving the availability of anesthesia providers, equipment, and medicines. It already has an excellent track record in this area, and the SAFE-T campaign is a timely initiative that should be supported by individuals (through the SAFE-T Network), industry, and patient-focused organizations (through the SAFE-T Consortium).
SETTING STANDARDS AND MEASURING PROGRESS
A number of papers in this issue call for the development of international standards or highlight the importance of existing standards in the task of improving access to safe anesthesia.9,12,15 Developing appropriate standards is challenging, and those involved in their creation need to be vigilant to ensure that standards are achievable and affordable in low-resource settings. Roy and colleagues9 have used the example of India to highlight the challenges of applying a single standard to one country, such as India, which he describes as being both “resource-rich and resource-poor.” The call for more detailed and robust cost effectiveness analyses of models of care by McQueen and Kassebaum15 is timely, and such analyses should, ideally, precede strong recommendations in guidelines and standards.
The International Standards for a Safe Practice of Anesthesia 2010 listed continuous pulse oximetry as “highly recommended.”16 This coincided with the inclusion of the pulse oximeter in the WHO Surgical Safety Checklist and thus facilitated the success of Lifebox, which has introduced over 15,000 oximeters to LMICs since 2011.17 Lifebox has successfully combined appropriate equipment development, the successful use of short course teaching, and advocacy for safe surgery and anesthesia and is a great example of what can be achieved in a short time after sensible guideline development.
Not only must standards be set—targets must be established and progress must be measured. The metrics determined by LCoGS in 2015 are now being collected in many countries and are proving to be valid and feasible.18 It is vital that these indicators are used to inform national surgical, obstetric, and anesthesia plans (NSOAPs) and assist in making the lack of safe surgery and anesthesia more visible to the policy makers and funders. It is crucial that leaders in anesthesia are included in the development of NSOAPs.
THE SPECIAL PROBLEM OF OBSTETRICS
Shaw and Christilaw19 have emphasized the crucial role that anesthesia has in the provision of safe obstetric care and in reducing maternal mortality. Millennium Development Goal 5 called for a 75% reduction in maternal mortality ratio by 2015. While there has been some significant progress, this goal has not been achieved. Nine hundred fifty-one million women do not have access to emergency obstetric care, with the major barrier being the lack of trained staff. It is clear that safer anesthesia for caesarean sections can make a difference. Obstetric and regional anesthesia are important components of anesthesia training. The benefits from short courses to anesthesia providers are becoming clearer, and the Safer Anaesthesia from Education (SAFE) Obstetrics course has shown promise in promoting practice change for those involved in obstetric care.20
THE BURDEN OF PAIN
It is estimated that the burden of chronic pain in LMICs is significant with a prevalence of 34%.21 The required increase in surgery will exacerbate this issue, and it is vital that health care workers are educated and barriers to access to appropriate medications are minimized. Appropriate resources for pain management must be planned for in NSOAPs and we must remain vigilant for further attempts to restrict access to essential medicines such as opioids.
HOW WILL THIS BE PAID FOR?
The training of the estimated 1.27 million surgical, obstetric, and anesthesia providers estimated by LCoGS to be required by 20302 will demand considerable investment. It is estimated that this cost will be 45 billion dollars. The provision of infrastructure to support this upscaling of the workforce and the costs of service delivery must also be planned for. Including workforce planning in NSOAPs is vital for calculating national health budgets. Current evidence from Sub-Saharan Africa suggests that LMIC governments need external assistance for training.7 This may come from foreign governments or nongovernmental organizations, including national societies, high-income country universities, and hospitals. Novel funding solutions will be needed. A futurist view of anesthesia from 2030 has been presented by Hendel and Absalom.22 They suggest that large corporations may see the benefits of maintaining a healthy population by becoming more involved in health services in LMICs. Smaller private organizations, acting as social enterprises, have already had successes in health service provision in LMICs.23 There will be no universal solution to the problem of funding, and a variety of approaches will be needed in each country or region.
Precedents for large-scale intervention to tackle humanitarian crises exist. The ongoing, coordinated global response to the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) epidemic since the 1980s has been remarkable and should serve as a model to those in the surgical and anesthesia community as to what can be achieved.24 Arguably, the crucial point in the HIV response was in 2001 when the United Nations endorsed a Declaration of Commitment on HIV/AIDS. This was followed by the establishment of the President’s Emergency Plan For Aids Relief, which has formed partnerships with the United Nations, the WHO, and private organizations. In addition to the development of prevention measures and new treatments, these partnerships have worked to ensure ready, affordable access to medications. This is an example of how advocacy, target setting, and coordination of resources can strengthen health systems.
What brought such a response to the global call for arms in addressing the HIV/AIDS epidemic? In our opinion, it was the fact that the disease was spreading rapidly from low- to high-income regions of the world, into the world we know. A similar response was seen when patients with Ebola began to arrive in Europe and North America. Suddenly, these infectious diseases began to threaten those who could afford to respond and those who were less advantaged, so everyone worked together to develop a rapid solution to the problems.
Lack of access to safe anesthesia and surgery threatens 5 of the 7 billion people who occupy this planet. That far exceeds the risks of HIV/AIDS and Ebola. However, the deficiency is seen mainly in countries with few resources and, in general, does not threaten the well-off. Therefore, it is difficult to generate the response required to deliver safe anesthesia and surgical care to those who need it. The report of the LCoGS and the 2015 WHA resolution are a call to arms for anesthesia, surgery, and obstetrics. Anesthesia & Analgesia is shining a spotlight on these issues for our readers with the publication of this special edition of the Journal. We believe that all governments, both rich and poor, need to respond, and respond now and effectively. Anesthesia communities also have a moral imperative to act. For those 5 billion people in need, it is their right to expect that we will.
Name: Robert J. McDougall, MBBS, FANZCA.
Contribution: This author helped cowrite the article.
Conflicts of Interest: None.
Name: Angela C. Enright, MB, FRCPC.
Contribution: This author helped cowrite the article.
Conflicts of Interest: A. C. Enright is a member of the Board of Lifebox Foundation.
This manuscript was handled by: Thomas R. Vetter, MD, MPH.
Acting EIC on final acceptance: Thomas R. Vetter, MD, MPH.
1. World Health Organization. WHA68.15: Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Geneva: WHO World Health Assembly; 26 May 2015. Geneva, Switzerland. Available at: apps.who.int/gb/ebwha/pdf_files/WHA68/A68_R15-en.pdf
Accessed October 21, 2017.
2. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.
4. Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth J. The WFSA Global Anesthesia Workforce Survey. Anesth Analg. 2017;125:981–990.
5. Morriss WW, Milenovic MS, Evans FM. Education: the heart of the matter. Anesth Analg. 2018;126:1298–1304.
6. Lundbeg G, Baric A, Pescod DC, Pescod K. Anesthesia development in Mongolia: strengthening anesthesia practice in Mongolia through education and continuing professional development. Anesth Analg. 2018;126:1287–1290.
7. Zoumenou E, Chobli M, le Polain de Waroux B, Baele PL. Twenty years of collaboration between Belgium and Benin in training anesthesiologists for Africa. Anesth Analg. 2018;126:1321–1328.
8. Kudsk-Iverson S, Shamambo N, Bould MD. Strengthening the anesthesia workforce in low- and middle-income countries. Anesth Analg. 2018;126:1291–1297.
9. Weiser TG, Bekele A, Roy N. Safe surgery globally by 2030: the view from surgery. Anesth Analg. 2018;126:1105–1108.
10. Lipnick MS, Bulamba F, Ttendo S, Gelb AW. The need for a global perspective on task-sharing in anesthesia. Anesth Analg. 2017;125:1049–1052.
11. Lifebox Foundation. The Checklist Effect [video]. 2016.TVF International.
12. Khan FA, Merry AF. Improving anesthesia safety in low-resource settings. Anesth Analg. 2018;126:1312–1320.
13. Nickerson JW, Chikumba E. Access to medicines for improving access to safe anesthetic care. Anesth Analg. 2018;126:1405–1408.
14. Joshi GP, Onajin-Obembe B. The role of ketamine in low- and middle-income countries: what would happen if ketamine becomes a scheduled drug? Anesth Analg. 2016;122:908–910.
15. Kassebaum NJ, McQueen K. The role of cost-effectiveness analysis in global anesthesia. Anesth Analg. 2018;126:1397–1399.
16. Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth. 2010;57:1027–1034.
17. Lifebox Foundation. Available at: http://www.lifebox.org/what-we-do/pulse-oximetry/
. Accessed November 25, 2017.
18. Watters DA, Guest GD, Tangi V, Shrime MG, Meara JG. Global surgery system strengthening: it is all about the right metrics. Anesth Analg. 2018;126:1329–1339.
19. Shaw D, Christilaw J, Munjanja SP. Safe surgery globally by 2030: the essential role of anesthesia, the view from obstetrics. Anesth Analg. 126:1109–1111.
20. Evans FM, Duarte JC, Haylock Loor C, Morriss W. Are short subspecialty courses the educational answer? Anesth Analg. 2018;126:1305–1311.
21. Jackson T, Thomas S, Stabile V, Shotwell M, Han X, McQueen K. A systematic review and meta-analysis of the global burden of chronic pain without clear etiology in low- and middle-income countries: trends in heterogeneous data and a proposal for new assessment methods. Anesth Analg. 2016;123:739–748.
22. Hendel S, Absalom AR. Anesthesia: the view from 2030. Anesth Analg. 2018;126:1409–1412.
23. Bhattacharyya O, Khor S, McGahan A, Dunne D, Daar AS, Singer PA. Innovative health service delivery models in low and middle income countries: what can we learn from the private sector? Health Res Policy Syst. 2010;8:24.
24. Piot P, Quinn TC. Response to the AIDS pandemic–a global health model. N Engl J Med. 2013;368:2210–2218.