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Strengthening the Anesthesia Workforce in Low- and Middle-Income Countries

Kudsk-Iversen, Søren; Shamambo, Naomi; Bould, M., Dylan

doi: 10.1213/ANE.0000000000002722
Global Health: Special Article

The majority of the world’s population lacks access to safe, timely, and affordable surgical care. Although there is a health workforce crisis across the board in the poorest countries in the world, anesthesia is disproportionally affected. This article explores some of the key issues that must be tackled to strengthen the anesthesia workforce in low- and lower-middle-income countries. First, we need to increase the overall number of safe anesthesia providers to match a huge burden of disease, particularly in the poorest countries in the world and in remote and rural areas. Through using a task-sharing model, an increase is required in both nonphysician anesthesia providers and anesthesia specialists. Second, there is a need to improve and support the competency of anesthesia providers overall. It is important to include a broad base of knowledge, skills, and attitudes required to manage complex and high-risk patients and to lead improvements in the quality of care. Third, there needs to be a concerted effort to encourage interprofessional skills and the aspects of working and learning together with colleagues in a complex surgical ecosystem. Finally, there has to be a focus on developing a workforce that is resilient to burnout and the challenges of an overwhelming clinical burden and very restricted resources. This is essential for anesthesia providers to stay healthy and effective and necessary to reduce the inevitable loss of human resources through migration and cessation of professional practice. It is vital to realize that all of these issues need to be tackled simultaneously, and none neglected, if a sustainable and scalable solution is to be achieved.

From the Department of Anesthesiology, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.

Accepted for publication November 2, 2017.

Funding: None.

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

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Reprints will not be available from the authors.

Address correspondence to M. Dylan Bould, MBChB, MEd, MRCP, FRCA, Department of Anesthesiology, Children’s Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Rd, Ottawa, Ontario K1H8L1, Canada. Address e-mail to dbould@cheo.on.ca.

The majority of the world’s population lacks access to safe, timely, and affordable surgical care.1 The barriers to improving this situation are numerous, relating to the complex ecosystem needed to provide perioperative care, which includes issues as diverse as national transport infrastructure and systems for the procurement of essential medicines. Perhaps the most universal and significant obstacle is the lack of availability of well-trained health care professionals to provide surgical, anesthesia, and nursing care: a strong professional workforce empowered to advocate for patients and with a vision to improve the health care systems in which they work. Although there is a health workforce crisis across the board in the poorest countries in the world, anesthesia is one of the specialties that is disproportionally affected and is plagued by issues of low status that prevents the development of a specialty that has a critical role to play in obstetrics, trauma, pain, critical care, perioperative medicine, and all surgical specialties.

According to a recent survey, there are 436,596 specialist/physician anesthesiologists worldwide; however, it is estimated that this number needs to at least double.1–3 Yet only 12% work in low- and lower-middle-income countries (LMICs), which includes over 48% of the global population. Put into context, the disparity of the workforce becomes more obvious: in the United Kingdom and United States, the specialist anesthesiologist density is 18 and 21 per 100,000 population, respectively, compared to, for example, 0.13 and 0.02 per 100,000 population in the Democratic Republic of Congo and Afghanistan, respectively, driving the need for independent nonphysician anesthesia practice in the latter countries.4 Although global numbers of nonphysician anesthesia providers (NPAPs) are less clear, available data regarding anesthesia provision in LMICs suggest that NPAPs greatly outnumber specialist anesthesiologists.2 , 5–9 However, the total number of anesthesia providers remains <1 per 100,000 population in many countries, especially in Sub-Saharan Africa.3 Unsurprisingly, the lack of skilled anesthesia providers has been associated with high perioperative morbidity and mortality rates.10 , 11 The shortage of trained anesthesia personnel is compounded by difficulty in retaining health care staff in rural areas, thus limiting, even further, access to safe anesthesia.12

Strengthening the anesthesia workforce must therefore be an immediate and ongoing priority. This article explores some of the key issues that we believe must be addressed to achieve this:

  1. Increasing the number of anesthesia providers to match a huge burden of disease, particularly in the poorest countries in the world and in remote and rural areas;
  2. Improving the competency of anesthesia providers: the knowledge, skills, and attitudes required to manage both complex and high-risk patients and to lead improvements in the quality of perioperative and critical care;
  3. Working and learning together with colleagues in interprofessional teams in a complex surgical ecosystem;
  4. Developing a workforce that is resilient to burnout and the challenges of an overwhelming clinical burden and very restricted resources: it is essential for the anesthesia providers to stay healthy and effective and necessary to reduce the inevitable loss of human resources through migration and cessation of professional practice. This includes a broad range of complex issues, such as high-level advocacy for the importance of anesthesia, and ensuring that the anesthesia providers are adequately reimbursed for the work that they do.

We will make the argument that addressing all of these issues is necessary to achieve an acceptable solution to the current anesthesia workforce crisis. There are many other important areas that affect the quality of care, for example, issues surrounding infrastructure, equipment availability, and drug shortages. While important, these issues will not be discussed in this article as they are not specific to human resources for health and so are outside the scope of this discussion.

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INCREASING THE NUMBER OF SAFE ANESTHESIA PROVIDERS

To reach a surgical workforce of minimum 20 per 100,000 population by 2030, the Lancet Commission on Global Surgery (LCGS) estimates a further 1.27 million providers of anesthesia, surgery, and obstetrics need to be trained.1 This means approximately doubling the workforce, requiring significant expansion of existing training schemes or establishment of new training schemes altogether. The cost of training is between 16 and 45 billion USD for LMICs alone.1 There is currently no funding mechanism available to achieve this goal. The amount of money required is comparable to the funds disbursed by The Global Fund to Fight AIDS, Tuberculosis and Malaria since 2002, and it seems likely that a similar kind of major international partnership would be required to finance this scaling up of the workforce. This in turn will require a huge advocacy effort to promote surgical and anesthesia care as a global health priority.

To meet surgical demand, >100 countries globally use anesthetic task shifting/sharing, that is, having NPAPs or general practitioners, instead of specialist anesthesiologists, provide anesthesia care. Task shifting, as defined by the World Health Organization (WHO), is where tasks are moved from high-skilled workers to workers with shorter training to make best use of the human resources available.13 The LCGS advocates a model of task sharing rather than task shifting, putting the emphasis on a shared responsibility of care between the specialist anesthesiologist and the NPAP.1 This is in no way unique to anesthesia and has been demonstrated to be a safe and cost-effective model to increase access to surgical, obstetric, and HIV care.14–19 In task sharing, the specialist anesthesiologist will train, mentor, and at times, directly supervise the NPAP. The debate in mainly high-income countries (HICs) regarding NPAPs and the role of task shifting/sharing in anesthesia is both heated and polarized. Concerns raised on either side of the argument may not be relevant in all settings, and entrenched views need to be challenged by evidence.20 Unfortunately, only limited and often conflicting data are available.21 , 22 Ultimately, as the need for absolute numbers of anesthesia providers is so huge in LMICs and it takes so long to train a physician anesthesiologist, it seems imperative to use task sharing if there is any hope of achieving the targets of access to surgery set out by LCGS.

A review of qualitative data concerning the effect of task shifting on nonphysician health providers offers several key learning points of relevance to anesthesia: for example, to best contribute to these programs, it is crucial to ensure that NPAPs enter into a supportive system where they have a clearly defined role and a manageable workload. Furthermore, there should be a concerted effort to provide further training and a means for career progression.23 Supervision of NPAPs from specialist anesthesiologists remains largely absent.7 , 24 This may become a patient safety concern, and in many locations, the practice of NPAPs is not regulated and their training may vary between years of curricula-based education to learning on the job.7 Of concern is “informal substitutions,” that is, task shifting occurring when there is, for example, a need for anesthesia provision but no trained workers to perform the job.25 There should be engagement with established training programs to assess the capacity to safely expand the intake as well as the ability to provide ongoing education for graduates.26 Hence, as we strongly advocate task sharing as a sustainable solution for the current crisis in human resources, the shared responsibility of the model requires an increase in not only NPAPs but also physician anesthesia numbers.

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IMPROVING THE COMPETENCY OF ANESTHESIA PROVIDERS

With the pressure to rapidly increase the workforce numbers, we must not forget that quality is just as important as quantity. The quality of the workforce depends on several factors but most importantly the competencies of those anesthesia providers. Training programs vary markedly in different contexts. Dubowitz and Evans27 outline that how available training in LMICs can be broadly divided into 3 main categories: (1) countries with no organized training program and few, if any, specialist anesthesiologists; (2) countries with an organized training program but significant educational needs and limited number of specialist anesthesiologists; and (3) countries with an organized training program and adequate trainers but possible lack in skills, oversight, or resources. What becomes apparent is the need to ensure that the strengthening (or formation) of a program is done in close consultation with the local stakeholders to ensure anesthesia providers have the right competencies with relevance to the local context.27 There is a remarkable variation in models of anesthesia training globally in terms of requirements of entry to the program, length of training, and the content of the curriculum. There is currently no international accreditation, standardization, or even guidelines for anesthesia training, and despite the importance of context, this would seem to be a potential mechanism to improve the quality of training. Competency-based models are becoming increasingly common in high-income settings28 and are not without controversy,29 but there are little data on this model in LMICs.

Strong leadership in anesthesia is required to ensure the development of robust systems of perioperative care that will enable patient safety. In high-income settings, it is increasingly recognized that poor outcomes are more often due to failures of systems of practice or teamwork than from individual errors. Although there are little data on the development of these kinds of competencies in anesthesia in LMICs, our experience working with and/or being from LMICs suggests that they are if anything more important in that context. We believe that it is vital for anesthesia training programs in LMICs to provide competencies not only in theoretical knowledge and clinical skills but also in broader nonmedical expert domains such as leadership, professionalism, systems-based practice, and nontechnical skills (NTSs) such as communication and situational awareness.30 , 31 To expect these competencies to be achieved, it is necessary to have dedicated formal teaching and assessment of these domains of learning. These competencies may not be needed in every anesthesia provider, but they need to be built into a task-sharing model and may be required in both physician and nonphysician providers alike. There has been an increased interest in NTSs in the medical education literature, and key elements have been incorporated into the core competencies of recently updated postgraduate training in United States and Canada.32 , 33 The available literature on NTSs suggests that having high situational awareness, effective communication, and decision making is associated with positive patient outcomes, while having poor NTSs increases the chance of preventable errors.34 There is ongoing debate as to the most effective means of assessing and supporting the development of these skills, but they need to be formally incorporated into the curriculum. A limited but encouraging body of evidence exists suggesting that simulation training is a useful tool in low-resource settings, as it provides a low-cost means of improving both critical clinical skills and NTSs.35–37 A further part of leadership development includes a strong professional body of anesthesia providers, probably through a national anesthesia society, which can support practice nationally including creating protocols for safe clinical care.

Several initiatives show potential for scaling up the specialist workforce. Multiple examples exist for partnerships between countries classified as being LMICs and HICs, which have enabled the establishment of successful training programs in collaboration between present staff and visiting faculty.38–42 These partnerships allow targeted financial support to establish the program, alongside external specialist input until the in-country capacity is strong enough to become self-sustaining.38 , 42 This capacity is crucial as it enables the establishment of specialist anesthesia training in countries with the greatest need, which are often the countries with few or no specialist anesthesiologists to begin with. Furthermore, there has been an increase in opportunities for postgraduate trainees in HICs to support these partnerships through fellowships. By allowing the visiting faculty to be made up of fellow trainees from partnering countries, there is an opportunity for colearning and a breakdown of the historic hierarchical North–South structure, which again allows for trainees from both countries to develop professionally.43 , 44 The World Federation of Societies of Anaesthesiologists provides fellowships for specialist trainees from low-income countries to undertake subspecialty training in partnering institutions around the world. For 3–12 months, the trainee can gain experience of a different health system and develop further experience in their field of interest.45

Currently, partnerships are only scratching the surface of what is required to achieve LCGS goals. Hands-on external support may be the only option in countries with very low capacity for both anesthesia provision and training. In other countries where anesthesia is more developed, external financial support may be required to allow the development of homegrown solutions.

Continued professional development (CPD) provides a means for the anesthesia provider to stay up to date and strengthen competencies for safe practice. However, in a high-demand low-resource setting where CPD may be of most benefit, it may also be the most difficult to access. Nevertheless, there is good evidence to suggest that it improves patient care and job retention.46 , 47 A number of different global initiatives have been established with the intention of providing CPD in LMICs. For example, the Safer Anaesthesia from Education courses provide training to both NPAPs and specialist anesthesiologists in obstetric or pediatric anesthesia, and soon there will be a multidisciplinary course focused on the operating room.48 Another example is the Primary Trauma Care course, which provides multidisciplinary education in the acute management of trauma.49 Yet another example is the Lifebox training course, which over the course of a day provides education in pulse oximetry and the WHO surgical safety checklist.50 Common to all these courses is that they are tailored to low-resource settings, focus on key aspects of safe practice, and that they focus on sustainability of the CPD by either making the course material freely available or providing a Train the Trainer course for local staff.

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ENCOURAGING INTERPROFESSIONAL SKILLS

Anesthesia and perioperative care invariably requires working within a team of other health care professionals, including surgeons, obstetricians, nurses, midwives, radiographers, lab technicians, among many others. Often patient outcomes depend more on the collective actions of the whole perioperative team than on the competence of any 1 individual. Poor teamwork is a significant contributor to most adverse events in perioperative care.51 Traditional hierarchical structures and choice of working language can cause barriers to effective team work.52 , 53 Conversely, effective teamwork and intercollegiate trust can positively affect patient safety and patient satisfaction.54–56 Although traditionally different professions and medical specialties are trained in silos separate from each other, from our experience, important skills are better taught by having authentic teams learning together. The WHO definition is that “interprofessional education occurs when [learners] from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”57 This kind of team training has been shown to improve team behavior, team member confidence, and surgical mortality.51 By providing a way for teams to collaborate and optimize the skills of individual members, it is possible to, among other things, decrease patient complications, clinical error rates, and staff turnover.54 , 58

This can only be achieved by greater coordination between different specialists and professions when planning educational activities, which may be workshops, simulation, part of a formal curriculum, or even activities such as debriefing after a difficult case or reviewing institutional mortality and morbidity. These same issues should be considered when engaging in HIC–LMIC partnerships, which often have a narrow specialty-/professional-specific mandate, which does not encourage interprofessional learning. Inevitable logistical challenges in getting diverse teams together for formal learning mean that this kind of activity may remain relatively infrequent, but this does not undermine its value to learners.

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PREVENTING BURNOUT AND ENCOURAGING THE RETENTION OF ANESTHESIA PROVIDERS

Anesthesia often suffers from a low status compared to other medical specialties.59–61 In many low-income countries, there have been postgraduate training programs in surgery and obstetrics for many years but none in anesthesia. Particularly in rural areas, a patient may be lucky to have anesthesia provided by a trained NPAP, while elsewhere, it may instead be delivered by an intern with only minimal exposure to anesthesia as a medical student, or even by the surgeon. When health care professionals are used to seeing anesthesia as an afterthought, it is challenging to develop a strong professional body of anesthesiologists; there is little incentive to enter the profession, resources for anesthesia and critical care tend to be neglected and working conditions are poor. Lack of appropriate reimbursement may compound this issue. The increased stress and high workload associated with the small pool of available anesthesiologists may discourage medical students from applying to anesthesia.62–64 Furthermore, medical and research organizations with high availability of funding and career potential (eg, organizations receiving funds earmarked for HIV-related work) might pull undergraduates toward other specialties.65 In addition, anesthesia has a low number of health care providers to deal with a huge burden of disease. In our experience, this situation improves very little with the first few new anesthesiologists to join professional practice, so there is an inertia problem where it is difficult to get to a point where there are enough anesthesia providers that any have reasonable working conditions. The consequences of this are difficulty in recruiting to anesthesia, burnout of anesthesia providers with associated risks to patient safety and the health of the workforce, and ultimately poor retention of anesthesia providers who either leave medicine or leave the country.

Perhaps the most obvious threat to the sustainability of the anesthesia workforce is migrating away from areas of greatest need rather than toward them. While some might be for personal or family reasons or to seek new challenges or a life in a richer country, it is worth trying to identify preventable factors, as the trend is well recognized and contributes to the shortage of skilled anesthesia providers.66 , 67 Globally, we observe a “brain drain,” a net movement of health care professionals from LMICs to HICs. Lantz et al66 found on review of the specialist databases in 14 HICs that 12% of their surgical workforce (anesthesiologists, surgeons, and obstetricians) came from LMICs, and half of these came from a country in workforce crisis. “Pull” factors include a workforce shortage in HICs due to aging populations and medical advances, leading to an indiscriminate dependence on international medical graduates.66 Factors that “push” health care workers out of LMICs are common in anesthesia practice: low professional satisfaction, lack of career progression, lack of resources, and high workload as well as more general issues like political instability.68 The same push and pull factors are observed within countries where there is a move away from rural areas, where there is the greatest need, toward urban centers.69–72

To increase retention of anesthesia providers, we need to target both push and pull factors. A systematic review of motivation and retention of health care workers in developing countries found that increased salary, career progression, skilled hospital management, education and training opportunities, and recognition by the employer were important.67 Interestingly, financial incentives on their own are not enough to retain health care workers.67 , 71 , 73 Instead, addressing retention through opportunities in training and career progression, provides an ideal means of both supporting the scale up of the anesthetic workforce and countering outward migration.40 To target the pull factors, HICs need to address their own workforce shortage.74 Furthermore, in 2010, the WHO facilitated the creation and universal adoption of a code of practice to mitigate the unethical recruitment of health personnel from LMICs.75 It is the responsibility of HICs to actively adhere to both the code of practice and to engage with the recommendations of the subsequent WHO task force.12 , 76

Burnout syndrome has been defined as a triad of exhaustion, depersonalization, and reduced personal accomplishment.77 It occurs when there is a chronic mismatch between job demands and resources to cope with the demands and is also an important push factor.78 The second criterion, depersonalization, refers to a coping mechanism involving withdrawal from work, cynicism, and detachment from people entrusted to one’s care, which may be particularly problematic as health care systems in low-income countries may lack mechanisms to ensure accountability from health care professionals. Negative consequences of burnout include medical errors, errors in judgment, poor interpersonal relationships at work, absenteeism, low recruitment, drug misuse, and suicidal ideation.79 Anesthesia is internationally recognized as a stressful specialty with known high levels of burnout among specialist anesthesiologists,80 and the evidence suggests that long working hours, low job satisfaction, and junior status all increase the incidence of burnout.62 While only limited evidence exists, it seems likely that in the context of reduced human resources and increased surgical burden, the risk of burnout is even higher. While some of the risk factors are the same (eg, long working hours, low job satisfaction), some of the studies from low-resource settings add new considerations.81–83 One study evaluating health care staff in a hospital in Ethiopia found that job insecurity, poor relationships with managers, and abuse from staff or patients were risk factors for burnout.84 Furthermore, a South African study found that junior doctors who experience high levels of emotional exhaustion were more at risk of leaving the hospital.83

When planning or implementing a scale up of human resources for health in anesthesia, there can be a tension between (1) the need to improve access to skilled anesthesia care as quickly as possible and (2) the need to find a sustainable solution including reducing the risk of anesthesia providers burning out. For example, a low-income country may have a very small number of anesthesiologists but a new postgraduate anesthesia training program. It may seem a moral imperative to send those first graduates to widely dispersed smaller provincial hospitals, where a large population has little or no access to skilled anesthesia care. However, an unintended consequence of that may be that each individual anesthesia provider is overworked and at risk of burnout and even medical migration away from that country. This may also affect the ability of the new training program to become sustainable, without a suitable critical mass of locally developed educators to take on leadership of the program. Ultimately, there is no easy solution to this tension, but the problem demands that the needs of sustainability and the well-being of anesthesia providers are carefully considered. Any program that aims to scale up anesthesia training must consider early on whether those anesthesia providers are going to be able to have a fulfilling career and to work to mitigate threats to this, including any modifiable push factors.

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CONCLUSIONS

To address the shortcomings of global anesthesia, workforce strengthening is crucial. However, it is a complex task, largely obscured by a lack of data and a very heterogeneous population in need. Nevertheless, we have described what we believe are 4 key issues that must be addressed to overcome the shortcomings with the caveat that further research may add both depth and refinement to increase success and sustainability of the interventions.

It is clear that the number of anesthesia providers must be increased, and we believe that the solution requires a concerted effort to support and train both NPAPs and specialist anesthesiologists. Second, there must be a focus on improving and supporting the competencies for both the existing and the new workforce. Third, there should be a focus on team-based training and management. Finally, all initiatives should include consideration for preventing burnout and retention of the anesthesia providers. It is our opinion that the failure to tackle any one of these issues will result in a weak link in efforts to strengthen the workforce and risk failing to achieve the intended outcomes. We believe it is vital that all of these issues need to be tackled simultaneously if a sustainable and scalable solution is to be achieved.

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DISCLOSURES

Name: Søren Kudsk-Iversen, MBChB.

Contribution: This author helped with the initial draft, critical review, and editing of the manuscript.

Conflicts of Interest: None.

Name: Naomi Shamambo, MBChB, MMed.

Contribution: This author helped with critical review and editing of the manuscript.

Conflicts of Interest: N. Shamambo is the Publicity Secretary of the Society of Anaesthetists of Zambia.

Name: M. Dylan Bould, MBChB, MEd, MRCP, FRCA.

Contribution: This author helped with developing the initial outline, critical review, and editing of the manuscript.

Conflicts of Interest: M. D. Bould is the chair of the Canadian Anesthesiologists’ Society International Education Foundation, a member of the World Federation of Societies of Anesthesiologists Education Committee, and the lead for the Zambia Anaesthesia Development Program (ZADP), a partnership between the Association of Anaesthetists of Great Britain and Ireland and the University Teaching Hospital, Lusaka.

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

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