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Featured Articles: Editorial

Anesthesia Capacity in Rural Zambia, Malawi, and Tanzania: The Anesthesiologist’s Perspective

Kasole-Zulu, Tuma MBChB*; Ndebea, Ansbert S. MD; Chikumbanje, Singatiya S. MBBS; Bould, M. Dylan MBChB§

Author Information
doi: 10.1213/ANE.0000000000004638

See Article, p 845


Although the world is increasingly rapidly urbanizing,1 there is a great disparity between countries. Most of the population of sub-Saharan Africa live in rural areas and especially so in the poorest countries. For example, 56.5% of Zambians, 66.2% of Tanzanians, and 83.1% of Malawians live in rural areas.2 Rural populations, with a huge burden of surgical disease,3 have particularly poor access to safe, timely, and affordable surgical care. District-level hospitals almost never have specialists in surgery, obstetrics, or anesthesia. During medical school and internship, the general practitioners (GPs) who staff district hospitals have some training in surgical skills; for example, they are expected to be able to perform cesarean deliveries. However, these GPs are not trained in anesthesia.

In Tanzania, Malawi, and Zambia, most anesthesia care in rural areas is provided by nonphysician anesthesia providers (NPAPs). These anesthesia providers either have a nursing background or are clinical officers/assistant medical officer anesthetists (a nonphysician cadre who has studied for a medical diploma before entry into anesthesia training). However, even these NPAPs are few for the burden of disease, are therefore overworked, become burned out, and often leave anesthesia practice in rural areas. In some district hospitals, there is no one with formal anesthesia training, and provision of anesthesia is left to the surgeon (GP) or someone else who is expected to “learn on the job”—a euphemism that may mean being given a syringe of ketamine but few instructions on how to manage the case while the surgeon works.

This is symptomatic of how far anesthesia is behind our surgical colleagues, even within the context of chronic underinvestment across surgical disciplines. As East and Southern African countries have developed their health care and medical education systems after independence in the 1960s, postgraduate training programs in surgery and obstetrics tend to have been prioritized. In Tanzania, physician anesthesia training began in 1982, but it has been challenging to recruit physicians to a specialty low in status, and only around 40 anesthesiologists have been trained since then. The first medical school in Malawi was not built until 1991, and residency training in general surgery began in 20054 and in anesthesia only in 2010. To date, there are only 4 Malawian-trained anesthesiologists. In Zambia, the School of Medicine at the University of Zambia opened in 1966. There has been a surgical residency program since 1986,5 but there was no training program for anesthesiologists before 2011.6 The first anesthesia graduates in 2015 have had the challenge of having to build a profession of anesthesiology from the day they finished their residency.


In the SURG-Africa study by Gajewski et al7 published in this edition of Anesthesia & Analgesia, our surgical colleagues have found what those of us working in these areas already know too well—capacity for anesthesia care is dismal and is often the rate-limiting step in providing safe, timely, and affordable surgical care. Problems with the availability of equipment, essential drugs, and the most basic infrastructure, such as electricity and water, are widespread. Lack of human resources for health is ubiquitous. This could be considered within the “5-S” framework8 (stuff, staff, space, systems, and surveillance), and in our experience, although the SURG-Africa study did not include this, weak systems of care and lack of appropriate surveillance are equally widespread. This study was completed by a team of 14 investigators from Ireland, the Netherlands, Malawi, Zambia, and Tanzania, including epidemiologists and surgeons but not a single anesthesia provider. This study was designed to look at deficiencies in surgical care provision, but when the investigators found that anesthesia was the biggest problem, they focused the first publication from this study entirely on anesthesia. We are grateful to them for shining the spotlight on the challenges well known within our specialty.

The SURG-Africa study uses the PIPES Surgical Assessment Tool to examine surgical capacity in Malawi, Tanzania, and Zambia. This tool considers 5 different domains: personnel, infrastructure, procedures, equipment, and supplies. Personnel includes both physician and nurse anesthetists, which seems reasonable, but we should be cautious, because there are many different anesthesia provider training models, with 30 different models in sub-Saharan Africa alone.9 Interestingly, this domain has no maximum score and so neither does the overall PIPES score. Infrastructure covers many items that are key to anesthesia care, such as the availability of running water, electricity, and a postoperative care unit. Procedures list 40 specific items, of which some are particularly relevant to anesthesia: resuscitation, cricothyroidotomy, regional anesthesia blocks, spinal anesthesia, ketamine anesthesia, and general anesthesia. Equipment lists 22 items, many that are essential for anesthesia, such as oxygen, an oximeter, and endotracheal tubes. Many are missed; for example, it is our experience that it is entirely likely that an operating room may have a pediatric endotracheal tube but no appropriate pediatric laryngoscope (or the other way round), and the latter is not included. Supplies list 22 items, few directly relevant to anesthesia, and this item is perhaps the most problematic. There is no mention of essential anesthesia medications in this tool, an issue that is of widespread concern throughout Zambia, Malawi, and Tanzania, where it is well known that there is either inconsistent or consistently poor access to essential medications at the best of times, as well as concerns of substandard and fraudulent medicines.10,11 Indeed, the poor quality of anesthesia medications was raised in the qualitative data. The PIPES tool may be filled out by any perioperative health care provider, and the information about anesthesia may be returned by a surgeon or administrator rather than by an anesthesia provider. Of 76 hospitals included in the quantitative part of the study, 43 anesthesia providers were surveyed—so for almost half of the hospitals included (at best), no anesthesia provider was actually consulted in quantitative data collection. In Zambia, only 7 anesthesia providers were included over 24 hospitals, so in 70% of hospitals, there was no anesthesia input in quantitative data collection. Other research using PIPEs12 has shown that responses differ by professional group. This can be expected to be a major limitation on the accuracy of the data—in our experience working in Zambia, Tanzania, and Malawi, surgeons and nurses often do not have a precise idea of what is going on in anesthesia (and vice versa).

There are alternative tools available for the evaluation of anesthesia capacity. The World Federation of Societies of Anaesthesiologist’s (WFSA) Anaesthesia Facility Assessment Tool (AFAT)13 is based on the 2018 World Health Organization (WHO)-WFSA International Standards for a Safe Practice of Anaesthesia and allows a detailed assessment of anesthesia. It has 8 domains: infrastructure, blood products, information management (including systems issues such as mortality reviews), workforce, service delivery (including key safety concerns such as using the surgical safety checklist and handover protocols), case mix/perioperative mortality, medications, and equipment. The survey must be completed by an anesthesia provider. No tool is perfect, but in our experience, this tool is detailed, comprehensive, and very well suited to the context in Zambia, Malawi, and Tanzania.

A strength of the SURG-Africa study was including mixed quantitative and qualitative methods. However, despite the focus of this article being anesthesia capacity, relatively few anesthesia providers were included as participants or informants in the qualitative phase even more than the quantitative phase. For the qualitative data collection, of 33 hospitals included over the 3 countries, only 12 anesthesia providers were interviewed—so around 2 of 3 hospitals (at best) had no anesthesia provider involved in the qualitative data collection. To some extent, this tells us something important: clearly every professional group thinks that anesthesia is a critical bottleneck. But for robust qualitative data, we must ask the right people the right questions. Where is the voice of the anesthesia providers?

We completely understand that the SURG-Africa team had a remit to look at surgical care across the board and needed to choose a tool that included more surgical items, such as PIPES, which has previously been validated for this purpose. We appreciate also that the finding that anesthesia posed the biggest challenges was unexpected. However, this presents a conundrum. The results of this study ring true to us. Anesthesia care is desperately underdeveloped across Tanzania, Malawi, and Zambia, and especially in rural areas. It does not surprise us that this group considers it to be a bottleneck in improving perioperative care. However, there is still a huge knowledge gap in quantifying this issue. The SURG-Africa data are a post hoc analysis, which uses a tool that is not validated for the purpose, with noncensus nonrandom sampling for quantitative data and flawed sampling of the supporting qualitative data. Anesthesia seems to have been somewhat of an afterthought in this study, with apparently little direct input from anesthesia colleagues into study design, analysis, or interpretation of results. This clearly affects the quality of the study. Measuring anesthesia capacity without measuring the reliability of access to essential anesthesia drugs is like speaking of the capacity to perform surgery without considering whether or not sutures are available, and this is just one example. It should therefore be an urgent priority to comprehensively quantify anesthesia capacity in rural East and Southern Africa, with alternative tools specific to anesthesia needs. Until we have these data, we cannot truly know where we should focus or if we are making progress.


Even in this post-Lancet Commission14 era of National Surgical Obstetric and Anesthesia Plans15 (NSOAPs) and Surgeons, Anesthesiologists, and Obstetricians16,17 (SAOs), it is as obvious to us as a box empty of endotracheal tubes that S ≠ O ≠ A. We are grateful for the SURG-Africa study, and we in no way wish to single them out for any perceived lack of collaboration with anesthesia, but in our experience, this study is emblematic of some unfortunate realities in global health partnerships. Any partnership that focuses on a narrow part of the surgical ecosystem is at high risk of failing to actually improve patient outcomes, as issues are rarely confined to just surgeons or just anesthesia. However, partnerships almost routinely fail to engage with the “big picture” (and anesthesia partnerships are not immune to this). This happens even in countries with a comprehensive NSOAP, including both Zambia and Tanzania. Partnerships, programs, and studies of perioperative care often remain “siloed,” when we should instead be working together, using all the expertise of our teams. Why is this?

The answer to this question is beyond the scope of this editorial, but should itself be considered a priority to be answered. So we will conclude by again thanking our surgical colleagues for highlighting that the development of anesthesia ought to be the first priority in improving surgical care, but also a call to action: anesthesia must be meaningfully involved in all research, quality improvement, program development, and policy that relates to perioperative care. Beware tokenism and box-ticking, and consider us (and, vitally, the still more forgotten team members, such as operating room nurses) as equal partners, there are visionary emerging leaders in anesthesia in the region, but they often struggle to be seen as they remain in the shadows of surgery and obstetrics. Their expertise is just as vital. We all share the goal to improve perioperative care, and we can only meet these goals by working together. This is the only way that the populations of Zambia, Malawi, and Tanzania will be able to reliably access safe, timely, and affordable surgical care.


Name: Tuma Kasole-Zulu, MBChB.

Contribution: This author helped draft and edit this editorial.

Name: Ansbert S. Ndebea, MD.

Contribution: This author helped draft and edit this editorial.

Name: Singatiya S. Chikumbanje, MBBS.

Contribution: This author helped draft and edit this editorial.

Name: M. Dylan Bould, MBChB.

Contribution: This author helped draft and edit this editorial.

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



AFAT = = Anaesthesia Facility Assessment Tool

GP = = general practitioner

NPAP = = nonphysician anesthesia provider

NSOAP = = National Surgical Obstetric and Anesthesia Plan

PIPES = = PIPES Surgical Assessment tool - Personnel, Infrastructure, Procedures, Equipment, and Supplies

SAO = = Surgeons, Anesthesiologists, and Obstetricians

WFSA = = World Federation of Societies of Anaesthesiologists

WHO = = World Health Organization


1. United Nations Department of Economic and Social Affairs Population Dynamics, 2018 Revision of World Urbanization Prospects. Available at: Accessed August 28, 2019.
2. United Nations Department of Economic and Social Affairs Population Dynamics, 2018 Revision of World Urbanization Prospects. Available at: Accessed August 28, 2019.
3. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health. 2015;3(Suppl 2):S8–S9.
4. Henry JA, Frenkel E, Borgstein E, Mkandawire N, Goddia C. Surgical and anaesthetic capacity of hospitals in Malawi: key insights. Health Policy Plan. 2015;30:985–994.
5. Bowa K, Goma F, Yikona JINM, Mulla YF, Banda S. A review of outcome of postgraduate medical training in Zambia. Med J Zambia. 2008;35:88–93.
6. Janowicz A, Kasole T, Measures E, et al. Development of education and research in anesthesia and intensive care medicine at the university teaching hospital in Lusaka, Zambia: a descriptive observational study. Anesth Analg. 2017;125:287–293.
7. Gajewski J, Pittalis C, Lavy C, et al. Anaesthesia capacity of district-level hospitals in Malawi, Tanzania, and Zambia: a mixed-methods study. Anesth Analg. 2020;130:845–853.
8. Bitton A, Veillard JH, Basu L, Ratcliffe HL, Schwarz D, Hirschhorn LR. The 5S-5M-5C schematic: transforming primary care inputs to outcomes in low-income and middle-income countries. BMJ Glob Health. 2018;3:e001020.
9. Law TJ, Bulamba F, Ochieng JP, et al.; Global Anesthesia Workforce Study Group. Anesthesia provider training and practice models: a survey of Africa. Anesth Analg. 2019;129:839–846.
10. Jochberger S, Ismailova F, Lederer W, et al.; “Helfen Berührt” Study Team. Anesthesia and its allied disciplines in the developing world: a nationwide survey of the Republic of Zambia. Anesth Analg. 2008;106:942–948.
11. Mumphansha H, Nickerson JW, Attaran A, et al. An analysis of substandard propofol detected in use in Zambian anesthesia. Anesth Analg. 2017;125:616–619.
12. Markin A, Barbero R, Leow JJ, et al. Inter-rater reliability of the PIPES tool: validation of a surgical capacity index for use in resource-limited settings. World J Surg. 2014;38:2195–2199.
13. The World Federation of Societies of Anaesthesiologists Anaesthesia Facility Assessment Tool. Available at: Accessed August 28, 2019.
14. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.
15. Citron I, Sonderman K, Subi L, Meara JG. Making a case for national surgery, obstetric, and anesthesia plans. Can J Anaesth. 2019;66:263–271.
16. Holmer H, Lantz A, Kunjumen T, et al. Global distribution of surgeons, anaesthesiologists, and obstetricians. Lancet Glob Health. 2015;3(Suppl 2):S9–11.
17. Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth J. The WFSA Global Anesthesia Workforce Survey. Anesth Analg. 2017;125:981–990.
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