Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala

Abstract

BACKGROUND: 

International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development.

METHODS: 

In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented.

RESULTS: 

Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking.

CONCLUSIONS: 

This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

KEY POINTS

• Question: What is the current capacity to provide safe surgical and anesthetic care in public surgical hospitals in Guatemala?
• Findings: We found deficiencies in the availability of key medications, equipment, and personnel, and in the provision of postoperative care and pain management.
• Meaning: This first nationwide comprehensive survey revealed that Guatemalan public surgical hospitals do not meet the current World Federation of Societies of Anaesthesiologists Standards for Safe Anesthetic Care.

Recent landmark publications have highlighted surgery and anesthesia as vital components of universal health coverage (UHC).^1–4 These reports have expanded to National Surgical, Anesthesia, and Obstetric Plans (NSOAPs), which offer coordinated, government-led efforts to expand surgical care through national planning.^5,6 However, data to guide financing and capacity building remain limited in many low-middle-income countries (LMICs). While guidelines defining minimum standards for anesthesia care exist, the number of facilities that meet these standards is unknown.¹ In Guatemala, there is little information about the current level of surgical and anesthesia capacity. Country-specific data on the state of public surgical and anesthesia care are needed to help the Guatemalan Ministry of Public Health and Social Assistance [Ministerio de Salud Pública y Asistencia Social] (MSPAS) direct their efforts.

Country Overview

Guatemala, reclassified from lower- to upper-middle-income country in 2018, is the largest economy and most populated country in Central America. Approximately half of its 17 million inhabitants live in poverty, and 40% are <14 years old.⁷ Its population is equally divided between urban and rural areas and grouped into 8 governmental regions.⁸ It ranks 127 of 189 countries and territories on the United Nations Human Development Index (medium category).⁹

A complex interplay of public, private, and military health care exists in Guatemala. The public sector, which consists of the MSPAS, the Guatemalan Social Security Institute, and the Military Health Service, provides health coverage to about 88% of the population.^8,10 The private sector, composed of for-profit and nonprofit institutions, provides health services for the remaining 12% and is inaccessible for most people due to cost. For the poor, marginalized, and those living in rural areas, the MSPAS is the primary option for obtaining health care. There are many hurdles to accessing surgical services through MSPAS, including transportation challenges, linguistic barriers (most of the indigenous population speak only the native Mayan language), ethnic discrimination, and a concentration of surgical services in the nation’s capital.^7,11

Similar to other LMICs, previously published data suggest, but do not adequately quantify, deficiencies to meet surgical needs.¹² The purpose of this study was to perform the first MSPAS-supported countrywide assessment of anesthesia capacity in all public Guatemalan hospitals. Data collected could then be used to help direct efforts by the MSPAS and local governments for improvements in surgical and anesthesia care.

METHODS

This is a cross-sectional survey of all Guatemalan public hospitals providing surgical care using the World Federation of Societies of Anaesthesiologists (WFSA) anesthesia facility assessment tool (AFAT) questionnaire.¹³ This tool was developed to assess national anesthesia capacity and an individual hospital’s ability to meet the World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia.¹ In March of 2018, the survey was sent by the Guatemalan MSPAS to all public hospitals providing surgical care. Before distribution, the survey was translated by the MSPAS into Spanish. Hospital directors were contacted by the MSPAS via e-mail and asked to complete the survey. Individual hospital directors engaged their administrators, surgeons, anesthesiologists, and nurses at each facility based on the ability to answer the survey questions. While there were 46 public hospitals in Guatemala in 2018, the AFAT was distributed to the 41 hospitals identified by the MSPAS to provide surgical care at the time of the survey. All 41 hospitals completed the questionnaire. Public sector hospitals were defined by the MSPAS as those funded through the national health system. Hospitals were classified by the MSPAS as a district level, regional, or national referral hospital based on the type of personnel and specialty services available. For example, district hospitals are required to have only 4 main specialties: obstetrics, pediatrics, internal medicine, and surgery (often provided by general physicians with experience in the specialty). Regional hospitals offer the services provided at district hospitals as well as orthopedics, anesthesia by physicians, critical care, neonatology, gynecology, and others depending on local needs. The national referral hospitals offer all specialties and subspecialties.

Each facility was assessed across the domains of infrastructure, information management, service delivery, blood product services, surgical cases, workforce, medications, and equipment. Availability was assessed using a 6-point Likert scale as defined by the AFAT.¹³ We present the percentage of hospitals that reported availability as “always” or “almost always” (“always” = 100% of the time; “almost always” = 76%–99% of the time). When referencing medications and equipment, the WHO-WFSA uses the term “highly recommended” as the equivalent of mandatory¹; therefore, we use the equivalent term “mandatory” throughout.

Statistical Analysis

Descriptive statistics by facility type were calculated and presented. Frequencies, medians, and interquartile ranges (IQRs) are reported. Analysis was conducted in RStudio v1.2.1335 and Microsoft Excel. This article adheres to the applicable Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Ethics Approval

Institutional Review Board exemption (IRB-P00027992) was obtained by Boston Children’s Hospital (February 23, 2018). In Guatemala, any information collected by the MSPAS is considered public data.

RESULTS

Hospital Characteristics and Basic

We identified 36 of 46 (78%) public hospitals across Guatemala that provided surgical care in 2018. This included 20 district hospitals, 14 regional hospitals, and 2 national referral centers (Figure). While the survey was distributed to the 41 public hospitals initially deemed by the MSPAS to provide surgical care, 5 additional hospitals were found to not provide surgical care in 2018 and were excluded from the analysis. The median number of hospital beds, surgical beds, and the presence of a postanesthesia care unit (PACU) and an intensive care unit (ICU) by hospital level are shown in Table 1. The majority of hospitals providing surgical care reported having a PACU (N = 29/36, 81%), though ICU infrastructure varied across hospital types. While all national hospitals and 79% of regional hospitals surveyed reported having an ICU that could provide mechanical ventilation and continuous monitoring, only 20% of district hospitals reported having such capabilities.

Table 1. - Hospital Type—Characteristics and Infrastructure

	District (N = 20)	Regional (N = 14)	National referral (N = 2)
Definitiona	Few specialties (internal medicine, obstetrics, pediatrics, general surgery); often only 1 general practice provider; limited laboratory services	More differentiated by function with as many as 5–10 clinical specialties, including eye care	Highly specialized staff and technical equipment; clinical services highly differentiated by function
Median number of beds per hospital (IQR)	67 (45–97)	162 (140–178)	925 (922–929)
Median number of surgical beds per hospital (IQR)	24 (11–34)	40 (18–42)	320b
Median number of total operating theaters per hospital (IQR)	3 (2–3)	6 (4–7)	28 (28–29)
Median number of functional operating theaters per hospital (IQR)	2 (2–3)	4 (2–5)	25 (22–27)
Presence of PACU	75%	86%	100%
Presence of ICUc	20%	79%	100%

Abbreviations: ICU, intensive care unit; IQR, interquartile range; PACU, postanesthesia care unit.

^aDefinition as per Guatemalan Ministry of Public Health and Social Assistance.

^bNo data from 1 of the 2 national hospitals.

^cICU or high-dependency unit that can provide both mechanical ventilation and continuous monitoring.

Figure.: Guatemalan public hospitals providing surgical care.

All hospitals surveyed reported having operating rooms; however, 20% of them were not functional. All 36 hospitals, regardless of level, reported that running water and electricity were always or almost always available, while only 38.9% (N = 14/36) of hospitals reported having internet availability.

In regard to transfusion capacity, 75% of surveyed hospitals reported the ability to obtain whole blood or packed red blood cells within 1 hour during an emergency. The majority of hospitals (83%) reported using patient family members as the primary blood source, while 6 hospitals (17%) reported using off-site blood banks.

When we examined recordkeeping practices, only 1 hospital (regional level) reported using purely electronic health care records, while 13 hospitals (36%) reported using only paper. The majority of hospitals (61%, N = 22/36) reported using a combination of both electronic and paper records. All hospitals reported always keeping a surgical logbook, while 94% (N = 34/36) of hospitals always or almost always kept an anesthesia record.

Over half of hospitals surveyed (58%, N = 21/36), including both national referral centers, reported receiving donations of supplies (medications, equipment, or disposables) from international organizations or institutions within the past year.

Surgical and Obstetric Capacity

Workforce

Table 2. - National Distribution of Full-Time SAO Providers at Publicly Funded Hospitals

	District hospitals N = 20	Regional hospitals N = 14	National hospitals N = 2	All hospitals N = 36
Total numbers
Physician surgeons	89	69	55	213
General (nonspecialist) physicians who provide surgerya	16	37	45	98
Obstetrician/gynecologists	93	80	47	220
General (nonspecialist) physicians who provide cesarean deliveriesa	16	21	32	69
Physician anesthesiologistb	39	49	52	140
Nonspecialist physician anesthetistsa	12	27	56	95
Nurse anesthetistc	33	28	4	65
Median numbers (IQR)
Physician surgeons	2 (0–2)	3 (0–8)	28 (22–33)	2 (0–3)
General (nonspecialist) physicians who provide surgerya	0 (0–0)	1 (0–2)	23 (11–34)	0 (0–1)
Obstetrician/gynecologists	3 (2–4)	4 (0–8)	24 (18–29)	3 (0–5)
General (nonspecialist) physicians who provide cesarean deliveriesa	0 (0–0)	0 (0–1)	16 (8–24)	0 (0–1)
Physician anesthesiologistsb	1 (0–1)	3 (1–5)	26 (23–30)	1 (1–4)
Nonspecialist physician anesthetistsa	0 (0–1)	0 (0–0)	28 (26–30)	0 (0–1)
Nurse anesthetistc	0 (0–2)	1 (0–4)	2 (1–3)	0 (0–3)

Abbreviations: IQR, interquartile range; SAO, surgeons, anesthesiologists, and obstetricians.

^aA graduate of a medical school who has not completed a formalized specialist training program.

^bA graduate of a medical school who has completed a nationally recognized specialist anesthesia training program.

^cA graduate of a nursing school who has completed a nationally recognized nurse anesthetist training program.

Our survey found both the surgical and obstetric workforces were unequally distributed across hospital type. The majority were reported at the national referral hospitals and the remaining distributed among the regional and district hospitals. Of the 213 full-time surgeons, a quarter (N = 55) worked at the 2 national referral hospitals. Median numbers of workers per hospital type are reported in Table 2. We found the density of full-time physician surgeons and obstetricians/gynecologists at publicly funded hospitals to be 1.2 and 1.3/100,000 population, respectively.

Procedures

Each national referral hospital performed on average 1559 surgeries within the past 30 days of survey completion, while regional and district hospitals reported an average of 370 and 252 surgeries, respectively.

The majority of Guatemalan public hospitals (83%) performed all 3 Bellwether procedures: laparotomy, cesarean delivery, and treatment of an open fracture (75% of district hospitals, 93% of regional referral centers, and 100% of national centers). More specifically, across all hospitals, 97% (N = 35/36) of hospitals performed laparotomy, 94% (N = 34/36) performed cesarean deliveries, and 86% (N = 31/36) hospitals performed open fracture repair. Most hospitals (94%) performed surgery for children <5 years of age.

Anesthesia Capacity

Workforce

There were 300 full-time anesthesia care providers reported across the 36 public surgical hospitals in Guatemala (Table 2). Of these, 140 (46.7%) were physician anesthesiologists. The remainder consisted of 95 (31.7%) nonspecialist physician anesthesia providers (defined by the WFSA as medical school graduates who have not completed a formalized anesthesia training program), and 65 (21.7%) nurse anesthetists.^1,14 We found the density of full-time physician anesthesiologists at publicly funded surgical hospitals to be 0.81/100,000 population. The density of all physician anesthesiologists (full and part-time) was 1.3/100,000 population.

Anesthetic Medication and Equipment Availability

Our results showed that many of the mandatory intraoperative medications, based on WHO-WFSA standards, were widely available across hospital levels (Table 3). There was complete availability of benzodiazepines and local anesthetics at all hospitals surveyed. While all national and regional hospitals reported the availability of epinephrine and atropine, 10% of district hospitals (N = 2/20) did not have these available. Morphine, the only mandatory pain medication, was not widely available at all facilities. However, an alternative opioid, fentanyl, was available at all national and district hospitals and at 93% of regional hospitals surveyed. No hospital surveyed reported having intravenous dextrose.

Table 3. - Anesthetic Medications and Equipment Availability % of Hospitals Reporting Medication as Always or Almost Always Available

Medications (highly recommended)
	District hospitals (%) N = 20	Regional hospitals (%) N = 14	National hospitals (%) N = 2	All hospitals (%) N = 36
Intraoperative
Ketamine	90	93	100	92
Diazepam or midazolam	100	100	100	100
Morphine	75	86	100	81
Local anesthetic (eg, lidocaine or bupivacaine)	100	100	100	100
Resuscitative
Oxygen (eg, oxygen concentrator, cylinders, or pipeline)	70	92.8	100	89
Epinephrine (adrenaline)	90	100	100	94
Atropine	90	100	100	94
Dextrose IV	0	0	0	0
Equipment (highly recommended)
Defibrillator	0	0	100	6
Face masks	70	100	100	84
Oral airways (adult and pediatric)	70	71	100	72
Laryngoscope and appropriate sized blades (adult and pediatric)	75	64	100	72
Endotracheal tubes (adult and pediatric)	70	93	100	81
Self-inflating bags (adult and pediatric)	80	79	100	81
Intubation aids (eg, bougies)	35	50	100	45
Suction device and catheters	45	79	50	58
Equipment for IV infusions and medication injection (adult and pediatric)	70	93	100	81
Equipment for spinal anesthesia or regional blocks	85	100	100	92
Stethoscope	95	93	50	92
Pulse oximeter	90	64	50	78
Carbon dioxide detector	10	21	50	17
Noninvasive blood pressure monitor	95	71	50	83
Sterile gloves	100	100	100	100
Adequate lighting	95	86	100	92
Tilting operating table	90	78	100	86
Equipment (other)
Median number of functional anesthesia machines per hospital (IQR)	2 (2–3)	4 (2–4)	25 (22–27)	3 (2–4)

Abbreviations: IQR, interquartile range; IV, intravenous.

The median numbers of functional anesthesia machines at district, regional, and national hospitals were 2 (IQR 2–3), 4 (IQR 2–4), and 25 (IQR 22–27), respectively. None of the regional or district hospitals surveyed reported having defibrillators available. Carbon dioxide detectors, including spot check or continuous waveform capnography, were available at 10% of district hospitals, 21% of regional hospitals, and 50% of national referral centers surveyed. While airway equipment, including face masks, oral airways, laryngoscopes, endotracheal tubes, self-inflating bags, and intubation aids were available at all national hospitals surveyed, availability at district and regional hospitals varied. Intubation aids (bougies) were also in limited supply at the regional and district hospitals.

See Supplemental Digital Content, Tables 1–3, https://links.lww.com/AA/D267, for full Likert scale availability from “always” to “never” of all medications and equipment by hospital level.

Other Perioperative Practices

Table 4. - Perioperative and Postoperative Practices % of Hospitals Reporting Item/Action as Always or Almost Always Available or Performed

	District hospitals (%) N = 20	Regional hospitals (%) N = 14	National hospitals (%) N = 2	All hospitals (%) N = 36
How often are patients evaluated by an anesthesia provider before administration of anesthesia?	50	93	100	69
When indicated, how often are prophylactic antibiotics given before skin incision in the operating theater?	45	93	100a	64
How often is the WHO surgical safety checklist (or locally modified version) used in the operating rooms?	10	43	100	28
For general or neuraxial anesthesia cases, how often is a designated anesthesia provider continuously present inside the operating theater with the patient?	10	86	100	44
Is there a “handover protocol” for the transfer of care from one anesthesia provider to another in the operating theater?	0	0	0	0
Postoperative care
How often are personnel trained to administer analgesics and recognize airway/hemodynamic compromise physically present in the PACU/recovery room?	40	100	100	69
How often is continuous pulse oximetry available for monitoring a patient for the entire duration of care in the PACU/recovery room?	67	58	100	66
How often is NIBP measurement available for all patients in the PACU/recovery room?	73	75	100	76
How often is oxygen immediately available in the PACU/recovery room?	93	100	100	97
How often is suction immediately available in the PACU/recovery room?	53	92	100	72
How often is a self-inflating bag-mask immediately available in the PACU/recovery room?	60	75	100	69
How often is this facility able to provide mechanical ventilation for postoperative patients who require ventilator support outside the operating theaters?	15	71	50	39

Abbreviations: NIBP, noninvasive blood pressure; PACU, postanesthesia care unit; WHO, World Health Organization.

^aData available from only 1 of the 2 national referral hospitals.

Our survey found that practice patterns ranged widely across hospital levels. While all national and most regional hospitals (93%) reported that patients were evaluated by an anesthesia provider before receiving anesthesia, only 50% of district hospitals did so (Table 4). All national hospitals reported utilizing the WHO surgical safety checklist or a locally modified version, while 43% of regional hospitals and only 10% of district hospitals did so. Only 10% of district hospitals reported having a designated anesthesia provider continuously present inside the operating theater with the patient during general or neuraxial anesthesia cases. No hospital reported having a “handover protocol” for transfer of care from one anesthesia provider to another in the operating theater.

Postoperative Care and Pain Management

Table 5. - Pain Management % of Hospitals Reporting Item/Action as Always or Almost Always Available or Performed

Item	District hospitals (%) N = 20	Regional hospitals (%) N = 14	National hospitals (%) N = 2	All hospitals (%) N = 36
Nonopioids
Acetaminophen (paracetamol)	75	93	0	78
Nonsteroidal anti-inflammatory drug	95	100	100	97
Gabapentin	15	29	0	19
Opioids
Tramadol	35	71	0	47
Oxycodone	5	14	0	8
Morphine	75	86	100	81
Codeine	10	0	0	6
Fentanyl	100	93	100	97
Methadone	5	0	0	3
Nalbuphine	5	7	0	6
Practices
Assessment of pain in first 24 h postoperatively	0	0	0	0

While the majority of hospitals surveyed reported having a dedicated PACU area (Table 1), only 40% of district hospitals reported having trained staff physically present in the postoperative care area (Tables 4 and 5). Monitoring was reportedly not always available in either the regional or district hospitals surveyed. The most commonly available nonopioid and opioid pain medications were nonsteroidal anti-inflammatory medications (NSAIDs) and fentanyl, respectively. They each had 97% availability across all hospitals surveyed. No hospital surveyed reported assessing postoperative pain using pain scales within 24 hours after surgery.

DISCUSSION

The WHO-WFSA International Standards for a Safe Practice of Anesthesia outlines minimum standards for safe care.¹ The AFAT was developed to assess individual facilities’ abilities to meet these standards.¹³ Our study represents the first ministry-led countrywide assessment of public sector anesthesia capacity in Guatemala—a country with UHC. Three main areas of concern were identified: workforce deficiencies, lack of basic anesthetic infrastructure including medications and equipment, and inadequate postoperative care, including pain management.

Workforce

The Guatemalan full-time surgeons, anesthesiologists, and obstetricians (SAO) workforce density of 3.3/100,000 population remains far below the target 20/100,000 population by 2030, recommended by the Lancet Commission.² If one includes nonspecialist and nonphysician providers, the SAO density increases to 5.2/100,000. However, only 23% of this task-sharing workforce works in district hospitals, suggesting that Guatemala has the same difficulties in incentivizing nonspecialists and nonphysicians to work in rural areas as physicians.

We found a physician anesthesiologist density of 1.3/100,000 in public hospitals, which is the lowest in Latin America, where the regional average is 2.17/100,000.¹⁴ Our figure is also lower than the 1.9/100,000 previously reported by the WFSA, which represents the density from both private and public facilities.^14,15 Since almost 90% of Guatemalans rely on public health care, our findings more accurately reflect the density of physician anesthesiologists caring for the population. Our finding that 90% of district hospitals do not have an anesthesia provider continuously available during general or neuraxial anesthesia is very concerning. It is another indicator that not only are there insufficient anesthesia providers in Guatemala, those who are present are maldistributed, with the district hospitals fairing the worst. Provisions for incentives are needed to increase and attract anesthesia providers to the rural and district hospital setting.

Nonphysician anesthesia personnel make up a substantial component of the anesthesia workforce in many LMICs.^14,16,17 The WFSA workforce map currently reports that there are no nonphysician anesthesia providers in Guatemala.^14,15 However, our assessment found that nurse anesthetists made up over one-fifth of all anesthesia providers in public Guatemalan surgical hospitals, and over half (51%) of them worked at district hospitals. This discrepancy highlights a limitation of the WFSA workforce survey because it was done at a national level with physician anesthesia societies. The AFAT avoids some of this bias by elucidating the cadres and numbers of providers who are administering anesthesia care in the country. Although the only nurse anesthesia program in Guatemala was closed in 2008, the role that nurse anesthetists currently play in supporting anesthesia care is evident. Government-led efforts are needed to expand opportunities for anesthesia training with whatever cadres it deems appropriate.

Basic Infrastructure

Overall, the supply of medications and utilities was found to be robust compared to many LMICs.^16,18 However, we found deficiencies still existed, particularly at district and regional hospitals, where highly recommended medications such as ketamine, atropine, epinephrine, or even oxygen may be unavailable. In contrast to medications, the availability of basic anesthesia equipment was more varied. A previous assessment found 66% of public hospitals did not have a pulse oximeter.¹⁹ Despite a subsequent donation of 140 Lifebox pulse oximeters, we found nearly a quarter of surveyed hospitals still had inadequate intraoperative pulse oximeter availability. Basic monitoring equipment was even lacking at one of Guatemala’s large national referral hospitals. This highlights that equipment availability did not always equate with urban location or hospital size. Access to a defibrillator was nonexistent at the district and regional hospitals. The paucity of resuscitative equipment presents safety concerns for patients undergoing surgery and anesthesia. Closure of this gap, particularly at the district and regional hospitals, is urgently needed.

Postoperative Care and Pain Management

Lack of robust postoperative care and treatment of pain is common in many LMICs.^20–22 This is true in Guatemala, where one-fifth of all hospitals surveyed reported lacking a designated PACU. For those that did have PACUs, the availability of personnel and equipment was scarce at the district hospitals. Such deficiencies should be addressed as complication rates in the PACU can be 20%–25%.²³

A variety of pain medications were available across hospitals surveyed, despite pain never being formally assessed postoperatively. Interestingly, the availability of many opioid and nonopioid pain medications was lower at national hospitals than at the regional or district hospitals. One possible explanation is increased medication usage at the national hospitals and more rapid depletion of supply before replenishment. Drug procurement in Guatemala is based on centralized price negotiation and decentralized purchasing, where each respective health area directorate is responsible for procurement and distribution.²⁴ According to the MSPAS, district hospitals, being less complex, are able to rotate their inventory more effectively. Attention to these supply chain bottlenecks may ensure more continuous availability and appropriate medication usage.

Anesthesia and Surgical Care Under UHC

Despite the WHO recognition of surgery and anesthesia as vital components of UHC, access to such care within UHC systems remains understudied.^4,6,25 Health care spending in Guatemala has been reported as high 6.3% of gross domestic product (GDP); however, this value represents both public and private expenditures, most of which is spent on the private sector.⁸ In reality, public health sector spending represents only 1.2% of the GDP (M. Alberto Figuero Alvarez, former Vice Minister of Health 2018-2019, Guatemala Ministry of Health, personal communication, June 15, 2020). The deficiencies we found highlight an end result of the lack of funding of the public health sector. Since nearly 90% of the population relies on public health care, investments are needed to ensure optimal health outcomes. These may include increased funding for education, improved supply chain distribution for medications and equipment, as well as programs to incentivize anesthesia providers to work at district hospitals. National surgical planning is a process that should facilitate improvements in countries where UHC is being implemented.

Limitations

Despite being the most comprehensive anesthesia facility assessment in Guatemala to date, our study has several limitations. We did not assess the estimated 62 private, nonprofit, or mission hospitals that provide care for about 12% of the population.²⁶ Furthermore, this assessment was administered by employees at each facility and not by an independent observer. This does potentially add a source of bias to the data, but it also provides a practical way in which countries can self-administer the tool. While the AFAT provides a comprehensive evaluation of anesthesia capacity, standardization with the WHO-WFSA standards document is not exact. Definitions around various categories of equipment (eg, intubation aids) or employment were difficult to capture accurately. The part-time workforce is ill-defined and could represent overlap if a worker is employed at multiple hospitals. Improved alignment with future versions of the AFAT would allow for a more accurate data representation. Finally, quantitative measurement tools may not fully capture the nuanced situations surrounding resource inadequacy.²⁷ Our baseline assessment identifies areas for further in-depth analysis, possibly via qualitative methods, to better understand root causes and propose solutions.

CONCLUSIONS

In this first countrywide, ministry-led comprehensive assessment of anesthesia capacity in publicly financed Guatemalan surgical hospitals, we found that hospitals meet some of the WHO-WFSA standards, but this is uneven across facilities, and there are a few items that are still universally unavailable. The density of physician anesthesiologists and other SAO providers is critically low. Our findings demonstrate that focused investments, especially in expanding the workforce and increasing availability of select medications and equipment, could help to improve anesthesia safety. Our assessment provides baseline data to inform strategies for ensuring the availability of these essential resources and future service delivery planning for safe surgical and anesthetic care in Guatemala.

DISCLOSURES

Name: Yuanting Zha, MD, MPH.

Contribution: This author helped search the literature, analyze and interpret the data, create the tables and supplemental materials, and write, revise, and approve the final version of the manuscript.

Name: Paul Truché, MD, MPH.

Contribution: This author helped analyze and interpret the data, create the tables/figures, and write and approve the final version of the manuscript.

Name: Erick Izquierdo, MD, PhD.

Contribution: This author helped design the study, survey tool translation into Spanish, collect and compile the data, and review, edit, and approve the final version of the manuscript.

Name: Kathrin Zimmerman, BA.

Contribution: This author helped search the literature, create the figure design, and review, edit, and approve the final version of the manuscript.

Name: Sandra de Izquierdo, MD.

Contribution: This author helped design the study, survey tool translation into Spanish, collect the data, and review, edit, and approve the final version of the manuscript.

Name: Michael S. Lipnick, MD.

Contribution: This author helped interpret the data and review, edit, and approve the final version of the manuscript.

Name: Tyler J. Law, MD.

Contribution: This author helped interpret the data and review, edit, and approve the final version of the manuscript.

Name: Adrian W. Gelb, MBChB.

Contribution: This author helped interpret the data and review, edit, and approve the final version of the manuscript.

Name: Faye M. Evans, MD.

Contribution: This author helped participate in the study design, interpret the data, write, edit, and revise the manuscript, oversee the project, and approve the final version of the manuscript.

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