The Specialist Anesthesiology Workforce in East, Central, and Southern Africa: A Cross-Sectional Study : Anesthesia & Analgesia

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The Specialist Anesthesiology Workforce in East, Central, and Southern Africa: A Cross-Sectional Study

Asingei, Juventine MPH*; O’Flynn, Eric P. MSc; O’Donovan, Diarmuid T. MD*; Masuka, Sophia C. MBA; Mashava, Doreen MMed, FCA, ECSA; Akello, Faith V. PGDip§; Ulisubisya, Mpoki M. MMed, FCA, ECSA

Author Information
Anesthesia & Analgesia 136(2):p 230-237, February 2023. | DOI: 10.1213/ANE.0000000000006134

Abstract

KEY POINTS

  • Question: What are the demographic characteristics of the anesthesiologist workforce of East, Central, and Southern Africa?
  • Findings: The anesthesiologist workforce can be broadly characterized as young, locally trained, generalist, concentrated in urban areas, majority men but increasingly women, and insufficient in number but growing.
  • Meaning: The current anesthesiologist workforce in East, Central, and Southern Africa is insufficient to meet clinical need; strategies to expand the workforce are needed and should focus on increasing the number of locally trained anesthesiologists while also addressing their maldistribution.

See Article, page 227

The populations of the East, Central, and Southern African regions receive only 30% of the estimated 31.5 million surgical procedures they require annually.1 Patients in Africa who do receive surgery are twice as likely to die after surgery than the global average, despite a lower risk profile.2 Complications from anesthesia have been found to be a significant risk factor for maternal mortality after cesarean delivery, the most commonly performed surgical procedure in Africa.2–4 The interconnected issues of limited access to surgical care in Africa and poor surgical outcomes are complex and multifactorial. Inadequate access to safe anesthesia plays a role in both issues.

An insufficient anesthetic workforce is a key barrier to safe surgery. In most Sub-Saharan African countries, anesthesia is provided by both physician anesthesiologists (hereafter referred to as “anesthesiologists”) and nonphysician anesthesia providers (NPAPs), with NPAPs present in greater numbers5 and likely to provide the majority of anesthesia care. Even in an environment in which anesthesia care is primarily delivered by nonphysicians, anesthesiologists have a vital role in the management of complex cases, and often also in training and clinical governance. The numbers of anesthesiologists in most African countries are very low. Only 5 of the 47 countries comprising the World Health Organization (WHO) African region have >1 anesthesiologist per 100,000 population,5 far fewer than the proposed minimum ratios of 55 or 46 anesthesiologists per 100,000 population recommended for the delivery of accessible, safe anesthetic services.

A detailed understanding of the anesthesiologist workforce in East, Central, and Southern Africa may inform future strategies to expand this workforce. While the number of anesthesiologists per country in East, Central, and Southern Africa has been described previously,5 the specific demographics of this workforce have not been described in detail. This study aimed to describe the demographic characteristics, geographical distribution, and other characteristics of the anesthesiologist workforce within the 8 member countries of the College of Anaesthesiologists of East, Central, and Southern Africa (CANECSA). The study also aimed to update previously published total numbers of anesthesiologists in each country,5 allowing for the identification of workforce trends.

METHODS

Ethics approval for this study was granted by the institutional review board (IRB) of the College of Surgeons of East, Central, and Southern Africa (March 25, 2020), the research ethics committee (REC) of the Royal College of Surgeons in Ireland (reference 202005021), and the REC of Queen’s University Belfast (reference MHLS 20_70). The requirement for written informed consent of subjects was waived by each IRB/REC.

Study Design and Setting

This study used a cross-sectional design to provide a snapshot of the anesthesiologist workforce in the CANECSA member countries: Eswatini (formerly known as Swaziland), Kenya, Malawi, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe7 at a point in time. Data collection was undertaken from May 2020 to September 2020. Primary outcomes were: total number of anesthesiologists in the region and their demographics, including gender, age, country of practice, current work location, country of origin, and country where they received their initial anesthesia qualification. This study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines for cross-sectional studies.8

Anesthesiologists

The study aimed to identify all qualified anesthesiologists working in the CANECSA region. For the purpose of this study, we defined qualified anesthesiologists as medical doctors with a recognized postgraduate specialist qualification in anesthesia, such as an MMed (anesthesia) degree or equivalent. Other cadres of anesthesia provider, such as trainee anesthesiologists, doctors providing anesthesia without formal training, NPAPs (including nurse anesthetists, anesthetic technicians, and anesthetic officers), and anesthesiologists who work in the region as part-time visitors, were excluded.

Data Collected

Data collected for each anesthesiologist are shown in Supplemental Digital Content, Table 1, https://links.lww.com/AA/D1000. Variables analyzed for each anesthesiologist were: gender, age, current clinical practice, country of origin, academic qualifications, subspecialty training, hospital of primary employment and location, medical training status, and ownership of the hospital. When available, academic qualification variables included the year, institution, and country in which the qualifications were obtained. Hospital ownership type was recorded as either public or private, the latter of which included private for-profit, private not for profit, and all others not categorized as public or government owned.

Data Sources

Data sources analyzed to identify anesthesiologists included: CANECSA records of college members and fellows, national medical council registers, anesthesia association/society registers, Zambia College of Medicine and Surgery records, and training course attendance records. Notably, the Anesthesiology Association of Uganda had an unpublished validated anesthesiologist database for Uganda produced in conjunction with the University of California, San Francisco, which was included in the study. In the CANECSA context, both “membership” and “fellowship” refer to types of organizational membership, not to training posts.

A formal validation exercise was undertaken to cross-check, update, and expand all existing records individually through consultation with the primary sources and direct contact with anesthesiologists, their peers, and employers. This included direct requests for information to hospitals, hospital groups, and nongovernmental organizations, and direct requests for information to individual anesthesiologists. Data were only included for analysis when verified from 2 or more sources.

National population data were obtained from the United Nations Department of Economic and Social Affairs.9 City and town populations were obtained from World Population Review.10

Table 1. - Anesthesiologists per 100,000 Population Compared to the 2015 to 2016 WFSA Global Anaesthesia Workforce Study
Country This study (2020) WFSA Global Anaesthesia Workforce Study 5 (2015–2016) selected data
2020 numbers of anesthesiologists 2019 population estimate 9 Anesthesiologists per 100,000 population 2015–2016 number of anesthesiologists 2015 population estimate Anesthesiologists per 100,000 population
Eswatini 4 1,160,164 0.34 7 1,287,000 0.54
Kenya 176 52,573,967 0.33 152 46,050,000 0.33
Malawi 4 18,628,749 0.02 5 17,215,000 0.03
Rwanda 32 12,626,938 0.25 14 11,610,000 0.12
Tanzania 36 58,005,461 0.06 24 53,470,000 0.04
Uganda 66 44,269,587 0.15 47 39,032,000 0.12
Zambia 26 17,861,034 0.15 21 16,212,000 0.13
Zimbabwe 67 14,645,473 0.46 63 15,603,000 0.4
Total 411 219,771,373 0.19 333 200,479,000 0.17
Adapted from Mashava.5
Abbreviation: WFSA, World Federation of Societies of Anaesthesiologists.

Table 2. - Anesthesiologist Demographics (N = 411)
Characteristic No. (%)
Age
 Anesthesiologists for whom age data were available 157 (38.2%)
 Range 31–73
 Median (first–third quartiles) 41 (37–49)
Gender
 Anesthesiologists for whom gender data are available 400 (97.3%)
 Male 254 (63.5%)
 Female 146 (36.5%)
Anesthesiologists younger than median age (≤40 y)
 Total 75
 Men 44 (58.7%)
 Women 31 (41.3%)
Anesthesiologists older than median age (≥42 y)
 Total 76
 Men 51 (67.1%)
 Women 25 (32.9%)

Data were collated, cleaned, deduplicated, anonymized, and coded in password-protected Microsoft Excel spreadsheets. Data were analyzed using IBM SPSS, version 25.

Statistical Methods

Descriptive statistics are used to summarize study findings. As the study population is not normally distributed, median and quartiles are used.

RESULTS

For some variables, data were not recorded for every anesthesiologist. In reporting the results, we indicate when data were unavailable.

Anesthesiologists

A total of 411 anesthesiologists were identified in the CANECSA region in 2020, as shown in Table 1. Kenya had the largest number of anesthesiologists (n = 176), with 42.8% of all anesthesiologists in the region. Malawi and Eswatini had the smallest number, with each country having 4 anesthesiologists, or 1% of the anesthesiologist workforce in the region. The ratio of anesthesiologists per 100,000 population was 0.19 for the CANECSA region as a whole. Zimbabwe had the highest anesthesiologist to population ratio (0.46 per 100,000), >20× higher than Malawi (0.02 per 100,000). A majority of anesthesiologists in the region (57.2%) were CANECSA members or fellows.

Clinical Practice

Data on current clinical practice were available for 379 anesthesiologists, 92.2% of the total data set. Of those for whom data were available, 368 (97.1%) anesthesiologists within CANECSA were confirmed to be actively practicing in a clinical capacity, and 11 individuals (2.9%) were in entirely nonclinical roles such as management or research.

Demographics

Anesthesiologist demographic data are shown in Table 2. Gender was recorded for 400 anesthesiologists, 97.3% of the total data set, while age data (as of December 31, 2020) were available for 157 anesthesiologists, 38.2% of the total data set.

Work Location

Work location was recorded for 382 anesthesiologists, 92.9% of the total data set. Their geographic distribution of anesthesiologists per 100,000 population at the subnational level is shown in Figure 1, which is also accessible as an online interactive map.11 Of those for whom work location was recorded, 285 (69.3%) were based in the main commercial cities of their countries of practice: Manzini (Eswatini), Nairobi (Kenya), Blantyre (Malawi), Kigali (Rwanda), Dar es Salaam (Tanzania), Kampala (Uganda), Lusaka (Zambia), and Harare (Zimbabwe), as shown in Figure 2. Of anesthesiologists for whom location information was available, the majority (n = 258, 67.5%) were based in cities of >1 million people, with 76 (19.9%) in cities of between 100,000 and 1 million people, and 48 (12.6%) located in cities of <100,000 people.

F1
Figure 1.:
Anesthesiologist density at subnational level in CANECSA member countries where location is known. Figure created by Ms Hailey Sledge using ArcGIS software. CANECSA indicates College of Anaesthesiologists of East, Central and Southern Africa.
F2
Figure 2.:
Anesthesiologist location of practice.
F3
Figure 3.:
Anesthesiologist country of training and practice.
Table 3. - Subspecialty Training of Anesthesiologists in the CANECSA Region
Country No subspecialty recorded Critical care Pediatric Regional Cardiothoracic Pain Obstetric Neuroanesthesia Multiple subspecialties Other Total
Subspecialty trained anesthesiologist number (as % of all anesthesiologists in that country)
Eswatini 3 (75) 1 (25) 0 0 0 0 0 0 0 0 4
Kenya 123 (70) 6 (3) 11 (6) 2(1) 11 (6) 7 (4) 2 (1) 6 (3) 6 (3) 2 (1) 176
Malawi 3 (75) 0 1 (25) 0 0 0 0 0 0 0 4
Rwanda 26 (81) 2 (6) 1 (3) 0 1 (3) 1 (3) 0 0 1 (3) 0 32
Tanzania 32 (89) 0 0 0 3 (8) 0 0 0 1 (3) 0 36
Uganda 47 (71) 5 (8) 3 (5) 3 (5) 1 (2) 0 2 (3) 0 3 (5) 2 (3) 66
Zambia 17 (65) 2 (8) 3 (12) 0 1 (4) 0 1 (4) 0 2 (8) 0 26
Zimbabwe 61 (91) 1 (1) 3 (4) 1 (1) 0 1 (1) 0 0 0 0 67
Total 312 (76) 17 (4) 22 (5) 6 (1) 17 (4) 9 (2) 5 (1) 6 (1) 13 (3) 4 (1) 411
Abbreviation: CANECSA, College of Anaesthesiologists of East, Central and Southern Africa.

Public or private (for-profit or not for profit) employment status was recorded for 339 anesthesiologists, 82.5% of the data set. Of these, 253 (74.6%) practiced in a public facility, and 86 (25.4%) practiced in a private facility. The majority of anesthesiologists (n = 244, 72%) were based in institutions that offered medical training.

Country of Origin

Country of origin data were recorded for 407 anesthesiologists. Of those, the majority (n = 397, 97.5%) were originally from within CANECSA member countries, and the majority (n = 387, 95.1%) were working in their countries of origin or nationality. Eswatini had the greatest proportion (n = 2; 50%) of foreign anesthesiologists, although a small total number of anesthesiologists (n = 4).

Country of Training

The country in which they received their first specialist anesthesiology qualification was recorded for 387 anesthesiologists. Of these, 357 (92.2%) received their first specialist anesthesiology qualification within the CANECSA region.

The majority of those for whom data were available practice in the country in which they undertook anesthesiology training (n = 345; 89.1%), as shown in Figure 3. Two (0.5%) anesthesiologists were trained in the Democratic Republic of Congo. An additional 28 (6.8%) completed training in Asia (India and Pakistan), Europe (United Kingdom, the Netherlands, Belgium, Russia, and Yugoslavia), North America (Canada and the United States), and Australia. There were no anesthesiology training programs in Eswatini at the time of this analysis; therefore, all anesthesiologists in that country trained abroad.

Subspecialty Training

Subspecialty training was recorded for 99 anesthesiologists, 24% of the total data set. The most commonly recorded subspecialties were pediatric (n = 22), cardiothoracic (n = 17), and critical care (n = 17), as shown in Table 3, with 13 anesthesiologists having recorded >1 subspecialty. The location in which this subspecialist qualification was obtained was recorded for 45 anesthesiologists, of whom 36 (80%) trained outside the continent, all in either Europe or North America.

DISCUSSION

The anesthesiologist workforce in the member countries of CANECSA can be broadly characterized as young, locally trained, generalist, concentrated in urban areas, mostly men but increasingly women, and insufficient in number, but increasing.

Insufficient Anesthesiologist Workforce

The total number of anesthesiologists (411) in the CANECSA region is very low (0.19 per 100,000 population). No country exceeds 0.5 per 100,000 population. These ratios are orders of magnitude below estimates of the minimum ratios of 55 or 46 anesthesiologists per 100,000 population that are recommended for the delivery of accessible, safe anesthetic services. Anesthesiologists are needed to help drive workforce development, contribute to national surgical planning, and play a vital role in training and clinical governance of NPAPs.

Many Sub-Saharan African countries face challenges in recruiting physicians to specialize in anesthesia, including issues related to working conditions and pay, inadequate infrastructure, lack of mentorship, and migration.5,12–16 In this context, it is not surprising that numbers are low in the CANECSA region. Our findings suggest that the workforce is growing; we found 411 anesthesiologists, an increase of 78 (24%) from the number found in these countries in the World Federation of Societies of Anaesthesiologists (WFSA) Global Anaesthesia Workforce Study undertaken in 2015 and 2016,5 as shown in Table 1. The median age of 41 years suggests a youthful and growing workforce.

Despite the growing numbers of anesthesiologists, the ratio of anesthesiologists per 100,000 population has only increased modestly from 0.17 to 0.19, due to population growth of >19 million (9.6%)5,9 over the same period of time. Of the total increase of 78, nearly half (n = 36; 46%) of the increase was necessary simply to maintain the same anesthesiologist: population ratio.

Some countries seem to have been more successful at expanding their anesthesiologist workforce. Rwanda has more than doubled its anesthesiologist/population ratio from the 2015 to 2016 period, although the number of anesthesiologists in Rwanda (n = 32) remains low relative to the population (0:25 per 100,000 population).5 It is not known whether emigration of locally trained anesthesiologists from the region has greatly affected the workforce. Retention is high among surgeons trained in the region,17 and future study is required to understand whether this holds true for anesthesiologists.

Gender

The anesthesia workforce in the region, while predominantly men, contains a higher proportion of women than surgical specialties.18 Younger anesthesiologists are more likely to be women, suggesting that anesthesiology may be moving toward equal numbers of male and female practitioners. As elsewhere in the world,19 an increasing proportion of medical school graduates in Sub-Saharan Africa are women. If anesthesia is seen by these female graduates as an attractive career path, this may present an opportunity to significantly grow the anesthesiology workforce as a whole.

Maldistribution

The clustering of anesthesiologists in major cities is consistent across countries in the region. However, the majority of the population in all CANECSA countries live in rural areas,20 many of which are far from the major cities. Access to a hospital that is able to provide safe surgical care within 2 hours is 1 of the 6 core surgical indicators from the Lancet Commission on Global Surgery.1 It is likely that a significant proportion of the population of the region is unable to access a hospital with an anesthesiologist within 2 hours. Attention must be paid to the distribution of anesthesiologists as well as to their total number.

Homegrown Generalists

Countries in the region rely strongly on a “homegrown” anesthesiology workforce (ie, practitioners who are born and trained in the countries in which they practice). The majority of anesthesiologists appear to be generalists rather than subspecialists, which may be appropriate for the region. Subspecialty training was generally undertaken outside the continent.

Implications

Our findings have implications for human resources for health planning in the CANECSA region. All countries in the region, with the exception of Eswatini, are reported to be implementing or developing national surgical, obstetric, and anesthesia plans.21 This study identified challenges to the attainment of an optimal anesthesia workforce, such as the maldistribution of anesthesiologists relative to population. It also identified opportunities, such as the relatively high percentage of women in the anesthesiology workforce, combined with the increasing numbers of female medical school graduates. Our findings furthermore suggest that an expansion of high-quality anesthesiology training across the region is sorely needed. The launch of the CANECSA training program in 2021 addressed this need by offering a common syllabus and examinations for trainee anesthesiologists throughout the region.22

Training takes place in accredited training hospitals, many of which are not university-affiliated teaching hospitals, thus expanding the number of training posts, particularly in nontraditional settings.

Limitations

This analysis only considers fully qualified anesthesiologists who are not the only anesthesia providers in the region. The majority of the anesthesia workforce is comprised of NPAPs.5 Further studies are needed to describe the characteristics of other cadres of anesthesia providers in the region.

This cross-sectional study provides a snapshot of the physician anesthesiologist workforce at a certain time, but complete accuracy is not possible, as the workforce is ever-changing. Additional confounding factors include the coronavirus disease 2019 (COVID-19) pandemic, which resulted in many institutions delaying graduation of new anesthesiologists, as well as delays in updates to registers. Anesthesiologists who are residents part time in the region were not included in this study.

Attempts were made to differentiate between anesthesiologists by the ownership of their hospitals of primary employment. However, many individuals hold several posts in different sectors, and it is not within the scope of this study to determine how individual anesthesiologists divide their time between public and private spheres.

For most variables, some data were unavailable. For substantial missing data, particularly the anesthesiologist age variable, figures should be treated with some caution. For cases in which no anesthesiologist subspecialty training is recorded, it has not been possible to determine whether such training has not been obtained, or the data are missing.

CONCLUSIONS

Strategies to expand the anesthesiologist workforce are required and should concentrate on increasing local education, training, and retention of anesthesiologists, while simultaneously developing solutions to address maldistribution.

ACKNOWLEDGMENTS

We thank the following for their contributions to data collection in this study: Dr Fred Bulamba (Association of Anesthesiologists of Uganda), Dr Stella Chikumbanje (Malawi), Dr Ednah Gisore (Kenya), Dr Michael Lipnick (University of California, San Francisco), Dr Dlamini Diana Lomangisi-Sserumaga (Eswatini), Ms Shelmith Macharia (Kenya Society of Anaesthesiologists), Dr Faith Vhenekai Moyo (Zimbabwe), Dr Christian Mukwesi (Rwanda), Dr Hazel Sonkwe Mumpansha (Zambia), Dr Abel Mwale (Zambia), Dr Janat Tumukunde (Uganda), and Dr Albert Ulimali (Tanzania). We thank Ms Hailey Sledge (Ireland) for assistance with data visualization.

DISCLOSURES

Name: Juventine Asingei, MPH.

Contribution: This author helped design the data collection processes, analyze the data, and led data collection; helped write the manuscript; approved the final manuscript; and accepts accountability for all aspects of the work.

Name: Eric P. O’Flynn, MSc.

Contribution: This author jointly conceived of this study, helped design the data collection processes and analyze the data, helped write the manuscript, approved the final manuscript, and accepts accountability for all aspects of the work.

Name: Diarmuid T. O’Donovan, MD.

Contribution: This author helped design the data collection processes and analyze the data, helped write the manuscript, approved the final manuscript, and accepts accountability for all aspects of the work.

Name: Sophia C. Masuka, MBA.

Contribution: This author helped design the data collection processes, analyze the data, and supported data collection; helped write the manuscript; approved the final manuscript; and accepts accountability for all aspects of the work.

Name: Doreen Mashava, MMed, FCA, ECSA.

Contribution: This author jointly conceived of this study, helped write the manuscript, approved the final manuscript, and accepts accountability for all aspects of the work.

Name: Faith V. Akello, PGDip.

Contribution: This author helped design the data collection processes, analyze the data, and supported data collection; helped write the manuscript; approved the final manuscript; and accepts accountability for all aspects of the work.

Name: Mpoki M. Ulisubisya, MMed, FCA, ECSA.

Contribution: This author jointly conceived of this study, helped write the manuscript, approved the final manuscript, and accepts accountability for all aspects of the work.

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

GLOSSARY

CANECSA
College of Anaesthesiologists of East, Central, and Southern Africa
COVID-19
coronavirus disease 2019
IRB
institutional review board
NPAP
nonphysician anesthesia provider
REC
research ethics committee
STROBE
Strengthening the Reporting of Observational Studies in Epidemiology
WFSA
World Federation of Societies of Anaesthesiologists
WHO
World Health Organization

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