World J Surg (2015) 39:833–841 DOI 10.1007/s00268-014-2775-9
ORIGINAL SCIENTIFIC REPORT
The Rate-Limiting Step: The Provision of Safe Anesthesia in Low-Income Countries Simon Hendel • Thomas Coonan Sarah Thomas • Kelly McQueen
•
Published online: 9 September 2014 Ó Socie´te´ Internationale de Chirurgie 2014
Abstract Background The importance of safe anesthesia for the best possible surgical outcomes in every patient is not disputed in high resource settings. Low-income countries lag far behind in the provision of, and training for, safe anesthesia practice. Too little is known about numbers and types of providers in a majority of low-income countries. Methods A review of the member societies of the World Federation of Societies of Anaesthesiologists was undertaken, and membership statistics of national societies were requested. Of the 126 members of the federation, only 14 represent low-income countries. Many non-federation-member countries are also low-income countries. Results The anesthesia infrastructure and personnel challenges in low-income countries contribute to poor patient outcomes and limited access to emergency and essential surgery. The presence of a functional anesthesia society provides a measure of the numbers of providers and a snapshot of local professional activities. Conclusion The establishment and maintenance of an anesthesia society is an indicator of respect for the profession and commitment to standards of practice, quality initiatives, and continuing medical education within the country.
Introduction S. Hendel Center for International Health, The Burnet Institute for Medical Research, 85 Commercial Road, Melbourne, VIC 3004, Australia e-mail: [email protected] T. Coonan Dalhousie University, Halifax Infirmary, 1796 Summer Street, Halifax, NS B3H 3A7, Canada e-mail: [email protected] S. Thomas University of Tennessee, Knoxville, USA e-mail: [email protected] K. McQueen (&) Department of Anesthesiology, Affiliate Faculty, Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 1301 Medical Center Drive, #4648 TVC, Nashville, TN 37232, USA e-mail: [email protected]
The impact of surgical care on the global burden of disease is indisputable as the post-2015 Development Goals come into focus. The global shift from communicable disease to non-communicable disease during the last 20 years is reflected in the global burden of disease (GBD) literature, and the 2010 study estimates that appropriate surgical intervention has the potential to impact nearly 28 % of the GBD [1–4]. The potential role of surgical intervention in decreasing disability and premature death will only be possible when both safe anesthesia and emergency and essential surgery are accessible to meet unmet need. The role of safe anesthesia is often neglected in the discussion of safe surgery. A delay in the development of outcomes collection and reporting hides the underlying patient safety issue, though much data do exist [5–24].
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The number of physicians per 10,000 population is a health indicator collected and reported by the World Health Organization (WHO) for the 146 member states. Health indicators at baseline and over time are indicative of the well-being of the population. They are used to benchmark improvement in the health system, and to reveal the impact of strategic interventions on overall health. The WHO does not capture data on specific medical specialties and specialist physicians. Therefore, the relative number of physicians is best utilized in combination with other health indicators to assess baseline population health and assess needs. A minimum number of anesthesiologists and surgeons per 10,000 population, geographically positioned, are required to meet emergency and essential surgical needs. High-income countries often track the number of physicians in a state, province, or country by medical licensure. While this offers a snapshot of the number of physicians currently licensed, the number is not specific for whether the physician is actively practicing in the region where the license is held, or if the physician holds one or more licenses simultaneously. The medical specialty chosen by the physician and the related credentialing completed is often reported in the licensing application, but physicians frequently practice outside the specialty indicated on the application, may no longer be practicing, or may hold a license with or without the actual delivery of care in the location where the license is held. Medical Society membership offers a similar snapshot into physician numbers. Specialty societies also offer insight into the numbers of specialty trained physicians. The limitations of the data provided by societies are similar to those of data provided by licensing bodies. The tracking of physicians is equally challenging in lowincome countries (LICs). Physicians are in great demand in the poorest countries, and therefore many doctors may practice without the appropriate credentialing. They may, therefore, be unknown to the Ministry of Health or other governing bodies. The specialists who choose to belong to medical societies may represent only a fraction of the workforce, but in the case of anesthesiology, which is truly in a state of crisis in LICs, the members of the anesthesia society undoubtedly represent the specialty leaders. Anesthesia providers in LICs include physicians, nurses, and technicians, have varying degrees of education and training, and may or may not be credentialed or licensed. These realities further complicate the understanding of anesthesia practice and provider numbers in each country. Recently, the literature has begun to report numbers and types of anesthesia providers in LICs [25–38]. The WHO Situational Analysis Tool database collected information on the number and type of anesthesia providers working in
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the full spectrum of medical facilities in 28 low- and middle-income countries (LMICs). A recent report revealed that 30.4 % (n = 344) of all medical facilities reported having no full- or part-time anesthesia personnel, including anesthesiologists, general doctors providing anesthesia, or nurse/clinical/assistant medical officers providing anesthesia. In these same institutions, only 41 % of the anesthesia providers were certified, registered, or licensed. Further, only 37.1 % (n = 485) of all medical facilities evaluated employed physician anesthesiologists, and of those only 50.9 % were certified, registered, or licensed [25]. The crisis of anesthesia in LICs The anesthesia crisis in LICs has grown in the last decade. The number of physician anesthesia providers in LICs is dwindling, impacted by ‘brain drain’, income disparity from other specialty physicians, and declining interest among medical students. Lack of infrastructure, including safety equipment and unpredictable medical supplies, have also contributed to the anesthesia crisis [16, 18, 19, 21, 24, 29, 30, 39–45]. The anesthesia-related perioperative mortality rate (POMR) is higher in LMICs and is related to shortfalls in trained personnel, infrastructure, and anesthesia equipment [32, 44]. In Afghanistan, with a population of 32 million, there are nine physician anesthetists; in Uganda, with a population of 27 million, there are 13, excluding expatriate providers [31]. In sub-Saharan Africa, anesthesia is provided by non-physician anesthetic providers in the majority of cases. Usually these providers work alone, unsupervised, and with limited training [46] (Table 1). A recent review of the literature identified 17 studies that documented surgical and anesthesia capacity from individual LMICs. This literature, representing 12 LIC and five middle-income countries (MICs), documented the anesthesia capacity of 555 facilities, and reported the types of providers practicing in the country surveyed. In terms of facilities, 66.3 % (281/424) and 54.3 % (198/364) had oxygen and electricity all of the time; 47 % (121/254) and 47 % (145/309) had anesthesia machines and pulse oximeters. Ketamine anesthesia was available in 72.9 % of hospitals reporting, whereas inhalational anesthesia was only available in 56.2 %. Alternative techniques, such as regional and spinal anesthesia, were available in 58.9 and 65.9 % of hospitals, respectively. Adult endotracheal tubes were available in 51 of 109 hospitals (47 %), and pediatric endotracheal tubes in 44/126 (35 %) [17]. Recent and evolving awareness of the role of safe anesthesia and surgery in improving global health (Disease Control Priorities [DCP]-3) requires that LICs invest in the
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Table 1 Comparing Anesthesia Societies between low-income countries and the USA, Canada, and Australia Country
Society name
Members
Total population
Physicians per 10,000 population
Longevity M/F
WHO rank (X/191)
Australia
ASA
3,025
23,050,000
38.5
80/84
30
Canada
CAS
1,877
34,838,000
20.7
80/84
32
USA
ASA
30,086
318,000,000
24.2
76/81
37
Bangladesh
BSA
60
155,000,000
3.6
69/70
88
Benin
SARB
32
10,051,000
0.6
56/59
97
Cambodia
CSA
150
14,865,000
2.3
64/66
174
Congo Ethiopia
SCARU ESA
20 16
4,337,000 91,729,000
1.0 0.3
57/59 59/62
166 180
Haiti
SHA
45
10,174,000
2.5
61/64
138
Kenya
KSA
120
43,178,000
1.8
58/61
140
Mali
SARMUM
32
14,854,000
0.8
50/53
163
Mozambique
AAM
17
25,203,000
0.3
52/53
184
Myanmar
ASMMA
120
52,797,000
5.0
63/67
190
Nepal
SAN
100
27,474,000
2.1
67/69
150
Rwanda
RSA
15
11,458,000
0.6
58/61
172
Uganda
USA
22
36,346,000
1.2
54/57
149
Zimbabwe
ZAA
50
13,724,000
0.6
53/55
155
Bangladesh: Bangladesh Society of Anesthesiologists; Benin: Societe d’Anesthesie-Reanimation du Benin; Cambodia: Cambodia Society of Anesthesiologists; Congo: Societe Congolaise d’Anesthesie Reanimation Urgences; Ethiopia: Ethiopian Society of Anesthesiologists; Haiti: Societe Haitienne d’Anesthesiologie; Kenya: Kenya Society of Anesthesiologists; Mali: Societe d’Anesthesie de Reanimation et de Medicine d’Urgence du Mali; Mozambique: Associacao de Anesthesiologistas de Mocambique; Myanmar: Anaesthetists Society of Myanmar Medical Association; Nepal: Society of Anaesthesiologists of Nepal; Rwanda: Rwanda Society of Anesthesiologists; Uganda: Uganda Society of Anesthesia; Zimbabwe: Zimbabwe Anaesthetic Association F female, M male, WHO World Health Organization
requisite infrastructure, medicines, equipment, and training. Increasing burdens in trauma and cancer, as well as unmet surgical needs in terms of obstetric conditions, will require increasing numbers of trained anesthesia providers. We sought to evaluate the state of physician anesthesia resources and the commitment to anesthesia standards and guidelines, and access to continuing medical education in LICs, with a novel evaluation of the existing societies of anesthesia.
Investigation of the society by website and direct contact was attempted with every society representing an LIC. The authors emailed the contact for the society listed on the WFSA website, requesting information on the society, including membership numbers and frequency of society meetings. The data received were compared between sources.
Results Methods A review of the 126 member societies of the World Federation of Societies of Anaesthesiologists (WFSA) was undertaken. Country-specific details were reviewed on the WFSA website, including member numbers, website availability, length of membership, and related educational activities [47]. When available, the society websites were reviewed. Updated national society membership numbers were requested and received from the WFSA. Membership data were also requested directly from the national anesthesia societies in the 14 LICs, using the email provided as a contact for the society.
A total of 126 national societies were identified as members of the WFSA. Of these, 14 represented LICs. Of the 79 countries without WFSA membership (Fig. 1) 30 are located in Africa; 18 of those 30 are LICs. There are 36 countries identified as LICs by the World Bank, and therefore only 39 % of LICs have representative anesthesia societies. This is in comparison with high-income countries, which all have representative anesthesia societies. WHO comparative health data from each country and the World Bank comparative health ranking were reviewed [48, 49]. Email contact with each of the 14 identified LIC societies was attempted. Of the 14 emails sent, only one was
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Fig. 1 World Federation of Societies of Anesthesia (WFSA) members and non-members
email returned as undeliverable. All other addresses were therefore assumed to be operational. Every society listed a representative member or contact with an email address on the WFSA national member page; however, none of the remaining 13 contacts responded to the enquiry sent by the authors. Three societies had a functional website, and review of these sites allowed comparison of data between the LIC society and the American, Australian, and Canadian societies (Table 2). Overall, LICs with representative societies report few anesthesia physician providers when compared with MIC and high-income countries (Table 3).
Discussion Recent assessments of anesthesia infrastructure in LMICs reveal a crisis in the provision of safe anesthesia care [4, 10, 24, 25, 30, 32, 41, 44, 45]. Contributing to this crisis in surgical access and patient safety are the limited number of trained providers, including very few practicing physician anesthesiologists; the limited access to essential medications; and the few functional patient safety monitors.
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Simultaneously, as the backdrop to this crisis, noncommunicable diseases (NCDs)—including trauma and cancer—is increasing and contributing to premature disability and death. Diagnosis, treatment, and palliation of NCDs frequently require surgical intervention. Physician anesthesia providers are essential to any healthcare system. These specialty trained physicians are needed for patient care and safety, education and training of other physician and non-physician providers, the establishment of local guidelines and standards, and for leadership with the medical community, government, and related societies. The dwindling numbers of physician anesthesia providers in LICs has contributed to poor patient outcomes and to unacceptably high POMR [10]. The encouragement and support of physician anesthesia providers must be considered part of any strategy to improve patient safety and increase the numbers of successful nurse and technician anesthesia providers [34, 50, 51]. Confirming the presence of national anesthesia societies and related membership, as well as WFSA membership, is another measure of the local commitment to anesthesia. This commitment, reflected in society membership, may be an useful surrogate for estimating the future of anesthesia
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Table 2 Low-income country anesthesia website comparison Country
Website/last updated
Contact information
Society information
Member information
Meeting information
Other
Bangladesh
www.bsabd.com, 2/2014
Mailing address, email, telephone #, website
Office holders, history of society
List of members
List of future conference dates (2014 and 2015), calendar of events
Information on specialty chapters, Journal of the Bangladesh Society of Anesthesiologists, information for anesthesia education
Congo
www.socaru.net, 5/2013
Mailing address, email, telephone #, website
Office holders, mission statement, and constitution
Kenya
www. anaesthesiakenya. co.ke, 2/2013
Mailing address, email, telephone #, website
Office holders, mission statement, and constitution
Reports of past conferences
List of members
education, training, and patient safety efforts in a particular region. Even the smallest societies (Congo, Rwanda, Mozambique) improve the stature of anesthesia in their countries and provide an opportunity to create and publish guidelines and standards. The established hierarchy of leadership, contacts, and meetings that societies are required to develop create opportunities for government dialogue. These structures may also allow clearer communication of expectations with schools, programs, and institutions training non-physician providers. There will be a shortage of physicians to deliver the majority of anesthesia in LICs for the foreseeable future. However, this is also true in many high-income countries where nurse and technician providers provide safe anesthesia care under the direction of a physician. This reality does not diminish the critical role of physicians within the specialty of anesthesia in LICs. Cataloging the shortage of physicians is a recognized aspect of healthcare system evaluation, and is recognized by the WHO and governments as a health indicator. Specialty physicians are not currently included as a country metric or health indicator. The impact of NCDs and the related role of surgery and anesthesia may soon demand that healthcare systems, governments, and perhaps even the WHO evaluate and report the anesthesiologists, obstetricians, and surgeons, and their related non-physician counterparts. This information is critical to planning for improving access to emergency and essential surgical services, and to expanding surgical care and safe anesthesia to avert disability and death related to NCD. Evaluating the non-physician provider base in LICs is a greater challenge. The surveys and reviews published in the last decade have improved the understanding of the nurse and technician providers for surgery and anesthesia at the
Reports of past conferences, calendar of events
List of common questions and answers for patients, discussion forum
country level [17, 19, 22, 23, 25, 31, 32, 42, 52–56]. But the information gap remains large due to the arduous and time consuming nature of surveys, as well as the reality that most surveys are based on representative samples and are not a thorough review of the entire system. The gap is even greater in most countries when considering the credentialing of nurses and technicians. Integral to the anesthesia provider analysis is patient safety. In high-income countries, physicians are leaders of patient safety initiatives and the guidelines that accompany them. As discussed, reports of excessive mortality in LICs are very much in the historical and current literature. In addition, there remains in the vicinity of 70,000 operating rooms globally without pulse oximetry, [57] and well documented shortages in personnel, essential medications and equipment [20, 23, 30, 32, 53, 55, 58–60]. Efforts are underway to encourage collection and reporting of POMR, at least 24 h post-operatively, as a baseline and benchmark of patient safety [61]. The spectrum of information, including specialist physician and non-physician provider numbers, and the POMR, will greatly inform the country-specific barriers to safe patient care and access to surgery. Even before these data are available, the global health community, focusing on the provision of emergency and essential interventions for the growing surgical burden of disease, must demand safe anesthesia in every operating location. The reality of the global anesthesia crisis has long been recognized. The flight of anesthesiologists to other medical specialties and higher income countries has been noted in LICs for decades. Simultaneously, fewer and fewer medical students are choosing anesthesia as a specialty. For those physicians remaining in anesthesia, their remuneration has not kept pace with that of their surgical counterparts, their professional development has lapsed,
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Table 3 Anesthesia providers, training programs, and working conditions by country reported in recent international publications Country, study
Anesthesiologists Number
Afghanistan, Dubowitz et al. [32]
Per 10,000 populationa 0.03
Anesthesia residency programs
Anesthetic officers/ nurse anesthetists
Available types of anesthesiab
0
Afghanistan, Iddriss et al. [20]
Bangladesh, Lebrun et al. [23]
30 % of facilities have limited oxygen delivery systems, 40 % have unreliable running water sources, and only 34 % have reliable electrical power 850
Congo, Dubowitz et al. [32]
0.56
Yes
Oxygen cylinders are available at all hospitals. 71 % of facilities have pulse oximeters in each OR and 100 % of facilities have an anesthesia machine in each OR. Limited number of anesthesiologists, which limits the ability to perform surgery
Occasional lack of electricity and water supply. All hospitals have access to oxygen. Only 63 % of hospitals have a pulse oximeter for each OR
0.02
Ethiopia, Chao et al. [30]
19
0.022
Yes, in all but 3 hospitals, anesthesia is provided by nonphysician personnel
Gambia, Iddriss et al. [20]
8
0.45
Yes, anesthesiologists deliver anesthesia in only 22.2 % of facilities
Kenya, Dubowitz et al. [32]
120
0.37
Yes, up to 300
Liberia, Sherman et al. [58]
0
0
0
Rwanda, Notrica et al. [55]
9
0.082
1 PG
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Working conditionsc
82.4 % of facilities are capable of ketamine anesthesia, 76.5 % are capable of regional. Spinal anesthesia and general inhalational are available in 72.2 % of facilities
77.8 % of facilities have consistent oxygen supplies, 50 % have consistent water supplies, and 44.4 % have consistent electricity. 70.6 % have working anesthesia machines
Yes, 19 nurse anesthetists and 1 non-anesthesiologist physician delivering anesthesia
81.2 % of facilities can provide spinal or ketamine anesthesia. 25 % can provide general anesthesia, and 12.5 % are capable of regional blocks
31.3 % of facilities have fulltime oxygen cylinders, 25 % have full-time electricity. 18.8 % have a functional anesthesia machine
Yes, average of 3 anesthesia technicians per hospital. Some uncertified nurses also practice anesthesia
Routine shortages of essential anesthesia medications such as diazepam
Backup generators are frequently used due to recurrent power outages. Access to clean running water is not a problem. Oxygen is hard to attain, but all facilities report access to oxygen concentrators when oxygen cylinders are not available. Pulse oximeters are scarce
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Table 3 continued Country, study
Anesthesiologists Number
Per 10,000 populationa
Anesthesia residency programs
Anesthetic officers/ nurse anesthetists
Available types of anesthesiab
Sierra Leone, Iddriss et al. [20] Sierra Leone, Groen et al. [53]
20 % of facilities have functioning anesthesia machines 1
Tanzania, Dubowitz et al. [32]
Yes, 23 nonphysician anesthesia staff 0.04
2, 4 residents in training
Tanzania, Penoyar et al. [59]
Uganda, Dubowitz et al. [32]
Uganda, Hodges et al. [60]
Working conditionsc
0.04
15
Zimbabwe, Dubowitz et al. [32]
2, 10 residents in training
0.047
0.3
Broken system: health workers spend 50–60 % of their time on productive tasks Yes, 87 % of anesthesia providers are nonphysicians
42 % of facilities have consistent access to oxygen. Pulse oximeters are scarce. 32 % have no access to an anesthesia machine. 37.5 % have both consistent running water and electricity
Yes, up to 300
Lack of infrastructure: 23 % of hospitals have capacity and equipment for safe delivery of anesthesia for adults, 13 % for children, \6 % for cesarean section
Yes, anesthesia is mainly provided by non-medical anesthetists, most with little training
Anesthesia for children consists of IM or IV ketamine or drawover anesthesia with halothane, but sometimes only ether is available. Local anesthesia is also common
Only 13 % of facilities are able to provide anesthesia for a child. Oxygen concentrators are used. Tracheal tubes are used and re-used
1, 150 residents/ year
IM intramuscular, IV intravenous, OR operating room, PG post-graduate a
Physicians are reported per 10,000 population by the WHO. Comparison from the USA is approximately 2 anesthesiologists per 10,000 population
b
Ketamine, spinal, general
c
Clean water and electricity, access to oxygen, pulse oximetry, and anesthesia machines
and the opportunities for leadership have dwindled. Only recently did LICs begin training nurse anesthesia providers to begin to fill the professional gap, [56] and, in many of the poorest countries, technicians, some with official training, and others without, have provided anesthesia without supervision, without monitors and, frequently, without oxygen.
Conclusions The global anesthesia crisis represents the largest barrier to access to safe surgery. Appreciating the gap in physician
anesthesiologists and other providers, as well as the POMR as a measure of patient safety, is required for the provision of emergency and essential surgery. Pivotal to the discussion around effective and sustainable provision of essential and emergency surgery is understanding and prioritizing the anesthesia workforce. Strategies to assess the anesthesia gap, equipment, and medicine needs must evolve from the static survey model if the growing surgical demands are to be met. Solutions for increasing the availability and safety of providers can only be found once the levels of training and credentials of existing providers have been assessed, and projections for future health service requirements have
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been estimated. Anesthesia societies and their physician leaders have an essential role in this process. The creation of guidelines, minimum training requirements, and examinations must be part of a successful credentialing program. Monitoring and benchmarking outcomes, and driving improvements, must also be physician led. In the absence of a physician leader at every hospital, a national society will need the authority to initiate change and ensure patient safety. Equally important as the challenge of preparing and training a cadre of professional independent anesthesia providers is the collection and analysis of anesthesia outcome data. Reliable data are essential in order to truly characterize the nature of the crisis, both to motivate policy makers and to inform pragmatic solutions as we move forward. National Physician Societies offer a snapshot into patient care and the healthcare system. Tracking and encouraging the progress of anesthesia societies, combined with following POMR over time, will allow for further analysis of country-based systems, patient safety, and opportunities for quality improvement. References 1. Murray CJ (2012) The global burden of disease study. Lancet 380:2053–2260 2. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D (2009) The burden of non-communicable diseases in South Africa. Lancet 374:934–947 3. McQueen KA, Casey KM (2010) The impact of global anesthesia and surgery: professional partnerships and humanitarian outreach. Int Anesthesiol Clin 48(2):79–90 4. McQueen KA, Ozgediz D, Riviello R et al (2010) Essential surgery: integral to the right to health. Health Hum Rights 12:137–152 5. Ouro-Bang’na Maman AF, Kabore RA, Zoumenou E, Gnassingbe K, Chobli M (2009) Anesthesia for children in sub-Saharan Africa: a description of settings, common presenting conditions, techniques and outcomes. Paediatr Anaesth 19(1):5–11 6. Ouro-Bang’na Maman AF, Tomta K, Ahouangbevi S, Chobli M (2005) Deaths associated with anaesthesia in Togo, West Africa. Trop Doct 35(4):220–222 7. Walker I, Wilson I, Bogod D (2007) Anaesthesia in developing countries. Anaesthesia 62(Suppl 1):2–3 8. Fenton PM, Whitty CJ, Reynolds F (2003) Caesarean section in Malawi: prospective study of early maternal and perinatal mortality. BMJ 327(7415):587 9. Mackay P, Cousins M (2006) Safety in anaesthesia. Anaesth Intensive Care 34:303–304 10. Bainbridge D, Martin J, Arango M, Cheng D (2012) Evidencebased Peri-operative clinical outcomes research G. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet 380:1075–1081 11. Hansen D, Gausi SC, Merikebu M (2000) Anaesthesia in Malawi: complications and deaths. Trop Doct 30:146–149
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World J Surg (2015) 39:833–841 35. Misra S, Koshy T (2009) Anesthesia in developing countries: one-way traffic? Anesth Analg 108:674–675 author reply 5 36. Mock C, Cherian M, Juillard C et al (2010) Developing priorities for addressing surgical conditions globally: furthering the link between surgery and public health policy. World J Surg 34:381–385. doi:10.1007/s00268-009-0263-4 37. Walker IA, Wilson IH (2008) Anaesthesia in developing countries: a risk for patients. Lancet 371:968–969 38. Zoumenou E, Gbenou S, Assouto P et al (2010) Pediatric anesthesia in developing countries: experience in the two main university hospitals of Benin in West Africa. Paediatr Anaesth 20:741–747 39. Henderson K (2007) Lessons from working overseas. Anaesthesia 62(Suppl 1):113-7 40. Hodges AM, Hodges SC (2000) A rural cleft project in Uganda. Br J Plast Surg 53:7–11 41. Howie SR, Hill S, Ebonyi A et al (2009) Meeting oxygen needs in Africa: an options analysis from the Gambia. Bull World Health Organ 87:763–771 42. Lipnick M, Mijumbi C, Dubowitz G et al (2013) Surgery and anesthesia capacity-building in resource-poor settings: description of an ongoing academic partnership in Uganda. World J Surg 37:488–497. doi:10.1007/s00268-012-1848-x 43. McCormick BA, Eltringham RJ (2007) Anaesthesia equipment for resource-poor environments. Anaesthesia 62(Suppl 1):54–60 44. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF (2010) The helsinki declaration on patient safety in anaesthesiology. Eur J Anaesthesiol 27:592–597 45. Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH (2010) International standards for a safe practice of anesthesia 2010. Can J Anaesth 57:1027–1034 46. Costello A, Azad K, Barnett S (2006) An alternative strategy to reduce maternal mortality. Lancet 368:1477–1479 47. World Federation of Societies of Anaesthesiologists. National member societies. http://www.wfsahq.org/about-us/nationalmember-societies. Accessed Feb 2014 48. World Health Organization. Countries. http://www.who.int/coun tries/en/. Accessed 28 Feb 2014 49. The World Bank Country and lending groups data http://data. worldbank.org/about/country-classifications/country-and-lendinggroups-Low_income. Accessed 28 Feb 2014
841 50. McQueen KA, Malviya S, Gathuya ZN, Tyler DC (2012) International advocacy for education and safety. Paediatr Anaesth 22:962–968 51. Newton M, Bird P (2010) Impact of parallel anesthesia and surgical provider training in sub-Saharan Africa: a model for a resource-poor setting. World J Surg 34:445–452. doi:10.1007/ s00268-009-0195-z 52. Greene NM (1991) Anesthesia in underdeveloped countries: a teaching program. Yale J Biol Med 64:403–407 53. Groen RS, Kamara TB, Dixon-Cole R, Kwon S, Kingham TP, Kushner AL (2012) A tool and index to assess surgical capacity in low income countries: an initial implementation in Sierra Leone. World J Surg 36:1970–1977. doi:10.1007/s00268-0121591-3 54. Manikandan S, Gitanjali B (2012) National list of essential medicines of India: the way forward. J Postgrad Med 58:68–72 55. Notrica MR, Evans FM, Knowlton LM, Kelly McQueen KA (2011) Rwandan surgical and anesthesia infrastructure: a survey of district hospitals. World J Surg 35:1770–1780. doi:10.1007/ s00268-011-1125-4 56. Rosseel P, Trelles M, Guilavogui S, Ford N, Chu K (2010) Ten years of experience training non-physician anesthesia providers in Haiti. World J Surg 34:453–458. doi:10.1007/s00268-0090192-2 57. Life Box (2014) What is the pulse oximetry gap? http://www. lifebox.org/about-lifebox/faq-2/what-is-the-pulse-oximetry-gap/). Accessed Feb 2014 58. Sherman L, Clement PT, Cherian MN et al (2011) Implementing Liberia’s poverty reduction strategy: an assessment of emergency and essential surgical care. Arch Surg 146:35–39 59. Penoyar T, Cohen H, Kibatala P et al (2012) Emergency and surgery services of primary hospitals in the United Republic of Tanzania. BMJ Open 2:e000369 60. Hodges S, Wilson J, Hodges A (2009) Plastic and reconstructive surgery in Uganda: 10 years experience. Paediatr Anaesth 19:12–18 61. McQueen KA (2013) Editorial perspective: global surgery: measuring the impact. World J Surg 37:2505–2506. doi:10.1007/ s00268-013-2198-z
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ORIGINAL SCIENTIFIC REPORT
The Rate-Limiting Step: The Provision of Safe Anesthesia in Low-Income Countries Simon Hendel • Thomas Coonan Sarah Thomas • Kelly McQueen
•
Published online: 9 September 2014 Ó Socie´te´ Internationale de Chirurgie 2014
Abstract Background The importance of safe anesthesia for the best possible surgical outcomes in every patient is not disputed in high resource settings. Low-income countries lag far behind in the provision of, and training for, safe anesthesia practice. Too little is known about numbers and types of providers in a majority of low-income countries. Methods A review of the member societies of the World Federation of Societies of Anaesthesiologists was undertaken, and membership statistics of national societies were requested. Of the 126 members of the federation, only 14 represent low-income countries. Many non-federation-member countries are also low-income countries. Results The anesthesia infrastructure and personnel challenges in low-income countries contribute to poor patient outcomes and limited access to emergency and essential surgery. The presence of a functional anesthesia society provides a measure of the numbers of providers and a snapshot of local professional activities. Conclusion The establishment and maintenance of an anesthesia society is an indicator of respect for the profession and commitment to standards of practice, quality initiatives, and continuing medical education within the country.
Introduction S. Hendel Center for International Health, The Burnet Institute for Medical Research, 85 Commercial Road, Melbourne, VIC 3004, Australia e-mail: [email protected] T. Coonan Dalhousie University, Halifax Infirmary, 1796 Summer Street, Halifax, NS B3H 3A7, Canada e-mail: [email protected] S. Thomas University of Tennessee, Knoxville, USA e-mail: [email protected] K. McQueen (&) Department of Anesthesiology, Affiliate Faculty, Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 1301 Medical Center Drive, #4648 TVC, Nashville, TN 37232, USA e-mail: [email protected]
The impact of surgical care on the global burden of disease is indisputable as the post-2015 Development Goals come into focus. The global shift from communicable disease to non-communicable disease during the last 20 years is reflected in the global burden of disease (GBD) literature, and the 2010 study estimates that appropriate surgical intervention has the potential to impact nearly 28 % of the GBD [1–4]. The potential role of surgical intervention in decreasing disability and premature death will only be possible when both safe anesthesia and emergency and essential surgery are accessible to meet unmet need. The role of safe anesthesia is often neglected in the discussion of safe surgery. A delay in the development of outcomes collection and reporting hides the underlying patient safety issue, though much data do exist [5–24].
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The number of physicians per 10,000 population is a health indicator collected and reported by the World Health Organization (WHO) for the 146 member states. Health indicators at baseline and over time are indicative of the well-being of the population. They are used to benchmark improvement in the health system, and to reveal the impact of strategic interventions on overall health. The WHO does not capture data on specific medical specialties and specialist physicians. Therefore, the relative number of physicians is best utilized in combination with other health indicators to assess baseline population health and assess needs. A minimum number of anesthesiologists and surgeons per 10,000 population, geographically positioned, are required to meet emergency and essential surgical needs. High-income countries often track the number of physicians in a state, province, or country by medical licensure. While this offers a snapshot of the number of physicians currently licensed, the number is not specific for whether the physician is actively practicing in the region where the license is held, or if the physician holds one or more licenses simultaneously. The medical specialty chosen by the physician and the related credentialing completed is often reported in the licensing application, but physicians frequently practice outside the specialty indicated on the application, may no longer be practicing, or may hold a license with or without the actual delivery of care in the location where the license is held. Medical Society membership offers a similar snapshot into physician numbers. Specialty societies also offer insight into the numbers of specialty trained physicians. The limitations of the data provided by societies are similar to those of data provided by licensing bodies. The tracking of physicians is equally challenging in lowincome countries (LICs). Physicians are in great demand in the poorest countries, and therefore many doctors may practice without the appropriate credentialing. They may, therefore, be unknown to the Ministry of Health or other governing bodies. The specialists who choose to belong to medical societies may represent only a fraction of the workforce, but in the case of anesthesiology, which is truly in a state of crisis in LICs, the members of the anesthesia society undoubtedly represent the specialty leaders. Anesthesia providers in LICs include physicians, nurses, and technicians, have varying degrees of education and training, and may or may not be credentialed or licensed. These realities further complicate the understanding of anesthesia practice and provider numbers in each country. Recently, the literature has begun to report numbers and types of anesthesia providers in LICs [25–38]. The WHO Situational Analysis Tool database collected information on the number and type of anesthesia providers working in
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the full spectrum of medical facilities in 28 low- and middle-income countries (LMICs). A recent report revealed that 30.4 % (n = 344) of all medical facilities reported having no full- or part-time anesthesia personnel, including anesthesiologists, general doctors providing anesthesia, or nurse/clinical/assistant medical officers providing anesthesia. In these same institutions, only 41 % of the anesthesia providers were certified, registered, or licensed. Further, only 37.1 % (n = 485) of all medical facilities evaluated employed physician anesthesiologists, and of those only 50.9 % were certified, registered, or licensed [25]. The crisis of anesthesia in LICs The anesthesia crisis in LICs has grown in the last decade. The number of physician anesthesia providers in LICs is dwindling, impacted by ‘brain drain’, income disparity from other specialty physicians, and declining interest among medical students. Lack of infrastructure, including safety equipment and unpredictable medical supplies, have also contributed to the anesthesia crisis [16, 18, 19, 21, 24, 29, 30, 39–45]. The anesthesia-related perioperative mortality rate (POMR) is higher in LMICs and is related to shortfalls in trained personnel, infrastructure, and anesthesia equipment [32, 44]. In Afghanistan, with a population of 32 million, there are nine physician anesthetists; in Uganda, with a population of 27 million, there are 13, excluding expatriate providers [31]. In sub-Saharan Africa, anesthesia is provided by non-physician anesthetic providers in the majority of cases. Usually these providers work alone, unsupervised, and with limited training [46] (Table 1). A recent review of the literature identified 17 studies that documented surgical and anesthesia capacity from individual LMICs. This literature, representing 12 LIC and five middle-income countries (MICs), documented the anesthesia capacity of 555 facilities, and reported the types of providers practicing in the country surveyed. In terms of facilities, 66.3 % (281/424) and 54.3 % (198/364) had oxygen and electricity all of the time; 47 % (121/254) and 47 % (145/309) had anesthesia machines and pulse oximeters. Ketamine anesthesia was available in 72.9 % of hospitals reporting, whereas inhalational anesthesia was only available in 56.2 %. Alternative techniques, such as regional and spinal anesthesia, were available in 58.9 and 65.9 % of hospitals, respectively. Adult endotracheal tubes were available in 51 of 109 hospitals (47 %), and pediatric endotracheal tubes in 44/126 (35 %) [17]. Recent and evolving awareness of the role of safe anesthesia and surgery in improving global health (Disease Control Priorities [DCP]-3) requires that LICs invest in the
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Table 1 Comparing Anesthesia Societies between low-income countries and the USA, Canada, and Australia Country
Society name
Members
Total population
Physicians per 10,000 population
Longevity M/F
WHO rank (X/191)
Australia
ASA
3,025
23,050,000
38.5
80/84
30
Canada
CAS
1,877
34,838,000
20.7
80/84
32
USA
ASA
30,086
318,000,000
24.2
76/81
37
Bangladesh
BSA
60
155,000,000
3.6
69/70
88
Benin
SARB
32
10,051,000
0.6
56/59
97
Cambodia
CSA
150
14,865,000
2.3
64/66
174
Congo Ethiopia
SCARU ESA
20 16
4,337,000 91,729,000
1.0 0.3
57/59 59/62
166 180
Haiti
SHA
45
10,174,000
2.5
61/64
138
Kenya
KSA
120
43,178,000
1.8
58/61
140
Mali
SARMUM
32
14,854,000
0.8
50/53
163
Mozambique
AAM
17
25,203,000
0.3
52/53
184
Myanmar
ASMMA
120
52,797,000
5.0
63/67
190
Nepal
SAN
100
27,474,000
2.1
67/69
150
Rwanda
RSA
15
11,458,000
0.6
58/61
172
Uganda
USA
22
36,346,000
1.2
54/57
149
Zimbabwe
ZAA
50
13,724,000
0.6
53/55
155
Bangladesh: Bangladesh Society of Anesthesiologists; Benin: Societe d’Anesthesie-Reanimation du Benin; Cambodia: Cambodia Society of Anesthesiologists; Congo: Societe Congolaise d’Anesthesie Reanimation Urgences; Ethiopia: Ethiopian Society of Anesthesiologists; Haiti: Societe Haitienne d’Anesthesiologie; Kenya: Kenya Society of Anesthesiologists; Mali: Societe d’Anesthesie de Reanimation et de Medicine d’Urgence du Mali; Mozambique: Associacao de Anesthesiologistas de Mocambique; Myanmar: Anaesthetists Society of Myanmar Medical Association; Nepal: Society of Anaesthesiologists of Nepal; Rwanda: Rwanda Society of Anesthesiologists; Uganda: Uganda Society of Anesthesia; Zimbabwe: Zimbabwe Anaesthetic Association F female, M male, WHO World Health Organization
requisite infrastructure, medicines, equipment, and training. Increasing burdens in trauma and cancer, as well as unmet surgical needs in terms of obstetric conditions, will require increasing numbers of trained anesthesia providers. We sought to evaluate the state of physician anesthesia resources and the commitment to anesthesia standards and guidelines, and access to continuing medical education in LICs, with a novel evaluation of the existing societies of anesthesia.
Investigation of the society by website and direct contact was attempted with every society representing an LIC. The authors emailed the contact for the society listed on the WFSA website, requesting information on the society, including membership numbers and frequency of society meetings. The data received were compared between sources.
Results Methods A review of the 126 member societies of the World Federation of Societies of Anaesthesiologists (WFSA) was undertaken. Country-specific details were reviewed on the WFSA website, including member numbers, website availability, length of membership, and related educational activities [47]. When available, the society websites were reviewed. Updated national society membership numbers were requested and received from the WFSA. Membership data were also requested directly from the national anesthesia societies in the 14 LICs, using the email provided as a contact for the society.
A total of 126 national societies were identified as members of the WFSA. Of these, 14 represented LICs. Of the 79 countries without WFSA membership (Fig. 1) 30 are located in Africa; 18 of those 30 are LICs. There are 36 countries identified as LICs by the World Bank, and therefore only 39 % of LICs have representative anesthesia societies. This is in comparison with high-income countries, which all have representative anesthesia societies. WHO comparative health data from each country and the World Bank comparative health ranking were reviewed [48, 49]. Email contact with each of the 14 identified LIC societies was attempted. Of the 14 emails sent, only one was
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Fig. 1 World Federation of Societies of Anesthesia (WFSA) members and non-members
email returned as undeliverable. All other addresses were therefore assumed to be operational. Every society listed a representative member or contact with an email address on the WFSA national member page; however, none of the remaining 13 contacts responded to the enquiry sent by the authors. Three societies had a functional website, and review of these sites allowed comparison of data between the LIC society and the American, Australian, and Canadian societies (Table 2). Overall, LICs with representative societies report few anesthesia physician providers when compared with MIC and high-income countries (Table 3).
Discussion Recent assessments of anesthesia infrastructure in LMICs reveal a crisis in the provision of safe anesthesia care [4, 10, 24, 25, 30, 32, 41, 44, 45]. Contributing to this crisis in surgical access and patient safety are the limited number of trained providers, including very few practicing physician anesthesiologists; the limited access to essential medications; and the few functional patient safety monitors.
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Simultaneously, as the backdrop to this crisis, noncommunicable diseases (NCDs)—including trauma and cancer—is increasing and contributing to premature disability and death. Diagnosis, treatment, and palliation of NCDs frequently require surgical intervention. Physician anesthesia providers are essential to any healthcare system. These specialty trained physicians are needed for patient care and safety, education and training of other physician and non-physician providers, the establishment of local guidelines and standards, and for leadership with the medical community, government, and related societies. The dwindling numbers of physician anesthesia providers in LICs has contributed to poor patient outcomes and to unacceptably high POMR [10]. The encouragement and support of physician anesthesia providers must be considered part of any strategy to improve patient safety and increase the numbers of successful nurse and technician anesthesia providers [34, 50, 51]. Confirming the presence of national anesthesia societies and related membership, as well as WFSA membership, is another measure of the local commitment to anesthesia. This commitment, reflected in society membership, may be an useful surrogate for estimating the future of anesthesia
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Table 2 Low-income country anesthesia website comparison Country
Website/last updated
Contact information
Society information
Member information
Meeting information
Other
Bangladesh
www.bsabd.com, 2/2014
Mailing address, email, telephone #, website
Office holders, history of society
List of members
List of future conference dates (2014 and 2015), calendar of events
Information on specialty chapters, Journal of the Bangladesh Society of Anesthesiologists, information for anesthesia education
Congo
www.socaru.net, 5/2013
Mailing address, email, telephone #, website
Office holders, mission statement, and constitution
Kenya
www. anaesthesiakenya. co.ke, 2/2013
Mailing address, email, telephone #, website
Office holders, mission statement, and constitution
Reports of past conferences
List of members
education, training, and patient safety efforts in a particular region. Even the smallest societies (Congo, Rwanda, Mozambique) improve the stature of anesthesia in their countries and provide an opportunity to create and publish guidelines and standards. The established hierarchy of leadership, contacts, and meetings that societies are required to develop create opportunities for government dialogue. These structures may also allow clearer communication of expectations with schools, programs, and institutions training non-physician providers. There will be a shortage of physicians to deliver the majority of anesthesia in LICs for the foreseeable future. However, this is also true in many high-income countries where nurse and technician providers provide safe anesthesia care under the direction of a physician. This reality does not diminish the critical role of physicians within the specialty of anesthesia in LICs. Cataloging the shortage of physicians is a recognized aspect of healthcare system evaluation, and is recognized by the WHO and governments as a health indicator. Specialty physicians are not currently included as a country metric or health indicator. The impact of NCDs and the related role of surgery and anesthesia may soon demand that healthcare systems, governments, and perhaps even the WHO evaluate and report the anesthesiologists, obstetricians, and surgeons, and their related non-physician counterparts. This information is critical to planning for improving access to emergency and essential surgical services, and to expanding surgical care and safe anesthesia to avert disability and death related to NCD. Evaluating the non-physician provider base in LICs is a greater challenge. The surveys and reviews published in the last decade have improved the understanding of the nurse and technician providers for surgery and anesthesia at the
Reports of past conferences, calendar of events
List of common questions and answers for patients, discussion forum
country level [17, 19, 22, 23, 25, 31, 32, 42, 52–56]. But the information gap remains large due to the arduous and time consuming nature of surveys, as well as the reality that most surveys are based on representative samples and are not a thorough review of the entire system. The gap is even greater in most countries when considering the credentialing of nurses and technicians. Integral to the anesthesia provider analysis is patient safety. In high-income countries, physicians are leaders of patient safety initiatives and the guidelines that accompany them. As discussed, reports of excessive mortality in LICs are very much in the historical and current literature. In addition, there remains in the vicinity of 70,000 operating rooms globally without pulse oximetry, [57] and well documented shortages in personnel, essential medications and equipment [20, 23, 30, 32, 53, 55, 58–60]. Efforts are underway to encourage collection and reporting of POMR, at least 24 h post-operatively, as a baseline and benchmark of patient safety [61]. The spectrum of information, including specialist physician and non-physician provider numbers, and the POMR, will greatly inform the country-specific barriers to safe patient care and access to surgery. Even before these data are available, the global health community, focusing on the provision of emergency and essential interventions for the growing surgical burden of disease, must demand safe anesthesia in every operating location. The reality of the global anesthesia crisis has long been recognized. The flight of anesthesiologists to other medical specialties and higher income countries has been noted in LICs for decades. Simultaneously, fewer and fewer medical students are choosing anesthesia as a specialty. For those physicians remaining in anesthesia, their remuneration has not kept pace with that of their surgical counterparts, their professional development has lapsed,
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Table 3 Anesthesia providers, training programs, and working conditions by country reported in recent international publications Country, study
Anesthesiologists Number
Afghanistan, Dubowitz et al. [32]
Per 10,000 populationa 0.03
Anesthesia residency programs
Anesthetic officers/ nurse anesthetists
Available types of anesthesiab
0
Afghanistan, Iddriss et al. [20]
Bangladesh, Lebrun et al. [23]
30 % of facilities have limited oxygen delivery systems, 40 % have unreliable running water sources, and only 34 % have reliable electrical power 850
Congo, Dubowitz et al. [32]
0.56
Yes
Oxygen cylinders are available at all hospitals. 71 % of facilities have pulse oximeters in each OR and 100 % of facilities have an anesthesia machine in each OR. Limited number of anesthesiologists, which limits the ability to perform surgery
Occasional lack of electricity and water supply. All hospitals have access to oxygen. Only 63 % of hospitals have a pulse oximeter for each OR
0.02
Ethiopia, Chao et al. [30]
19
0.022
Yes, in all but 3 hospitals, anesthesia is provided by nonphysician personnel
Gambia, Iddriss et al. [20]
8
0.45
Yes, anesthesiologists deliver anesthesia in only 22.2 % of facilities
Kenya, Dubowitz et al. [32]
120
0.37
Yes, up to 300
Liberia, Sherman et al. [58]
0
0
0
Rwanda, Notrica et al. [55]
9
0.082
1 PG
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Working conditionsc
82.4 % of facilities are capable of ketamine anesthesia, 76.5 % are capable of regional. Spinal anesthesia and general inhalational are available in 72.2 % of facilities
77.8 % of facilities have consistent oxygen supplies, 50 % have consistent water supplies, and 44.4 % have consistent electricity. 70.6 % have working anesthesia machines
Yes, 19 nurse anesthetists and 1 non-anesthesiologist physician delivering anesthesia
81.2 % of facilities can provide spinal or ketamine anesthesia. 25 % can provide general anesthesia, and 12.5 % are capable of regional blocks
31.3 % of facilities have fulltime oxygen cylinders, 25 % have full-time electricity. 18.8 % have a functional anesthesia machine
Yes, average of 3 anesthesia technicians per hospital. Some uncertified nurses also practice anesthesia
Routine shortages of essential anesthesia medications such as diazepam
Backup generators are frequently used due to recurrent power outages. Access to clean running water is not a problem. Oxygen is hard to attain, but all facilities report access to oxygen concentrators when oxygen cylinders are not available. Pulse oximeters are scarce
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Table 3 continued Country, study
Anesthesiologists Number
Per 10,000 populationa
Anesthesia residency programs
Anesthetic officers/ nurse anesthetists
Available types of anesthesiab
Sierra Leone, Iddriss et al. [20] Sierra Leone, Groen et al. [53]
20 % of facilities have functioning anesthesia machines 1
Tanzania, Dubowitz et al. [32]
Yes, 23 nonphysician anesthesia staff 0.04
2, 4 residents in training
Tanzania, Penoyar et al. [59]
Uganda, Dubowitz et al. [32]
Uganda, Hodges et al. [60]
Working conditionsc
0.04
15
Zimbabwe, Dubowitz et al. [32]
2, 10 residents in training
0.047
0.3
Broken system: health workers spend 50–60 % of their time on productive tasks Yes, 87 % of anesthesia providers are nonphysicians
42 % of facilities have consistent access to oxygen. Pulse oximeters are scarce. 32 % have no access to an anesthesia machine. 37.5 % have both consistent running water and electricity
Yes, up to 300
Lack of infrastructure: 23 % of hospitals have capacity and equipment for safe delivery of anesthesia for adults, 13 % for children, \6 % for cesarean section
Yes, anesthesia is mainly provided by non-medical anesthetists, most with little training
Anesthesia for children consists of IM or IV ketamine or drawover anesthesia with halothane, but sometimes only ether is available. Local anesthesia is also common
Only 13 % of facilities are able to provide anesthesia for a child. Oxygen concentrators are used. Tracheal tubes are used and re-used
1, 150 residents/ year
IM intramuscular, IV intravenous, OR operating room, PG post-graduate a
Physicians are reported per 10,000 population by the WHO. Comparison from the USA is approximately 2 anesthesiologists per 10,000 population
b
Ketamine, spinal, general
c
Clean water and electricity, access to oxygen, pulse oximetry, and anesthesia machines
and the opportunities for leadership have dwindled. Only recently did LICs begin training nurse anesthesia providers to begin to fill the professional gap, [56] and, in many of the poorest countries, technicians, some with official training, and others without, have provided anesthesia without supervision, without monitors and, frequently, without oxygen.
Conclusions The global anesthesia crisis represents the largest barrier to access to safe surgery. Appreciating the gap in physician
anesthesiologists and other providers, as well as the POMR as a measure of patient safety, is required for the provision of emergency and essential surgery. Pivotal to the discussion around effective and sustainable provision of essential and emergency surgery is understanding and prioritizing the anesthesia workforce. Strategies to assess the anesthesia gap, equipment, and medicine needs must evolve from the static survey model if the growing surgical demands are to be met. Solutions for increasing the availability and safety of providers can only be found once the levels of training and credentials of existing providers have been assessed, and projections for future health service requirements have
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been estimated. Anesthesia societies and their physician leaders have an essential role in this process. The creation of guidelines, minimum training requirements, and examinations must be part of a successful credentialing program. Monitoring and benchmarking outcomes, and driving improvements, must also be physician led. In the absence of a physician leader at every hospital, a national society will need the authority to initiate change and ensure patient safety. Equally important as the challenge of preparing and training a cadre of professional independent anesthesia providers is the collection and analysis of anesthesia outcome data. Reliable data are essential in order to truly characterize the nature of the crisis, both to motivate policy makers and to inform pragmatic solutions as we move forward. National Physician Societies offer a snapshot into patient care and the healthcare system. Tracking and encouraging the progress of anesthesia societies, combined with following POMR over time, will allow for further analysis of country-based systems, patient safety, and opportunities for quality improvement. References 1. Murray CJ (2012) The global burden of disease study. Lancet 380:2053–2260 2. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D (2009) The burden of non-communicable diseases in South Africa. Lancet 374:934–947 3. McQueen KA, Casey KM (2010) The impact of global anesthesia and surgery: professional partnerships and humanitarian outreach. Int Anesthesiol Clin 48(2):79–90 4. McQueen KA, Ozgediz D, Riviello R et al (2010) Essential surgery: integral to the right to health. Health Hum Rights 12:137–152 5. Ouro-Bang’na Maman AF, Kabore RA, Zoumenou E, Gnassingbe K, Chobli M (2009) Anesthesia for children in sub-Saharan Africa: a description of settings, common presenting conditions, techniques and outcomes. Paediatr Anaesth 19(1):5–11 6. Ouro-Bang’na Maman AF, Tomta K, Ahouangbevi S, Chobli M (2005) Deaths associated with anaesthesia in Togo, West Africa. Trop Doct 35(4):220–222 7. Walker I, Wilson I, Bogod D (2007) Anaesthesia in developing countries. Anaesthesia 62(Suppl 1):2–3 8. Fenton PM, Whitty CJ, Reynolds F (2003) Caesarean section in Malawi: prospective study of early maternal and perinatal mortality. BMJ 327(7415):587 9. Mackay P, Cousins M (2006) Safety in anaesthesia. Anaesth Intensive Care 34:303–304 10. Bainbridge D, Martin J, Arango M, Cheng D (2012) Evidencebased Peri-operative clinical outcomes research G. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet 380:1075–1081 11. Hansen D, Gausi SC, Merikebu M (2000) Anaesthesia in Malawi: complications and deaths. Trop Doct 30:146–149
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