Anesthesia and Analgesia in the Global Context

Global Burden of Surgical Disease

Nearly 30% of global morbidity and mortality is surgically treatable, with tens of millions of lives lost each year due to surgical conditions. This burden of surgical disease predominantly affects LMICs and kills 4 times more people than human immunodeficiency virus (HIV), TB, and malaria combined ( Fig. 2.1 ). In addition to negative impacts on health and well-being, there is also significant economic burden associated with surgical morbidity and mortality. By 2030, morbidity and mortality from surgical conditions could reduce annual gross domestic product (GDP) growth by an estimated 2% in LMICs. In the past, similar calculations were used to successfully generate global investment in malaria, but had estimated much lower (1.3%) decreases in GDP due to malaria. Without significant and immediate intervention, surgical disease will produce economic productivity losses of more than US$12 trillion for LMICs between 2015 and 2030. While it is generally agreed that surgical conditions account for a large proportion of global morbidity and mortality, precise data to support this have been lacking. This challenge has been attributed in part to a lack of resources being invested in such research and also to several inherent difficulties in quantifying surgical diseases.

The term “global burden of disease” (GBD) uses the disability-adjusted-life-year (DALY) as a unit to quantify premature death (years of life lost) and disability (years of life lived in a state of less than full health) ( Fig. 2.2 ). The DALY was originally developed for the seminal GBD 1990 Study to quantify the burden of different diseases around the world and has since become commonly used in public health and health economics. Because the DALY is routinely used to inform resource allocation, it has been utilized to describe surgical and pain disease burdens as well. The global health community has moved away from using terms such as third world, developed, or developing when describing countries’ level of economic development. Leading causes of DALYs are often reported geographically by World Bank income level (see Table 2.1 ) or more recently by socio-demographic index (SDI) ( Figs. 2.3 and 2.4 ). The SDI is a composite average of three indicators predictive of health outcomes: income per capita, average educational attainment (for population >15 years old), and total fertility rate.

The 2006 DCP2 publication was one of the first attempts to quantify surgical disease burden and did so by asking 18 surgeons for an educated guess, using convenience sampling and an online survey. Although the reported number (11%) was eye-opening and widely quoted, it was likely a significant underestimation.

In 2015, the DCP3 provided another attempt to assess the public health impact of surgical care by estimating morbidity and mortality averted by scaling up basic surgical and anesthesia services in LMICs (i.e., surgical care for appendicitis, paralytic ileus, intestinal obstruction, hernias, gallbladder and bile duct disease, maternal hemorrhage, obstructed labor, abortion and neonatal encephalopathy, trauma resuscitation, surgical airway, peripheral venous access, suturing, laceration and wound management, chest tube or needle decompression, fracture reduction, escharotomy, fasciotomy, skin grafting, and trauma-related laparotomy and amputation). They concluded that an estimated 1.4 million deaths and 77.2 million DALYs could be prevented each year by scaling up basic surgical and anesthesia services in LMICs.

The LCOGS produced another attempt to estimate global morbidity and mortality from surgical disease by asking 173 surgeons, anesthesiologists, internists, nurses, and public health practitioners from around the world, “What proportion of patients with the following conditions would, in an ideal world, require a surgeon for management?” The result of this survey was 28% to 32% of overall GBD requires a surgeon for management. Based on these results, LCOGS estimated that 30% of GBD is surgically treatable with an estimated 17 million lives lost per year due to surgical conditions.

These reports are consistent with the 1990 GBD Study data, which demonstrate that the morbidity and mortality associated with surgical diseases is significantly larger than that of HIV, TB, and malaria combined. Unintentional injuries are the single largest contributor of DALYs worldwide. The majority of deaths that can be prevented with surgical care are due to injuries (77%), maternal-neonatal conditions (14%), and digestive diseases (9%). Global industrialization and an “epidemiological transition” (i.e., people living longer) in many LMICs have resulted in rising noncommunicable disease and injury burdens (most notably from road traffic crashes) that will likely contribute to increased global surgical disease burden in the coming years.

Each of the methods previously described to estimate surgical disease burden is imperfect. Challenges and limitations include complex methodologies (e.g., Institute for Health Metrics and Evaluation [IHME], GBD Studies), difficulty with measuring and defining surgical diseases (e.g., the same neoplasm in one person may be treated with surgery but in another person may be treated with chemotherapy), and challenges in assigning DALYs to diseases (i.e., disability weighting) and assigning DALYs averted to surgical procedures. To overcome these shortcomings, additional metrics for global surgery and anesthesia have been proposed and include measuring disease prevalence, treatment backlogs for non fatal conditions, morbidity and mortality as a result of delays in care, social benefit, economic benefit, and value of a statistical life (rather than costs per DALY averted).

One significant role for the academic anesthesia community in the global context is working to increase efforts that better quantify the growing surgical disease and pain burdens in order to facilitate appropriate resource allocation and subsequent evaluation of interventions.

Global Burden of Pain

As with surgical disease burden, there is general consensus on the staggering prevalence and incidence of pain worldwide though there are relatively limited data and significant challenges to quantifying pain burden in the global context. Pain is one of the most common reasons for seeking medical attention, is among the top five causes of DALYs worldwide, and directly accounts for four (low back pain, neck pain, musculoskeletal pain, migraine) of the top 10 causes of years lived with disability (YLDs). These statistics do not even account for pain secondary to oncology, injury, or postoperative etiologies, which likely increase these numbers substantially. It is estimated that 10% to 25% of the world’s population suffer from recurring and chronic pain, with increasing numbers caused by intentional physical harm such as war, violence, and torture. Uncontrolled pain has many potential negative impacts on health, well-being, and economic productivity, including increased risk of myocardial infarction and chronic pain.

The 2017 Lancet Commission on Palliative Care and Pain Relief defined serious health-related suffering (SHS) as suffering associated with illness or injury that compromises physical, social, or emotional functioning, and cannot be relieved without medical intervention. Approximately half of all deaths worldwide involve SHS and more than 80% of people who die with SHS are from LMICs. It is estimated that 2.5 million children die with SHS each year. Ninety-eight percent of these children live in LMICs, and more than 90% of these deaths are avoidable. Among the top 10 conditions associated with SHS are HIV, malignancy, and injury. Though not as obvious as injury or cancer, HIV/AIDS is a major source of pain and analgesia need. Pain related to HIV is not routinely managed by anesthesiologists when compared to other more common pain etiologies, however, the relevance of HIV as a rallying point to advocate for greater access to analgesics in LMICs is discussed further in this chapter. In many countries, conditions such as diabetes, sickle cell, and leprosy are also responsible for significant pain burdens. With increasing longevity and industrialization, the disease burden for malignancy and injury are expected to increase significantly in LMICs. As providers with often the most experience administering analgesics, anesthesia providers play an expanded and critical role in pain management, especially in resource-constrained settings.

Disparities in Access, Affordability, and Safety

The exact level of disease burden attributable to surgical disease or pain is a focus of ongoing debate and research, yet it is generally accepted that the surgical, anesthesia, and pain crises are massive, largely avoidable, and disproportionately affect LMICs. Of the roughly 300,000 maternal deaths worldwide, 99% occur in low-resource settings (66% in sub-Saharan Africa) and the majority are preventable with relatively basic surgical, anesthesia, and perioperative care. Approximately 70% of global cancer deaths occur in LMICs, with the majority requiring surgical, anesthesia, or analgesia services. Scaling access to basic surgical and anesthesia services in LMICs could avert 77 million DALYs and 1.5 million deaths per year. Injury represents the majority (77%) of this avoidable morbidity and mortality, followed by maternal and neonatal conditions (14%). Approximately 90% of deaths and DALYs that are lost due to road traffic accidents occur in LMICs.

Based solely on the inequitable distribution of operating theatres, more than two billion people have no access to surgical services. When also accounting for timeliness, facility capacity, safety, and affordability, nearly 5 billion people—the majority of the world’s population—lack access to surgical and anesthesia care. The Global Initiative for Children’s Surgery (GICS) estimates that 1.7 billion children lack access to surgical care. [CR] It is estimated that approximately 143 million additional surgeries are required each year. Of the 234 million major surgical procedures performed annually, only 3% to 6% of them are estimated to occur in LIMCs. Disparities in access disproportionally affect lower-income areas like sub-Saharan Africa or South Asia, where more than 95% of the population do not have access to surgical and anesthesia care. In some higher-income areas like North America and Europe, access varies considerably, but generally more than 95% of the population has access ( Fig. 2.5 ). Even in HIC like the United States, access to anesthesia, surgical, and analgesia care can be limited for rural and underserved populations. It is estimated that universal access to “essential” surgical procedures (which include treatments for injury, obstetric complications, abdominal emergencies, cataracts, and congenital anomalies) would prevent approximately 1.5 million deaths per year or 6% to 7% of all preventable deaths in LMICs.

Inadequate access to analgesia is among the most neglected and inequitable global public health challenges. The global burden of pain disproportionately affects the world’s poor due to the high-burden conditions associated with pain (e.g., HIV, malignancy, and injury) in LMICs, and the general lack of access to analgesics. Although pain is the most common reason for seeking medical attention, and analgesia is considered a basic human right, gaps in access to analgesia are significant and among the most striking global health disparities worldwide. Injury and malignancy, two conditions with significant analgesia needs, represent a significant proportion of surgical disease burden in LMICs, yet the vast majority of LMIC populations have limited or nonexistent access to opiate analgesia. Six HICs account for 80% of the world’s opiate consumption, and countries that contain 17% of the world’s population (Canada, United States, Western Europe, Australia, and New Zealand) are responsible for 92% of the world’s opiate consumption ( Figs. 2.6 and 2.7 ). Pain and palliative care remain relatively neglected by the global health community and disproportionately affect vulnerable populations in LMICs. In recent decades, access to opiates has improved in some LMICs, but not all (e.g., consumption in Africa and South Asia has declined). Inequitable access to analgesia is not unique to LMICs and has been repeatedly described in many HICs, including the United States. Reasons for the inequitable distribution of analgesia are discussed further in the next section of this chapter.

For the proportion of the world’s population that has access to surgical and anesthesia care, they must confront significant disparities in safety. In the last half-century perioperative patient safety has improved by more than 10-fold, though the majority of the gains have been seen in HICs. In the United States during the 21st century, anesthesia-related mortality decreased from 1:1560 around 1950 to less than 1:13,000, and is significantly better than this in healthy patients. Worldwide, approximately 32 million people per year receive anesthesia without adequate monitoring, and more than 77,000 operating rooms (19%) worldwide lack pulse oximetry. In some regions, more than 70% of operating rooms lack pulse oximetry. Data on surgical outcomes in LMICs remain limited but have expanded significantly in the early part of the 21st century. Reports of perioperative mortality rates (POMRs) from low-income countries (LICs) have varied widely in both methodology and results, ranging from 0.2% to 6% overall, with significantly higher mortality for emergent procedures (10% overall, 20% for typhoid intestinal perforations). One international, prospective, observational cohort study of adults undergoing inpatient surgery in 247 hospitals from 25 African countries reported a 30-day in-hospital mortality rate (2.1%) that was twice the reported global average, despite a significantly younger and lower American Society of Anesthesiologists (ASA) physical classification patient population. In several African countries, anesthesia-related mortality has been reported to be in the 1:100s (Malawi 1:504; Zimbabwe 1:482; Nigeria 1:387 for C-sections; Togo 1:133 to 1:250). In one report of 24-hour surgical outcomes in Togo, 30 deaths occurred (total cases 1464), 22 were deemed avoidable, and 11 were due to avoidable anesthesia complications. Another report from Togo reported a mortality rate of 1:250 and found less than half of the 26 facilities surveyed had pulse oximetry, and none had capnography. In a national report on maternal mortality in South Africa, nearly 2.35% of recorded maternal mortalities were anesthesia related, and the majority (93%) were deemed avoidable. One of the most common causes of anesthesia death in this report was the provision of spinal anesthesia without skills necessary to manage an airway or convert to general anesthesia. Other commonly cited causes of avoidable anesthesia mortality in resource-constrained settings include inadequate staffing, monitoring, and drug overdose. A recent meta-analysis of anesthesia-related maternal mortality in LMICs found the risk of death from anesthesia for women undergoing obstetric procedures to be 1.2 per 1000 (vs. 3.8 per million in the United States), with higher risk reported if general anesthesia was used or if anesthesia was provided by a nonphysician . In this analysis, anesthesia was the cause in 2.8% of maternal deaths in LMICs and 13.8% of all deaths during or after C-section in LMICs. To state this differently, anesthesia-related maternal mortality is 300-fold higher for neuraxial and 900-fold higher for general anesthesia than is reported in the United States.

It is important to note that the relationship between hospital-based perioperative morbidity and mortality and surgical disease morbidity and mortality must be interpreted with caution in settings where patients lack access to hospitals. In other words, in an HIC a patient’s chances of dying from a ruptured viscous are roughly the same as the chances of dying from surgery for a ruptured viscous because more than 95% of the population has access to care. However, in an LIC, while the perioperative mortality for a ruptured viscous may be 10%, the majority of patients with this condition never make it to surgery and have mortality rates that are dramatically higher.

Affordability is another significant barrier to accessing surgical and anesthesia services. Each year, approximately 33 million people face catastrophic out-of-pocket expenditure due to payment for surgery and anesthesia ( Fig. 2.8 ) with an additional 48 million people facing catastrophic expenditure related to non medical costs of accessing surgical care (e.g., transportation, lodging, and food). Nearly half (3.7 billion) of the world’s population is at risk of catastrophic expenditure if they were to have surgical and anesthesia care. The majority of those at risk live in sub-Saharan Africa, and South and Southeast Asia. The issue of affordability applies not only to surgery itself but also to components of perioperative care including analgesia and transfusions. For example, in South America, a monthly prescription of opiate for chronic pain may cost 200% of annual income. In India (where nominal gross national income per capita is $1670), a unit of blood often costs up to $247 despite a legal limit of $25. Global health and development leaders including the WHO and World Bank prioritize financial risk protection as a key component of achieving universal health coverage goals for all countries. Despite relatively high out-of-pocket costs at the individual level for some procedures, surgery is a highly cost-effective public health intervention as discussed further in the following sections.

Misperceptions and Limited Data

Two common misperceptions about surgery and anesthesia have contributed to the delayed recognition of these fields as global public health priorities: (1) the scope and scale of surgical disease and pain burdens were vastly underestimated; and (2) surgical and anesthesia care were erroneously assumed to be too expensive and technology dependent to be done safely or cost-effectively in resource-constrained environments. In this section we discuss reasons why the surgical disease and pain burdens are historically poorly characterized. Misperceptions about cost-effectiveness and feasibility of safe surgery and anesthesia care also have roots in a historical data void, especially from LMICs.

Several innovative service delivery models in the public and private sectors of LMICs (e.g., Indus hospital, Aravind Eye Hospitals, and Narayana Hrudayalaya Heart Hospital) have demonstrated that it is feasible to provide cost-effective, safe, and affordable surgical and anesthesia care in resource-constrained countries.

Recent data have consistently demonstrated that surgical services are among the most cost-effective public health interventions ( Fig. 2.9 ). There are several methods to define cost-effectiveness thresholds, each with pros and cons. One of the most commonly cited methods uses GDP-based thresholds. This approach was suggested by the WHO Commission on Macroeconomics and Health and has been defined by authors from the WHO’s Choosing Interventions that are Cost–Effective project (WHO-CHOICE) as, “interventions that avert one DALY for less than average per capita income for a given country or region are considered very cost–effective; interventions that cost less than three times average per capita income per DALY averted are still considered cost–effective; and those that exceed this level are considered not cost–effective.”

In 2003 in Bangladesh, one of the earliest cost-effectiveness studies on surgical care reported the cost of emergency obstetric care at less than $11 per DALY averted. This was 3 times more cost-effective than the measles vaccine (in 2003 dollars). The DCP2 and DCP3 demonstrated cost-effectiveness of the first-level surgical hospital, with essential surgical services all being highly cost effective and many costing $10 to $100 per DALY averted. This is comparable to the cost-effectiveness of other public health interventions such as immunizations ($13-$26 per DALY) or bed nets for malaria prevention ($6-$22 per DALY), and much more cost-effective than other high-priority public health interventions such as HIV treatment ($500 per DALY). A recent analysis of the cost-effectiveness of a pediatric operating room in Uganda found a cost of $6.39 per DALY averted and $397.95 per life saved, with a net economic benefit of over US$5 million per year (cost of $41,000 per year).

In a 2012 forum hosted by the Copenhagen Consensus, five leading health economists, including four Nobel laureates, were asked how best to spend US$75 billion over 4 years to “advance global welfare,” especially in LMICs. The leading priority identified by the group was the expansion of surgical care capacity (US$3 billion per year).

In the past 5 years the global surgery and anesthesia communities have expanded the volume of data that dispel prior misconceptions and support prioritization of surgical and anesthesia care in the global health agenda. During this timeframe, there has also been an explosion of articles that expand available data on a wide range of global anesthesia and surgical topics. The majority of these articles have been published in the surgical journals though recently anesthesia publications have begun to actively support global anesthesia research. The global anesthesia community must increase research productivity in global health and also invest in advocacy, policy, and implementation sciences in order to ensure impact.

Advocacy and Policy

There are many reasons why surgery, anesthesia, and pain have historically not been prioritized by national health systems, donors, or the broader global health community. Although surgical disease accounts for 30% of global disease burden, less than 1% of development assistance for health supports delivery of anesthesia and surgical care. Imbalance between resource allocation and disease burden is found in many health conditions, though the degree of this disparity for surgical disease and pain is particularly striking.

As discussed previously, lack of disease burden data and misperceptions about safety and cost-effectiveness have significantly hindered advocacy efforts for global anesthesia and surgery. In a qualitative analysis of factors that have hindered political prioritization for global surgery, several additional factors were identified including: fragmentation of the global surgery community, lack of leadership and consensus, and inadequate political strategy (e.g., not capitalizing on opportunities such as the MDGs). In another analysis to determine why certain disease-specific global health networks are relatively more or less effective than others, four common challenges were highlighted, each with relevance to global anesthesia and surgery: (1) defining the problem and how it should be addressed; (2) positioning the issue in a way to inspire action by external audiences; (3) building coalitions that include stakeholders outside the healthcare sector (coalitions are too often dominated by HIC providers); and (4) creating governance institutions that facilitate collective action ( Fig. 2.10 ). Another study that examined factors influencing prioritization of surgery in national health systems concluded that sustained advocacy, effective framing of problems and solutions, robust country-level data, and support from regional and international partners were critical for success but often lacking.

Advocacy efforts for surgery, anesthesia, and pain face a few additional and relatively unique challenges. Unlike infectious diseases such as HIV or Ebola, surgical disease and pain are not pandemic and do not incite similar action by the HIC donor community. Furthermore, most surgical conditions and pain are difficult to advertise and are not disease specific. While select pediatric conditions (e.g., cleft lips) are easily marketable, other conditions like trauma, hernias, and cesarean section are more difficult to compassionately portray in media in attempts to improve public awareness.

The WHA resolution 68.15 emphasized advocacy and resource development in five key focus areas for global surgery (workforce, essential medicines, information management, service delivery, and advocacy). The LCOGS provided clear framing of problems (see Box 2.2 ), outlined priorities for country-level data collection, and helped to provide frameworks for national surgical, obstetric, and anesthesia plans (NSOAPs) in LMICs. As more NSOAPs are produced, they have the potential to serve as key rallying points for national advocacy efforts.

Anesthesia, surgery, and pain need global champions. Only recently has advocacy by leading global organization (e.g., the World Bank, WHO) and select local governments in LMICs focused attention on anesthesia and surgery in the global context. This is in part due to advocacy efforts by several relatively recent initiatives (e.g., LCOGS, The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care [G4 Alliance], WFSA, GICS, and several more). These multidisciplinary efforts must be expanded and sustained in order to reach the critical mass needed to overcome prior misperceptions and affect change. It is essential that advocacy efforts for surgery, anesthesia, and pain be consistent with the key messages of LCOGS, the Global Health 2035 Report, WHA resolution 68.15, and the SDGs, and emphasize that anesthesia, surgery, and analgesia are indispensable components of “universal health coverage.” No longer can surgery be seen as a vertical (i.e., disease-specific) program.

One key objective for advocacy efforts will be to identify new streams of funding from global donors, national budgets, private sectors, and innovative models. Similar to the large-scale funding initiatives to combat HIV/AIDS and other infectious diseases (e.g., the U.S. President’s Emergency Plan for AIDS relief, Gavi Vaccine Alliance, The Global Fund), surgery and pain require comparable attention and support. In addition to domestic and international financing mechanisms to support health system scale-up, public-private partnerships and innovative patient-level financial risk protection strategies must be integral components to advocacy efforts.

As leaders in safety, pain, perioperative care, and more, the global anesthesia community must actively engage in policy, research, and innovative global initiatives to expand access to quality care. Academic institutions from all countries can play a significant role in supporting a coordinated research agenda, creating a global voice for advocacy, sharing information, and harmonizing educational standards and opportunities. Anesthesia must follow the lead of other medical disciplines to not only cultivate but also support faculty and trainees with interests in global public health careers. Such advocacy will likely require coordination and partnership with multiple disciplines, including nonphysician provider cadres who perform a significant proportion of anesthesia services, especially in LICs.

Workforce Shortages and Strategies for Expansion

The critical shortage of trained anesthesia providers in resource-constrained settings is one of the most significant barriers to expanding access to safe surgical, anesthesia, and pain services for billions of people worldwide. Although shortages of many key members of the surgical workforce exist (including surgeons, obstetricians, pathologists, radiologists, laboratory technicians, nurses, biomedical engineers, and more), anesthesia provider shortages in LMICs are particularly striking and relatively neglected. Countries like the Central African Republic have no physician anesthesiologists and only 24 nonphysician anesthesia providers (NPAPs) for a population of nearly 5 million. Ethiopia, with a population of over 100 million people, has only 35 physician specialist anesthesiologists. A survey of emergency obstetric care capacity at facilities in Uganda found that lack of staff had the greatest correlation with observed mortality rates. In a survey of 64 public and private hospitals in Uganda, 84% did not have a physician specialist anesthesiologist, and 8% had no trained anesthesia providers at all. In another survey of anesthesia providers from five main referral hospitals in East Africa (Uganda, Kenya, Tanzania, Rwanda, and Burundi), only 7% reported adequate anesthesia staffing. In settings where providers exist but in small numbers, the workforce shortage is compounded by heavy administrative burdens and non-clinical duties.

While the anesthesia workforce shortage is most severe in LICs and particularly pronounced in sub-Saharan Africa, regional workforce shortages also exist in HICs and can significantly limit access to care for rural populations. In one survey of rural hospitals in the United States, 36% reported delay or cancellation of surgery due to a lack of anesthesia providers. Data from HICs demonstrate differences in trauma mortality are significantly worse starting at five miles from a trauma center in a major urban city. One can only imagine outcome differences in settings where there may be no surgical or anesthesia provider for tens or even hundreds of miles.

The optimal number of specialist surgical, anesthetic, and obstetric workforce (SAO) providers needed to give access to safe surgery is unknown and likely to vary significantly based on local resources and needs. The SAO density correlates with life-expectancy and in one study, as SAO providers increased from 0 to 20 per 100,000 population, maternal mortality decreased by 13.1% for each 10 unit increase in provider density ( Fig. 2.11 ). These benefits were also observed with workforce expansion beyond 20, though with less magnitude beyond 30 and 40 providers per 100,000 ( Fig. 2.12 ). Based on these findings, the LCOGS recommended prioritizing expansion of the SAO workforce to 20 per 100,000 population by 2030, with anesthesia-specific targets of 5 to 10 anesthesia providers per 100,000.

The density of SAO providers has been estimated at 0.7 per 100,000 population for LICs as compared with 56.9 per 100,000 population for HICs. Worldwide, 77 countries report an anesthesia provider density less than 5 per 100,000, with a 90-fold difference between the average physician workforce density in HICs as compared to LICs. The anesthesia workforce crisis is most severe in sub-Saharan Africa, where most countries have approximately 1.0 physician anesthesiologist per 100,000 population as compared to approximately 19 in Europe or 21 per 100,000 in the United States ( Fig. 2.13 ). Twenty-six countries in sub-Saharan Africa reported less than 0.5 physician anesthesia providers (PAPs) per 100,000. In many LICs, NPAPs provide the majority of anesthesia care. When NPAPs are included in calculations of total anesthesia provider density, 16 countries in sub-Saharan Africa still report less than 1 anesthesia provider per 100,000, and worldwide 70 countries still report less than 5 anesthesia providers per 100,000 population. Estimates from the WHO Global Surgical Workforce database demonstrate that 12% of the SAO workforce provides care for approximately a third of the world’s population. Worldwide, LICs and LMICs have 48% of the world’s population but only 20% of the SAO workforce.

Multiple factors have contributed to the ongoing surgical and anesthesia workforce crises in LMICs, including limited training infrastructure, relatively low professional status, lack of career advancement (especially for NPAPs), perceived limited job opportunities relative to other professions (e.g., infectious disease in LMICs), cost of training, inefficient hiring mechanisms, provider burnout, as well as internal (e.g., private practice in urban settings) and external brain drain (e.g., leaving the country). Lack of consensus on anesthesia practice models and polarized views on who should provide anesthesia care (i.e., physician versus nonphysician, supervised versus independent) are additional factors limiting a clear path for rapidly scaling the global anesthesia workforce ( Table 2.3 ). Task-sharing is a prominent and controversial component of many surgical workforce expansion efforts.

Each of the aforementioned challenges must be addressed as part of any national or international effort to expand the anesthesia workforce. The long-term goal of building robust training infrastructures in low-resource settings requires locally led plans for national advocacy, implementation, and evaluation. Such efforts can benefit from international investment and collaboration.

Significant heterogeneity in anesthesia care models exists worldwide. Although the varied anesthesia practice and training models have evolved to address different local needs and challenges, excess heterogeneity and lack of consensus on anesthesia workforce strategy may provide an additional challenge to global workforce expansion. For example, within sub-Saharan Africa, formal nonphysician training programs range from 3 to 72 months in duration with widely different entry requirements, no standardized curricula or assessment tools, and different scopes of practice. For countries seeking to increase anesthesia provider numbers, no clear roadmap exists. In most of these countries, task-sharing with NPAPs will likely play a key role in workforce expansion efforts. Collaborative efforts involving stakeholders from different countries and different anesthesia provider cadres can support anesthesia workforce expansion efforts by offering frameworks for anesthesia training, competency assessments, and potential practice models that are feasible with local resources and that meet local needs. Initiatives that ensure quality (e.g., education programs, credentialing bodies, and licensing exams) are as important as those that focus on increasing absolute numbers. The global anesthesia community can play a significant role via advocacy, research, education, and partnership to address many of the challenges that have created the current global anesthesia workforce crisis.

Infrastructure Challenges

The provision of surgical and anesthesia care requires infrastructure that is often lacking in many LMICs. As discussed elsewhere in this chapter, such infrastructure does not necessarily need to be high-cost or based on advanced technologies to provide safe care. In addition to the provider shortages already discussed, additional infrastructure challenges that frequently limit surgical and anesthesia service delivery include: underdeveloped patient referral and prehospital systems, medication and equipment shortages, and inadequate supply chains and facility resources.

In maternal health, and more recently for surgery and anesthesia, a “three delays framework” has been used to describe factors delaying timely access to safe healthcare services. The “first delay” in this model (delay in seeking care) may occur due to financial, cultural, education, or other patient factors. Anecdotally, fear of bad surgical outcomes (whether true or not) and more specifically a fear of anesthesia may also contribute to the “first delay.” The second and third delays are more directly linked to infrastructure limitations. The “second delay” (delay in reaching care) occurs when health facilities cannot be reached in a timely manner and may be due to geographic distance or challenges with transportation (e.g., bad road conditions, no access to a car, no money for public transport). Although efforts to improve healthcare infrastructure often focus on facility-based interventions, emphasis on infrastructure that minimizes this “second delay” is underappreciated despite evidence of cost-effectiveness. For example, the lack of prehospital care systems in many LMICs is a significant source of avoidable morbidity and mortality. The DCP3 estimates that 4.7 million deaths in LMICs each year are due to surgical conditions that are potentially addressable through prehospital and emergency care systems. In Uganda, less than 25% of the population lives within 2 hours of a surgical facility, and worldwide approximately 2 billion people lack access due to this second delay.

When discussing infrastructure limitations, most people think of the “third delay” (delay in receiving care), which occurs when patients reach a facility but may not receive adequate care because of limitations in facility resources. Data from 800 first-level health facilities in LICs demonstrate that relatively few first-level hospitals could provide C-sections (64%), laparotomies (58%), or open fracture repairs (40%), and most did not have reliable electricity (31%), running water (22%), oxygen (24%), or Internet access. Without reliable utilities, standard equipment like monitors, ventilators, anesthesia machines, and autoclaves are often not functional, assuming they are even present at all. In recent years, the number of surgical and anesthesia capacity assessment tools increased significantly, although most tools have focused on surgical care with limited ability to assess anesthesia or analgesia capacity.

The WHO Surgical Safety Checklist includes requirements for pulse oximetry, anesthesia machine check, and confirmation of instrument sterility, yet these may not currently be feasible in many LMIC health facilities. As the consensus on what constitutes “essential” or “standard” anesthesia and surgical safety equipment is evolving, it is universally agreed that far too many health facilities face routine shortages of even the most basic anesthesia equipment.

Inadequate access to indicator strips, maintenance support, power, and distilled water result in low compliance with the 2016 WHO/Pan American Health Organization (PAHO) standards for cleaning, disinfection, and sterilization in most LMICs. In a survey of 28 district hospitals in Zambia, 35% did not have a laryngoscope. A study from Nigeria found that most facilities could not provide general anesthesia (53%); another survey in the Democratic Republic of Congo demonstrated 40% of hospitals lack suction, and in Guatemala only 17% of facilities surveyed had capnography. In Uganda, a 2014 survey of health facilities that offer emergency services and surgical care revealed only 22% had pediatric airway equipment, 41% adult airway equipment, and 28% a pulse oximeter. In one survey about obstetric operating room capacity in the five main referral hospitals in East Africa (Uganda, Kenya, Tanzania, Rwanda, and Burundi), only 4% of the providers surveyed reported the presence of electrocardiograph (ECG), pulse oximetry, continuous blood pressure monitoring, capnography, thermometer, stethoscope, difficult airway cart, suction machine, recovery room, and intensive care unit (ICU) facilities. Access to reliable oxygen is a common problem in resource-constrained health systems. In such settings, oxygen is rarely available through central pressurized gas lines and more often provided via tanks or oxygen concentrators, the latter of which has been shown to offer long-term cost savings and increased reliability. (Further discussion of oxygen supply challenges in resource-limited settings is provided in the section, Essentials for Practice in Resource-Constrained Settings of this chapter)

Equipment donations are common in LMICs, however, they often have limited long-term impact and multiple unintended consequences. Donations are frequently made with limited understanding of local needs, lack of communication between donor and recipient, and absence of ongoing technical support or access to consumables. Well-intentioned donors are often unaware of WHO Guidelines for Medical Device Donation, or of the fact that purchase costs account for only 20% of total lifetime costs for a piece of equipment. As a result, up to 30% of donated equipment may only transiently or never become operational, and commonly accumulates in equipment graveyards because of a sense of obligation by recipients to not throw anything away. For example, donations of modern anesthesia machines from HICs is commonly encountered in many LMICs. Without reliable power, pressurized gas supplies, biomedical support, or access to disposables (e.g., carbon dioxide absorbent, humidity filters, circuit tubing), it is sometimes hard to argue in favor of these machines.

Reliable access to medications and blood are two additional common infrastructure challenges limiting access to safe surgery and anesthesia services worldwide. The WHO Essential Medicines List includes medications to safely perform general anesthesia, monitored anesthesia care (MAC), neuraxial, regional, local anesthesia, as well as acute and chronic pain management ( Box 2.3 ). Despite the existence of the list for more than 40 years, critical shortages of many medications persist. A WHO survey of all health facilities in Uganda examined availability of twelve anesthetic drugs (atracurium, bupivacaine, halothane, isoflurane, desflurane, sevoflurane, ketamine, lidocaine 2%, lidocaine 5% heavy spinal injection, midazolam, nitrous oxide, and suxamethonium) and found that only 2% of the surgical health facilities had all of these medications and only 19% had half. The same WHO survey in the Democratic Republic of Congo found that only 33% of hospitals had bupivacaine, 21% thiopental, and 16% halothane. Factors specifically affecting access to analgesics are discussed further in the next section, though supply chain, cold storage, and cost are common challenges that limit availability for many drugs. Drug quality is also a factor in some LMICs where variable manufacturing quality and fraud (i.e., counterfeiting) are commonly encountered. It is estimated that 1 in 10 medical products (e.g., medications) found in LMICs are substandard or falsified and result in hundreds of thousands of deaths each year.