The critical condition of anaesthesia provision in low-income and middle-income countries
Authors: Mpoki M Ulisubisya
Journal: The Lancet Global Health (2016)

Surgically treatable conditions represent nearly a third of the global disease burden, claiming 16·9 million lives per year and leading to millions more disabilities and injuries.1Meara J Leather A Hagander L et al.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1818) Google Scholar Although surgery has been labelled a priority for national universal health coverage plans,2WHOStrengthening emergency and essential surgical and anaesthesia care in the context of universal health coverage. World Health Organization Press, Geneva2015Google Scholar it remains exceedingly difficult to perform without a system in place to deliver anaesthesia. Safe surgery is impossible without a reliable supply of anaesthesia. In late August, 2016, the quadrennial World Congress of Anaesthesiologists will meet in Hong Kong to showcase the latest research and findings in anaesthesia and intensive care. The Congress will explore leading clinical and technological issues facing anaesthesia providers across all regions of the world. However, because billions of people in low-income and middle-income countries (LMICs) are without access to essential surgical and anaesthesia care,1Meara J Leather A Hagander L et al.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1818) Google Scholar this opportunity should be used to highlight the challenges inhibiting anaesthesia delivery in the world's most low-resource surgical settings. Anaesthesia remains an overlooked and under-resourced area of health care in LMICs. In a study of 11 sub-Saharan African countries, all had fewer than one physician-level anaesthetist per 100 000 population,4Dubowitz G Detlefs S McQueen K Global anesthesia workforce crisis: a preliminary survery revealing shortages contributing to undesirable outcomes and unsafe practices.World J Surg. 2010; 34: 438-444Crossref PubMed Scopus (117) Google Scholar leaving the vast majority of anaesthesia provision to those with a nursing degree or less.5Henry J Frenkel E Borgstein E Mkandawire N Goddia C Surgical and anaesthetic capacity of hospitals in Malawi: key insights.Health Policy Plan. 2015; 30: 985-994Crossref PubMed Scopus (63) Google Scholar In Tanzania, I am one of only 22 physician–anaesthetists in a country of 47 million people. Compounding this human-resource problem is a drastic infrastructure gap: two-thirds of hospitals in sub-Saharan Africa have unreliable electricity,6Adair-Rohani H Zukor K Bonjour S et al.Limited electricity access in health facilities of sub-Saharan Africa: a systematic review of data on electricity access, sources, and reliability.Glob Health Sci Pract. 2013; 1: 249-261Crossref PubMed Scopus (111) Google Scholar and another third have no access to medical oxygen—both of which are required for the delivery of safe general anaesthesia.7Vo D Cherian M Bianchi S et al.Anesthesia capacity in 22 low and middle income countries.J Anesth Clin Res. 2012; 3: 207Google Scholar Additionally, 40% of facilities in one study8Malkin R Perry L Effectiveness of medical equipment donations to improve health systems: how much medical equipment is broken in the developing world?.Med Biol Eng Comput. 2011; 49: 719-722Crossref PubMed Scopus (110) Google Scholar had no anaesthesia machine, in part because much of the medical equipment in LMICs is inoperable. That only 3·5% of the world's surgical operations are conducted in poor countries9Weiser TG Regenbogen SE Thompson KD et al.An estimation of the global volume of surgery: a modelling strategy based on available data.Lancet. 2008; 372: 139-144Summary Full Text Full Text PDF PubMed Scopus (1693) Google Scholar—which bear nine in ten trauma, maternal, and paediatric deaths10Baker T Critical care in low-income countries.Trop Med Int Health. 2009; 14: 143-148Crossref PubMed Scopus (114) Google Scholar, 11Kassebaum NJ Bertozzi-Villa A et al.Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2014; 384: 980-1004Summary Full Text Full Text PDF PubMed Scopus (966) Google Scholar—comes as no surprise. As long as developing-world health systems are ill prepared to offer safe anaesthesia and intensive care to patients in need of surgery, surgically treatable conditions will remain leading causes of death, the world will lose trillions of dollars in gross domestic product,1Meara J Leather A Hagander L et al.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1818) Google Scholar and we in the global health community will fail those in greatest need of our support. Through efforts like World Health Assembly Resolution 68/15; the Global Alliance for Surgery, Obstetric, Trauma, and Anaesthesia Care (the G4 Alliance); The Lancet's Commission on Global Surgery;12Meara JG Leather AMJ Hagander L et al.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (127) Google Scholar and the World Congress of Anaesthesiologists, global attention is increasingly focused on anaesthesia and surgical care. The opportunity exists to build on this momentum through prioritisation of anaesthesia and intensive-care capacity in LMICs. Countries should have educational programmes and incentives to train, retrain, and retain providers at all levels (physician–anaesthetists, nurse–anaesthetists, intensive-care providers, and biomedical technicians); strong supply chains for anaesthesia consumables; and anaesthesia equipment that is both appropriate for the setting and supported with spare parts and technicians trained to service it. Surgery's ability to preserve and prolong life hinges on our ability to provide safe and reliable anaesthesia. I declare no competing interests.