Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia: A Mixed-Methods Study

Abstract

Background:
District-level hospitals (DLHs) are the main providers of surgical services for rural populations in Sub-Saharan Africa (SSA). Skilled teams are essential for surgical care, and gaps in anesthesia impact negatively on surgical capacity and outcomes. This study, from a baseline of a project scaling-up access to safe surgical and anesthesia care in Malawi, Tanzania, and Zambia, illustrates the deficit of anesthesia care in DLHs.

Methods:
We undertook an in-depth investigation of anesthesia capacity in 76 DLHs across the 3 countries, July to November 2017, using a mixed-methods approach. The quantitative component assessed district-level anesthesia capacity using a standardized scoring system based on an adapted and extended Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) Index. The qualitative component involved semistructured interviews with providers from 33 DLHs, exploring how weaknesses in anesthesia impacted district surgical team practices and quality, volume, and scope of service provision.

Results:
Anesthesia care at the district level in these countries is provided only by nonphysician anesthetists, some of whom have no formal training. Ketamine anesthesia is widely used in all hospitals, compensating for shortages of other forms of anesthesia. Pediatric size supplies/equipment were frequently missing. Anesthesia PIPES index scores in Malawi (M = 8.0), Zambia (M = 8.3), and Tanzania (M = 8.4) were similar (P = .59), but an analysis of individual PIPES components revealed important cross-country differences. Irregular availability of reliable equipment and supply is a particular priority in Malawi, where only 29% of facilities have uninterrupted access to electricity and 23% have constant access to water, among other challenges. Zambia is mostly affected by staffing shortages, with 30% of surveyed hospitals lacking an anesthesia provider. The challenge that stood out in Tanzania was nonavailability of functioning anesthesia machines among frequent shortages of staff and other equipment.

Conclusions:
Tanzania, Malawi, and Zambia are falling far short of ensuring universal access to safe and affordable surgical and anesthesia care for district and rural populations. Mixed-methods situation analyses, undertaken in collaboration with anesthesia specialists-measuring and understanding deficits in district hospital anesthetic staff, equipment, and supplies-are needed to address the critical neglect of anesthesia that is essential to providing surgical responses to the needs of rural populations in SSA.

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XXX XXX • Volume XXX • Number XXX www.anesthesia-analgesia.org 1
DOI: 10.1213/ANE.0000000000004363
GLOSSARY
ANOVA = analysisofvariance; CO = Clinical Ofcer; DLHs = district-level hospital; GRAMMS =
Good Reporting of A Mixed Methods Study; HIV = human immunodeciency viruses; LIMCs =
low- and middle-income countries; MD = medical doctor; NGO = nongovernmental organizations;
NPAPs = nonphysician anesthesia providers; NPCs = nonphysician clinicians; NSOAP = National
Surgery Obstetric and Anesthesia Plan; OT = operating theater; PIPES = Personnel, Infrastructure,
Procedures, Equipment and Supplies; REC = research ethics committees; SAMPL = Statistical
Analyses and Methods in the Published Literature; SD = standard deviation; SSA = Sub-Saharan
Africa; STROBE = Strengthening the Reporting of Observational Studies in Epidemiology; SURG-
Africa = Scaling up Safe Surgery for District and Rural Populations in Africa; TB = tuberculosis;
WHO-WFSA = World Health Organization-World Federation of Societies of Anaesthesiologists
KEY POINTS
• Question: Considering the lack of published country-specific empirical studies comparing
anesthesia capacity across countries using standardized and validated methods, what is the
current state of anesthesia care at district hospitals in Malawi, Zambia, and Tanzania?
• Findings: None of the surveyed hospitals met international minimum safety standards for
anesthesia, and an in-depth investigation brought to light major cross-country differences in
the availability of essential anesthesia personnel, equipment, and supplies.
• Meaning: Country-specific interventions are urgently needed to improve anesthesia care at
the district level if the surgical needs of rural populations are to be addressed.
BACKGROUND: District-level hospitals (DLHs) are the main providers of surgical services for
rural populations in Sub-Saharan Africa (SSA). Skilled teams are essential for surgical care, and
gaps in anesthesia impact negatively on surgical capacity and outcomes. This study, from a
baseline of a project scaling-up access to safe surgical and anesthesia care in Malawi, Tanzania,
and Zambia, illustrates the decit of anesthesia care in DLHs.
METHODS: We undertook an in-depth investigation of anesthesia capacity in 76 DLHs across
the 3 countries, July to November 2017, using a mixed-methods approach. The quantitative
component assessed district-level anesthesia capacity using a standardized scoring system
based on an adapted and extended Personnel, Infrastructure, Procedures, Equipment and
Supplies (PIPES) Index. The qualitative component involved semistructured interviews with pro-
viders from 33 DLHs, exploring how weaknesses in anesthesia impacted district surgical team
practices and quality, volume, and scope of service provision.
RESULTS: Anesthesia care at the district level in these countries is provided only by nonphysi-
cian anesthetists, some of whom have no formal training. Ketamine anesthesia is widely used
in all hospitals, compensating for shortages of other forms of anesthesia. Pediatric size sup-
plies/equipment were frequently missing. Anesthesia PIPES index scores in Malawi (M = 8.0),
Zambia (M = 8.3), and Tanzania (M = 8.4) were similar (P = .59), but an analysis of individual
PIPES components revealed important cross-country differences. Irregular availability of reliable
equipment and supply is a particular priority in Malawi, where only 29% of facilities have uninter-
rupted access to electricity and 23% have constant access to water, among other challenges.
Zambia is mostly affected by stafng shortages, with 30% of surveyed hospitals lacking an
anesthesia provider. The challenge that stood out in Tanzania was nonavailability of functioning
anesthesia machines among frequent shortages of staff and other equipment.
CONCLUSIONS: Tanzania, Malawi, and Zambia are falling far short of ensuring universal
access to safe and affordable surgical and anesthesia care for district and rural populations.
Mixed-methods situation analyses, undertaken in collaboration with anesthesia specialists—
measuring and understanding decits in district hospital anesthetic staff, equipment, and sup-
plies—are needed to address the critical neglect of anesthesia that is essential to providing
surgical responses to the needs of rural populations in SSA. (Anesth Analg XXX;XXX:00–00)
Anesthesia Capacity of District-Level Hospitals in
Malawi, Tanzania, and Zambia: A Mixed-Methods Study
Jakub Gajewski, PhD,* Chiara Pittalis, MS,† Chris Lavy, MD,‡ Eric Borgstein, MD,§
Leon Bijlmakers, PhD,‖ Gerald Mwapasa, MS,§ Mweene Cheelo, MS,¶ Grace Le, MS,‡
Adinan Juma, MD,# John Kachimba, MD,¶ Paul Marealle, MD,** Nyengo Mkandawire, MD,§
Kondo Chilonga, MD,†† and Ruairi Brugha, MD†
From the *Institute of Global Surgery, Royal College of Surgeons in Ireland,
Beaux Lane House, Dublin 2, Ireland; †Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Beaux
Lane House, Dublin 2, Ireland; ‡Nufeld Department of Orthopaedics,
Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford,
United Kingdom; §Department of Surgery, University of Malawi, College
Copyright © 2019 International Anesthesia Research Society

Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
2 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
Anesthesia Capacity in Malawi, Tanzania, and Zambia
The last decade has seen growing efforts to ensure
anesthesia and surgical care are prioritized within
national health systems in low- and middle-income
countries (LMICs).1,2 Despite increased global investments,
4.8 billion people still lack access to safe surgical and anes-
thetic care.3–5 Sub-Saharan Africa (SSA), with its predomi-
nantly rural population, is most affected.1,3
Government and faith-based district-level hospitals
(DLHs) are the main surgical service providers outside
of main cities in SSA, yet most struggle to meet demand.1
DLHs undertake obstetric surgery, but many perform rela-
tively low numbers of major general surgery,6,7 with poor
anesthesia capacity among the key obstacles.5,8
The density of anesthesiologists in SSA is very low com-
pared with developed countries,9 and those few are concen-
trated in urban areas,1 resulting in anesthesia care in rural
settings being primarily provided by nurses and nonphysi-
cian clinicians (NPCs),10–12 known as nonphysician anesthe-
sia providers (NPAPs) and referred as such herein. NPAPs
have varying levels of education and training and may
or may not be credentialed or licensed.10,13,14 NPAPs often
practice without supervision or refresher training to main-
tain their skills.5 Moreover, in the resource-limited settings
where NPAPs operate, minimum standards for manpower,
infrastructure, and supplies necessary for safe anesthesia
delivery are often not met.15
Surveys are commonly used to measure these decien-
cies but normally without an in-depth investigation of their
drivers and consequences. There is also a dearth of published
country-specic empirical studies16 and analyses compar-
ing anesthesia capacity across countries using standardized
and validated methods. This article aims to close this gap by
measuring and exploring shortages based on a mixed-meth-
ods study performed in 3 SSA countries. The use of mixed
methods has been recommended as a way to overcome the
limitations of surveys.17,18 The quantitative component aims
to provide a standardized and comparable assessment of dis-
trict-level anesthesia capacity in the study countries, while
the qualitative component explores how weaknesses in anes-
thesia affect routine practices of district surgical teams and
quality of surgical care available to rural populations.
The study was undertaken as part of the Scaling up Safe
Surgery for District and Rural Populations in Africa (SURG-
Africa) project 2017–2020, conducted in Malawi, Tanzania,
and Zambia. SURG-Africa aims to improve surgical care
delivery at DLHs. A situation analysis was conducted in 2017
to inform the intervention and national surgical, obstetric, and
anesthesia planning.19 This study, designed by health systems
researchers and national surgical leaders, was conducted to
assess baseline surgical capacity in the participating countries
in a way that allows for multiple time point measures, and the
tools used reect that (see Methods section). A specic focus
on anesthesia capacity was not envisaged, beyond the limited
measures included in the chosen surgical capacity assessment
tools. However, the initial data analysis revealed the nding
that anesthesia was the biggest rate-limiting step in surgical
care in the studied countries, hence the decision to focus the
rst empirical publication of the SURG-Africa project on anes-
thesia. The research team does not include anesthesia special-
ists, which contributed to the limited scope and depth of the
analysis and interpretation of the ndings. This article reports
the post hoc analysis of ndings related to anesthesia capacity
of district hospitals collected as part of this situation analysis.
METHODS
Ethical Approval
Prior Ministry of Health approval for data collection and
informed audio-recorded consent for interviews from
respondents were obtained. All of the approving research
ethics committees (RECs) waived the requirement for writ-
ten informed consent. Ethical approval was granted by the
REC of the Royal College of Surgeons in Ireland, the project
consortium lead, under approval No. REC 1417. In the imple-
mentation countries, ethical approval was received from the
College of Medicine Research Ethics Committee in Malawi
(approval No. P.05/17/2179), the University of Zambia
Biomedical Research Ethics Committee (approval No. 005-
05-17), the Kilimanjaro Christian Medical College Research
Ethics and Review Committee (approval No. CRERC 2026),
and the National Institute for Medical Research in Tanzania
(approval No. NIMR/HQ/R.8a/Vol. IX/2600).
Study Design
A convergent mixed-method approach was used to provide
a systematic, in-depth understanding of the current state of
anesthesia care at DLHs and reported according to the Good
Reporting of A Mixed Methods Study (GRAMMS) stan-
dards.20 A description of the study is presented in the follow-
ing paragraphs, in line with applicable Statistical Analyses
and Methods in the Published Literature (SAMPL),
Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE),and reporting guidelines.21,22
Data Collection
To our knowledge, before this study, no reliable cross-coun-
try district-level data on anesthesia were available for any
of the 3 countries involved.13 A custom-made data collec-
tion tool kit, comprising qualitative and quantitative instru-
ments, was developed by the research team for this study.
First, the Personnel, Infrastructure, Procedures, Equipment
and Supplies (PIPES) cross-sectional survey was used to
assess availability of the respective elements of surgical capac-
ity.23 Several studies have endorsed PIPES as a valid and reli-
able measure of surgical capacity in resource-constrained
settings.23,24 We performed a post hoc analysis of the data
of Medicine Malawi, Mahatma Gandhi, Blantyre, Malawi; ‖Radboud
University Medical Center, Nijmegen, the Netherlands; ¶Department of
Surgery, Surgical Society of Zambia, University Teaching Hospital, Lusaka,
Zambia; #East Central and Southern Africa Health Community, Arusha,
Tanzania; **Tanzania Surgical Association, Muhimbili Orthopaedic Institute,
Dar Es Salaam, Tanzania; and ††Department of Surgery, Kilimanjaro
Christian Medical Centre, Moshi, Tanzania.
Accepted for publication July 1, 2019.
Funding: The Scaling up Safe Surgery for District and Rural Populations in
Africa (SURG-Africa) project is funded by the European Union Horizon 2020
Programme for Research and Innovation, under grant agreement No. 733391.
The authors declare no conicts of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s website (www.anesthesia-analgesia.org).
Reprints will not be available from the authors.
Address correspondence to Jakub Gajewski, PhD, Institute of Global Surgery,
Royal College of Surgeons in Ireland, Lower Mercer St, Dublin 2, Ireland.
Address e-mail to jakubgajewski@rcsi.ie.

Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
XXX XXX • Volume XXX • Number XXX www.anesthesia-analgesia.org 3
collected in 2017 looking specically at anesthesia capacity.
Based on the World Health Organization-World Federation
of Societies of Anaesthesiologists (WHO-WFSA) International
Standards for Safe Practice of Anesthesia,25 we selected 27 of
105 PIPES items that pertain to the provision of anesthesia
care (Supplemental Digital Content 1, Table 1, http://links.
lww.com/AA/C908). For each country, an anesthesia-specic
capacity score was computed at facility level, using the same
algorithm as for the overall PIPES. This score ranges from 0 to
innity, because questions about the availability of staff and
operating rooms have no maximum value.23 Higher scores are
indicative of higher capacity levels. This allows for compari-
sons across hospitals, countries, and over time.
Second, to validate and expand the information collected
through PIPES, a complementary tool was created that was
composed of closed- and open-ended questions, address-
ing previously published shortcomings of PIPES.18 It also
added other relevant domains, such as self-reported readi-
ness to provide surgical and anesthesia care, referral pat-
terns, availability of NPCs/NPAPs, and data management
and quality control measures.
Third, as part of the data collection, qualitative semistruc-
tured interviews were conducted using a qualitative case
study approach26 to explore and triangulate the quantitative
data and to gain a deeper understanding of gaps in anes-
thesia systems at the district level. Questions were derived
based on the previous experience of the research team work-
ing with district hospitals in the study countries8,27 and a
review of relevant literature. All tools are in Supplemental
Digital Content 2, Text 1, http://links.lww.com/AA/C909.
The custom-made tool kit was piloted at selected sites in
Zambia in July 2017 and adjusted before its wider use in all 3
countries. Data collection took place from July to November
2017. The detailed study design and sampling strategy have
been reported in a dedicated publication.28 SURG-Africa
researchers visited some of the sampled hospitals (Malawi 13
DLH visits, Tanzania 8, Zambia 14) and collected data from
the remaining ones at workshops organized by the project
(Malawi 9 DLHs, Tanzania 22 DLHs, Zambia 10 DLHs).
To complete the PIPES and the complementary tool, a
minimum of 2 key surgical team representatives were sur-
veyed per facility to maximize the validity and reliability
of the answers provided, as well as to minimize recall bias
(Table1).29 The survey was conducted in English. Questions
were read aloud by a team of full-time local and interna-
tional project researchers (J.G., C.P., A.J., G.M., M.C.), and
the respondents were asked to discuss each item and pro-
vide an agreed response. In some cases, the local researchers
used the local vernacular to explain or clarify questions. In
each country, a subsample of DLHs was randomly selected
for interviews with surgical, anesthesia, and nursing staff
(Table 1). No participant refused to be interviewed. The
qualitative interviews were conducted in each country
until data saturation was achieved; all were conducted in
English, audio recorded, and later transcribed.
Analysis
For the quantitative data analysis, descriptive statistics were
computed, and a 2-tailed analysis of variance (ANOVA)test
was used to explore differences and cross-country com-
parisons in the PIPES index score using SPSS-IBM v24(IBM
Corp, Armonk, NY). A thematic analysis was performed
for the qualitative data, using a top-down approach.30 Two
project researchers (J.G., C.P.) jointly designed a data coding
framework based on review of the literature and previous
experience in conducting qualitative studies with district-
level surgical providers.8,27 First, the researchers coded the
data using the coding framework. Additional codes were
developed in the second round of analysis. Third, the codes
were grouped into themes and presented to the wider team
of researchers to agree the nal structure of the analysis.
RESULTS
A total of 76 DLHs were included in the study, covering
almost all of Malawi (22/24 government district hospitals in
the country), the Northern Zone in Tanzania (30/35 district
hospitals in the Northern Zone), and Zambia (24/99 district
hospitals in the country; Table1).
Anesthesia Capacity Score
Malawi scored the lowest on the modied PIPES anesthesia
index score (M = 7.96, standard deviation [SD] = 1.05), fol-
lowed by Zambia (M = 8.25, SD = 0.91). Tanzania scored the
highest, on average, but had the biggest differences between
hospitals (M = 8.34, SD = 1.64). Differences between coun-
tries were not statistically signicant (F(2,73) = 0.59, P = .59).
In the qualitative analysis, anesthesia capacity to ensure
the delivery of adequate surgical services was not considered
sufcient by a majority of the respondents. When asked about
the main operating theater (OT) challenges, approximately
one-third of hospitals in the sample reported issues related to
anesthesia (number of skilled staff, equipment, or supplies)
as the primary problem in the provision of safe surgical care.
The analysis of individual PIPES items in the following sec-
tions provides further details on the situation in each country.
Personnel and Skills
On average, there were 2 anesthesia providers per hos-
pital in Malawi (range, 1–4) and in Tanzania (range, 0–4)
and 1 in Zambia (range, 0–2; Table2). According to survey
Table 1. Number of Hospitals and Cadres Included in the Study
Quantitative Survey (PIPES) Qualitative Interviews
Malawi Tanzania Zambia Malawi Tanzania Zambia
No. of hospitals per country N = 22 N = 30 N = 24 N = 9 N = 12 N = 12
No. of surgical provider participants (MD or NPC) 19 33 24 5 5 10
No. of anesthesia provider participants (NPAP) 16 20 7 4 5 3
No. of participating nurses working in operating
theater (general or formally qualied)
14 17 18 3 2 3
Total 49 70 49 12 12 16
Abbreviations: MD, medical doctor; NPAP, nonphysician anesthesia provider;NPC, nonphysician clinician; PIPES, Personnel, Infrastructure, Procedures, Equipment
and Supplies.

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4 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
Anesthesia Capacity in Malawi, Tanzania, and Zambia
responses, anesthesia care at district level is delivered by
NPAPs: in Malawi, anesthesia was administered exclusively
by Clinical Ofcers (COs; with formal training in anesthe-
sia); in Zambia, by a combination of COs (with formal train-
ing in anesthesia) and nurse anesthetists (formally trained
in anesthesia); and in Tanzania, mainly by nurse anesthe-
tists (formally trained in anesthesia). None of the surveyed
district hospitals had anesthesiologists.
When comparing anesthesia and surgical staff numbers,
the situation in Malawi was the worst with, on average 1
anesthetist for every 8 surgical providers (mean ratio, 1:8),
followed by Tanzania (mean ratio, 1:4). Zambia had a rela-
tively better ratio of 1:2; however, 7 of 24 sampled hospitals
in Zambia did not have any qualied anesthesia provider.
In these facilities, anesthesia was provided ad hoc by other
staff members who had received on-the-job orientation and
had no formal anesthesia training.
The qualitative ndings showed that the low numbers
of trained anesthesia providers had negative repercussions
on hospitals’ capacity to maintain essential surgical ser-
vices. Some hospitals reported that priority was given to
emergency cases, neglecting or postponing general elective
cases. Some hospitals, especially in Zambia, were not able to
manage emergency patients either (see Table3).
The service gaps created by the insufcient number of
anesthesia staff were covered, in some cases, by other mem-
bers of the surgical team, but this practice was considered
risky, as explained by 1 interview respondent:
(...) if the anesthetist is on leave, one of us has to act as an
anesthetist. So meaning shifting responsibility. And the one
who is shifting may not have the expertise of anesthesia. So
we just have the basic knowledge. Adverse events happens
[...], not having capacity to deal with that adverse event.
(DLH4_Medical licentiate_Zambia)
In hospitals where task sharing was not possible, staff could
work extended hours to ensure continued access to anesthesia
care for patients. The tiredness and decrease in concentration
caused by working overtime were also associated by study
participants with increased risks of adverse events.
(...) the anesthetists, currently we have two. That one is
working day and night when the other has to be off duty.
So, imagine working day and night. (DLH1_Nurse_Malawi)
Hospitals where adequate and continuous anesthesia
cover could not be guaranteed, especially at night, or when
only 1 anesthetist was available to deal with the caseload,
had no alternative but to refer some patients to other health
facilities.
Another challenge reported by the surveyed facili-
ties was the different level of training and uneven skills
between surgical and anesthesia cadres (Table4). This was a
problem particularly in Malawi, where all but 1 participant
mentioned it. The mismatch in capacity between surgical
and anesthesia providers contributed to referrals for certain
procedures that could otherwise have been handled locally.
Respondents highlighted the need for further training
and refresher training of already practicing clinicians as
essential to maintain the skill levels of the different cadres,
especially in anesthesia, and to ensure better teamwork and
support in the OT.
(...) if the anesthesia provider could be sent for pediatric
anesthesia [training] because to handle pediatric [cases] on
your own becomes difcult. (DLH4_Anesthetist_Malawi)
I don’t do pediatric cases. I am comfortable giving anesthe-
sia, but the surgeon is not. When you don’t do something
for a long time you tend to forget, so I would need some
refresher course. (DLH9_Anesthetist_Zambia)
In addition to limited personnel availability and skills,
respondents also mentioned poor staff motivation, com-
pounded by low levels of condence, as factors impacting
on anesthesia provision.
Better training and increasing the number of qualied
anesthesia providers at district hospitals were considered as
priorities in the immediate future. A respondent described
Table 3. Anesthesia Capacity at District-Level Hospitals
Malawi Tanzania Zambia
N = 22 (%) N = 30 (%) N = 24 (%)
Hospitals with an anesthesia provider formally trained in anesthesia 22 (100) 29 (96.7) 17 (70.8)
Hospitals reporting full anesthesia capacity to deal with all surgery cases expected to do 16 (73) 9 (30) 11 (46)
Hospitals with an anesthesia provider always available for elective surgery 18 (82) 28 (93) 15 (63)
Hospitals with an anesthesia provider always available for emergency surgery 21 (96) 27 (90) 14 (58)
Table 2. Number of Trained Anesthesia and Surgical Providers at District Hospitals by Country
Malawi Tanzania Zambia
Total Minimum Maximum Mean SD Total Minimum Maximum Mean SD Total Minimum Maximum Mean SD
Anesthesia
providers
48 1 4 2 0.66 68 0 4 2 0.94 24 0 2 1 0.78
Surgery
providers
364 9 31 17 6.42 265 2 24 9 4 88 1 8 4 1.62
Abbreviation: SD, standard deviation.
Table 4. Most Frequently Reported Obstacles to
Anesthesia Service Delivery by Country
No. of Hospitals in Qualitative
Study That Reported Issues With
Malawi Tanzania Zambia
N = 9 (%) N = 12 (%) N = 12 (%)
Skills 8 (89) 8 (67) 2 (17)
Anesthesia machine 4 (44) 9 (75) 2 (17)
Stafng 3 (33) 6 (50) 10 (83)
Availability of anesthesia drugs 2 (22) 6 (50) 3 (25)
Data are from semistructured interviews. Responses not mutually exclusive
>1 possible answer.

Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
XXX XXX • Volume XXX • Number XXX www.anesthesia-analgesia.org 5
how the recent arrival of a trained anesthetist improved the
hospital’s capacity to deliver surgical services and improved
OT productivity.
We can see that compared to last year we did more cases this
year (…) because now we have a qualied anesthetist who
was not there before (DLH5_Medical Licentiate_Zambia).
However, respondents believed that for these solutions
to be sustainable, attention must be given to staff retention,
as well as deployment, policies, as high staff turnover rates
at district hospitals contribute to the challenges.
Some [staff members] they come and they go. They say there
are no motivators [...] They want to seek greener pastures
outside. (DLH3_Anesthetist_Malawi);
So many people they come, they look at the area, they say I
can’t stay long. (DLH1_Medical Licentiate_Zambia).
Availability of Essential Infrastructure,
Equipment, and Supplies
An overview of availability of essential infrastructure,
equipment, and supplies for the provision of anesthesia
across the 3 study countries is presented in Table5, which
reports relevant PIPES items. Infrastructure shortages
were the most frequent in Malawi, where almost 70% of
hospitals had no reliable access to running water and only
1 (23%) in 5 DLHs had uninterrupted access to external
electricity, often lacking a backup generator (in nearly
half of DLHs). Supply of compressed oxygen was also a
common problem, lacking in around a third of surveyed
hospitals across the 3 countries. Other pieces of equip-
ment were also not generally available, with pediatric
oropharyngeal airway and endotracheal tubes most fre-
quently missing.
Around one-third of the sampled hospitals across all 3
countries reported not having anesthetic machines always
functioning. In addition, respondents reported that avail-
able machines were old and often malfunctional.
...we are still using an old machine, the manual one, which
usually would require some assistance from someone.
(DLH2_Anesthetist_Zambia)
The anesthesia machine is not working, what works is just
the small monitor. (DLH3_Anesthetist_Malawi)
In hospitals where anesthesia machines were functional,
respondents also reported problems with their numbers, espe-
cially in places with multiple OTs and only 1 machine available.
We also have one anesthesia working machine so it makes
it sometimes difcult if you want to be using both theatres,
operating rooms, but one working machine. (DLH1_Clinical
Ofcer_Malawi)
The anesthetic machine is either moved from one the-
ater to another as needed or, when this is not possible, the
additional theaters are simply not used. This practice was
reported as having negative consequences on the produc-
tivity of these hospitals as their potential surgical capacity
was not fully utilized.
Table 5. Number of Hospitals With Essential Infrastructure and Equipment for Administering Anesthesia
Always Available
Malawi Tanzania Zambia
N = 22 (%) N = 30 (%) N = 24 (%)
Infrastructure
Running water 7 (32) 25 (83) 16 (66)
External electricity 5 (23) 26 (87) 18 (75)
Backup generator 12 (55) 27 (90) 16 (67)
Oxygen: compressed (cylinder) 13 (59) 20 (67) 18 (75)
Oxygen: concentrator 20 (91) 26 (87) 19 (79)
Monitoring
Pulse oximeter 21 (96) 25 (83) 23 (96)
Stethoscopes 22 (100) 29 (97) 22 (92)
Thermometer 16 (73) 30 (100) 23 (96)
Blood pressure 20 (91) 27 (90) 23 (96)
Anesthesia equipment
Anesthetic machine 16 (73) 18 (60) 20 (83)
Oropharyngeal airway (adult size) 20 (91) 24 (80) 23 (96)
Oropharyngeal airway (pediatric) 16 (73) 21 (70) 20 (83)
Facemasks 20 (91) 23 (77) 21 (88)
Endotracheal tubes (adult) 20 (91) 23 (78) 21 (88)
Endotracheal tubes (pediatric) 17 (77) 19 (63) 17 (71)
Resuscitator bag and valve mask (adult) 22 (100) 26 (87) 24 (100)
Resuscitator bag and valve mask (pediatric) 20 (91) 26 (87) 22 (91)
Anesthesia disposables
IV infusion sets 18 (82) 25 (83) 22 (92)
IV cannulas 20 (91) 25 (83) 22 (92)
Syringes 21 (96) 26 (87) 22 (92)
Disposable needles 21 (96) 24 (80) 23 (96)
Anesthesia procedures
Regional anesthesia blocks 18 (82) 19 (63) 19 (79)
Spinal anesthesia 22 (100) 29 (97) 23 (96)
Ketamine anesthesia 22 (100) 30 (100) 24 (100)
General anesthesia 22 (100) 28 (93) 19 (79)
Table uses anesthesia PIPES tool data.
Abbreviations: IV, intravenous; PIPES, Personnel, Infrastructure, Procedures, Equipment and Supplies.

Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
6 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
Anesthesia Capacity in Malawi, Tanzania, and Zambia
As shown in Table 5, all anesthesia types are generally
provided, with ketamine being the most common. Ketamine
is offered as standard in all hospitals in the study countries
and sometimes as a necessary alternative when other types
of anesthesia are not available.
(...) but if we don’t have it [spinal] then we do alternatives.
We have been using ketamine, which is readily available
most of the time. (DLH2_Anesthetist_Zambia)
Improvisation was, in fact, a common theme across the
surveyed hospitals, as many reported having to rely on
what was available at the time of the operation to manage
cases. The supply of anesthesia medications, in particular,
was reported by interviewees as a problem, impairing hos-
pitals’ anesthesia capacity (Table 4). There were inefcien-
cies in the supply chain (eg, delays in provision, limited
range of drugs to cover different procedures), and poor
quality of products was used. Some DLH representatives
expressed concerns that the quality of anesthesia medica-
tions (“ancient drugs” reported to be in use in Tanzania) can
cause complications for patients.
(…) then you see the management of complications
arising from these drugs causes more complications.
(DLH1_Surgeon_Tanzania).
This was especially an issue when treating patients
with unstable clinical conditions or “very sick patients” (as
described by respondents), whose status may deteriorate as
a result of the poor quality of the anesthetic medications.
An absence of basic medications (eg, ketamine, propofol,
or thiopentone) or their poor quality, as reported by some
respondents, substantially limited the capacity of a hospital
to deliver safe surgical care.31
Limited availability of anesthesia medications or lack
of functional anesthetic machines prompts DLHs to refer
simple cases that should be handled locally to other health
care facilities.
...at times we refer patients unnecessarily mainly because we
don’t have an anesthetist who is available and able to provide
that type of anesthesia. (DLH8_Medical Doctor_Zambia).
DISCUSSION
This article reports some dimensions of anesthesia capacity
in a large sample of DLHs in Malawi, Tanzania, and Zambia,
lling a critical knowledge gap in the process of scaling-up
safe surgery in SSA.9,32 The focus is on the district hospital,
the primary provider of essential surgical, and anesthesia
care for the vast number of people living outside of urban
areas.4 This is also the level where such services should be
offered in a safe and affordable way.32
Challenges in district hospital anesthesia stafng, equip-
ment, and supplies in SSA are well documented in the liter-
ature1,15,33,34 but, as suggested by our evidence, may benet
from an in-depth exploration to fully understand impact as
well as to devise context-specic responses.
At rst glance, most DLHs in our study (self-)reported
having basic staff, equipment, and supplies to deliver anes-
thesia and overall capacity, as measured by the anesthesia
PIPES scores, were similar across the 3 countries. However,
our qualitative analysis showed that these crude mea-
sures were somewhat misleading. First, when comparing
results with the guidelines in the WHO-WFSA International
Standards,25 none of the surveyed DLHs met international
minimum safety standards. Second, an in-depth investi-
gation into individual PIPES components brought to light
major cross-country differences.
Specically, shortage of anesthesia providers seems to
be particularly problematic in Zambia. Some hospitals did
not have trained anesthesia providers at all, which greatly
increases risks for patients.35 Therefore, the 1:2 anesthesia to
surgical providers ratio should not be regarded as a positive
nding; it resulted from low numbers of surgical providers
compared to the other 2 countries. This manpower problem,
as documented also in other studies,27 was aggravated by
difculties in retaining existing staff due to factors such as
poor working and living conditions at district hospitals and
more lucrative positions in the private or nongovernmen-
tal organizations (NGO)health care sector, and/or in urban
areas.8,27 Opportunities for continuous training and career
growth, provision of nancial incentives, and good social
services have been proposed as retention strategies.1
Nonavailability of supplies and equipment was among
the most frequently reported challenges in Malawi. Basic
infrastructure, such as water and electricity, was not reliable
in around two-thirds of surveyed DLHs, even if the situa-
tion has improved in recent years.36 Malawi had the highest
numbers of anesthesia providers per hospital in our sam-
ple, but these gures need to be treated with caution. While
staff numbers were relatively high, overall skills levels were
reported as generally poor and not matching the skills level
of surgical providers. As supported by other studies, raw
staff numbers may not reect actual capacity to deliver sur-
gical services and surgical outputs37; other factors such as
skills, condence, and motivation also affect performance
of surgical teams.8 Previous research has proposed that
skills, condence, and attitudes of district clinicians may be
improved through supervision.8,16
Northern Tanzania faces multiple challenges, but in our
study, no individual factor stood out. Regional anesthesia
blocks were reported as not done in one-third of surveyed
facilities in Tanzania, unlike Malawi and Zambia, where
they were reported as commonly done. However, this nd-
ing needs to be treated with caution, because the question in
the PIPES tool did not clearly dene regional blocks, mak-
ing interpretation difcult. Also, availability of anesthesia
machines was lowest in Tanzania compared to Zambia and
Malawi, with reports of old and frequently faulty machines.
This critical shortage has been acknowledged in the
Tanzania National Surgery Obstetric and Anesthesia Plan
(NSOAP), and the government has prioritized the need for
functioning anesthesia machines, training on how to oper-
ate them, and maintenance plans.19
An important nding from our study is that decits
at the district level, especially in anesthesia, are driving
unnecessary referrals of patients needing basic surgical
interventions. This is a major issue for the rural communi-
ties served by district hospitals, as access to surgical care
in these locations is already limited and distance from
alternative and referral health facilities may be consider-
able. Further research is needed to estimate the additional
nancial burden this situation causes, both for health care
systems and patients. Lack of qualied anesthesiologists

Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
XXX XXX • Volume XXX • Number XXX www.anesthesia-analgesia.org 7
has forced the 3 countries in our study to adopt “task-shift-
ing” strategies, but evidence of the safety of this solution
is needed.12
One last key nding that emerged from this investiga-
tion is methodological. Research relying only on quanti-
tative measurements does not provide the full picture of
the actual situation on the ground, because they focus on
“taking stock” of available resources, without exploring
what impact identied shortages could have. Although this
capacity assessment study cannot claim that it identied the
breadth of issues related to anesthesia capacity in the stud-
ied countries, the use of a mixed-methods approach has pro-
vided useful, additional insights. Such methods seem to be
the most appropriate, because they explore both the “hard”
and the “soft” dimensions, not only measuring “how much”
but also exploring the “why and why not” dimensions of
the capacity to deliver safe surgery and anesthesia.
This study has limitations. First, the capacity to deliver
safe anesthesia formed 1 module within a broader tool and
approach to measure and explore safe surgery. Hence, we
included in the post hoc analysis only items that pertained to
minimum standards of anesthesia provision as described by
WHO-WFSA.25 The used tools were not designed to measure
anesthesia capacity, so the results need to be treated with
caution. While one cannot draw comprehensive conclusions
about anesthesia capacity in the studied hospitals, the nd-
ings unveil some aspects of anesthesia decits at the district
level, which would benet from further investigation. There
is a need for more in-depth studies using anesthesia-spe-
cic tools. There is also a need to develop a more targeted
instrument that would allow the measurement of anesthesia
capacity over time—ideally through an index score.
Second, there are limits to generalizing results nation-
wide in Tanzania, where the study was conducted only
in the Northern Zone (5 regions), and in Zambia, where
a representative sample of DLHs from 5 of 10 provinces
was included. Third, because this study was not originally
planned to focus on anesthesia capacity, the respondents
included in the sample comprise various members of surgi-
cal teams. Limited representation of anesthesia providers in
the sample could have impacted on the accuracy and reli-
ability of the data collected.
CONCLUSIONS
More than a decade ago, the recommendation was made
that anesthesia services in LMICs need to be better recog-
nized within national health care budgets and that the basic
requirements for safe anesthesia need to be prioritized.38 As
our results show, the reality of anesthesia care at the dis-
trict level in Malawi, Tanzania, and Zambia falls far short
of this modest and essential life-saving goal. The evidence
in this article supports the case for the studied countries to
invest in educational programs to train, retrain, and retain
anesthesia providers at all levels.39 More efforts should be
invested in assuring that supply chains for anesthesia care
are operational and easily accessible by district facilities
and that hospitals are provided with relevant equipment,
together with maintenance plans. The ndings in this article
go some way toward highlighting the critical importance
of anesthesia capacity, which is (or should be) at the heart
of Surgical Obstetric Trauma and Anesthesia responses
to meet the needs of neglected rural populations in SSA.
Global policy makers and funding bodies need to priori-
tize anesthesia and surgical care, ensuring that skilled staff,
infrastructure, and supplies are in place, because injury and
surgically treatable conditions kill more humans currently
than tuberculosis (TB), human immunodeciency viruses
(HIV),and malaria together, while the latter 3 receive the
majority of funding.40 E
ACKNOWLEDGMENTS
The authors would like to acknowledge the valuable input of
the following organizations and individuals: district hospi-
tal surgical teams who participated in this study in Malawi,
Zambia, and Tanzania; surgical, anesthesia, and operating
theater nursing associations in the partner countries who
guided the development of the study design incorporating
the local context; National Ministries of Health for endors-
ing the study; and Alina Cosma and Morgane Clarke for
their contribution to the manuscript development.
DISCLOSURES
Name: Jakub Gajewski, PhD.
Contribution: This author helped conceive the original idea and
study design; helped with data acquisition, analysis, and interpre-
tation; and helped review the literature, write the rst draft of the
manuscript, and approve the nal manuscript.
Name: Chiara Pittalis, MS.
Contribution: This author helped conceive the original idea and
study design; helped with data acquisition, analysis, and inter-
pretation; and helped critically appraise and approve the nal
manuscript.
Name: Chris Lavy, MD.
Contribution: This author helped conceive the original idea
and study design and critically appraise and approve the nal
manuscript.
Name: Eric Borgstein, MD.
Contribution: This author helped conceive the original idea
and study design and critically appraise and approve the nal
manuscript.
Name: Leon Bijlmakers, PhD.
Contribution: This author helped with data interpretation and
critically appraise and approve the nal manuscript.
Name: Gerald Mwapasa, MS.
Contribution: This author helped with data acquisition and criti-
cally appraise and approve the nal manuscript.
Name: Mweene Cheelo, MS.
Contribution: This author helped with data acquisition and criti-
cally appraise and approve the nal manuscript.
Name: Grace Le, MS.
Contribution: This author helped with data acquisition and criti-
cally appraise and approve the nal manuscript.
Name: Adinan Juma, MD.
Contribution: This author helped with data acquisition and criti-
cally appraise and approve the nal manuscript.
Name: John Kachimba, MD.
Contribution: This author helped conceive the original idea
and study design and critically appraise and approve the nal
manuscript.
Name: Paul Marealle, MD.
Contribution: This author helped conceive the original idea
and study design and critically appraise and approve the nal
manuscript.
Name: Nyengo Mkandawire, MD.
Contribution: This author helped conceive the original idea
and study design and critically appraise and approve the nal
manuscript.
Name: Kondo Chilonga, MD.
Contribution: This author helped conceive the original idea
and study design and critically appraise and approve the nal
manuscript.

Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
8 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
Anesthesia Capacity in Malawi, Tanzania, and Zambia
Name: Ruairi Brugha, MD.
Contribution: This author helped conceive the original idea and
study design and critically appraise and approve the nal manuscript.
This manuscript was handled by: Angela Enright, MB, FRCPC.
REFERENCES
1. Meara JG, Leather AJ, Hagander L, et al. Global surgery 2030:
evidence and solutions for achieving health, welfare, and eco-
nomic development. Lancet. 2015;386:569–624.
2. World Health Organisation. WHO Global Initiative for
Emergency and Essential Surgical Care. Sixth Biennial and
Tenth Anniversary Meeting. Geneva, Switzerland: World
Health Organisation; 2015.
3. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgi-
cal care: a modelling study. Lancet Glob Health. 2015;3:e316–e323.
4. Luboga S, Macfarlane SB, von Schreeb J et al; Bellagio Essential
Surgery Group (BESG). Increasing access to surgical services
in sub-Saharan Africa: priorities for national and international
agencies recommended by the Bellagio essential surgery group.
PLoS Med. 2009;6:e1000200.
5. Epiu I, Tindimwebwa JV, Mijumbi C et al. Challenges of anes-
thesia in low- and middle-income countries: a cross-sectional
survey of access to safe obstetric anesthesia in East Africa.
Anesth Analg. 2017;124:290–299.
6. Gajewski J, Dharamshi R, Strader M, et al. Who accesses sur-
gery at district level in sub-Saharan Africa? Evidence from
Malawi and Zambia. Trop Med Int Health. 2017;22:1533–1541.
7. Galukande M, Kaggwa S, Sekimpi P, et al. Use of surgical
task shifting to scale up essential surgical services: a feasibil-
ity analysis at facility level in Uganda. BMC Health Serv Res.
2013;13:292.
8. Gajewski J, Bijlmakers L, Mwapasa G, Borgstein E, Pittalis C,
Brugha R. ‘I think we are going to leave these cases’. Obstacles
to surgery in rural Malawi: a qualitative study of provider per-
spectives. Trop Med Int Health. 2018;23:1141–1147.
9. Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth J.
The WFSA global anesthesia workforce survey. Anesth Analg.
2017;125:981–990.
10. Enright A. Review article: safety aspects of anesthesia in under-
resourced locations. Can J Anaesth. 2013;60:152–158.
11. McGinn B, Zhou J. Anesthesia for cesarean delivery. Essent
Clin Anesth Rev Keywords, Quest Answers Boards. 2015:388–389.
doi:10.1017/CBO9781139584005.123
12. Lewis SR, Nicholson A, Smith AF. Physician anaesthetists
versus non-physician providers of anaesthesia for surgi-
cal patients. Cochrane Database Syst Rev. 2014;11:CD010357.
doi:10.1002/14651858.CD010357
13. Hendel S, Coonan T, Thomas S, McQueen K. The rate-limiting
step: the provision of safe anesthesia in low-income countries.
World J Surg. 2015;39:833–841.
14. Jochberger S, Ismailova F, Lederer W, et al; “Helfen Berührt”
Study Team. Anesthesia and its allied disciplines in the devel-
oping world: a nationwide survey of the Republic of Zambia.
Anesth Analg. 2008;106:942–948.
15. Epiu I, Wabule A, Kambugu A, Mayanja-Kizza H, Tindimwebwa
JVB, Dubowitz G. Key bottlenecks to the provision of safe
obstetric anaesthesia in low- income countries; a cross-sectional
survey of 64 hospitals in Uganda. BMC Pregnancy Childbirth.
2017;17:387.
16. Nyberger K, Jumbam DT, Dahm J, et al. The situation of safe
surgery and anaesthesia in Tanzania: a systematic review. World
J Surg. 2019;43:24–35.
17. Peters DH, Adam T, Alonge O, Agyepong IA, Tran N.
Implementation research: what it is and how to do it. BMJ.
2013;347:f6753.
18. Nwanna-Nzewunwa OC, Ajiko MM, Kirya F, et al. Barriers and
facilitators of surgical care in rural Uganda: a mixed methods
study. J Surg Res. 2016;204:242–250.
19. Ministry of Health Tanzania. National Surgical, Obstetric and
Anaesthesia Plan (NSOAP) 2018–2025. 2018. Available at:
https://docs.wixstatic.com/ugd/d9a674_4daa353b73064f70ab
6a53a96bb84ace.pdf. Accessed July 31, 2019.
20. Cameron R, Dwyer T, Richardson S, Ahmed E, Sukumaran A.
Lessons from the eld: applying the good reporting of a mixed
methods study (GRAMMS) framework. Electron J Bus Res
Methods. 2013;11:55–66.
21. Lang TA, Altman DG. Basic statistical reporting for articles
published in biomedical journals: the “Statistical Analyses and
Methods in the Published Literature” or the SAMPL guidelines.
Int J Nurs Stud. 2015;52:5–9.
22. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC,
Vandenbroucke JP; STROBE Initiative. The strengthening the
reporting of observational studies in epidemiology (STROBE)
statement: guidelines for reporting observational studies. Int J
Surg. 2014;12:1495–1499.
23. Groen RS, Kamara TB, Dixon-Cole R, Kwon S, Kingham TP,
Kushner AL. A tool and index to assess surgical capacity in low
income countries: an initial implementation in Sierra Leone.
World J Surg. 2012;36:1970–1977.
24. Markin A, Barbero R, Leow JJ, et al. A quantitative analy-
sis of surgical capacity in Santa Cruz, Bolivia. J Surg Res.
2013;185:190–197.
25. Gelb AW, Morriss WW, Johnson W, et al; International
Standards for a Safe Practice of Anesthesia Workgroup.
World Health Organization-World Federation of Societies of
Anaesthesiologists (WHO-WFSA) international standards for a
safe practice of anesthesia. Anesth Analg. 2018;126:2047–2055.
26. Baxter P, Jack S. The Qualitative Report Qualitative Case Study
Methodology: Study Design and Implementation for Novice
Researchers. Vol 13. Available at: https://nsuworks.nova.edu/
tqr/vol13/iss4/2. Accessed March 24, 2019.
27. Gajewski J, Mweemba C, Cheelo M, et al. Non-physician clini-
cians in rural Africa: lessons from the medical licentiate pro-
gramme in Zambia. Hum Resour Health. 2017;15:53.
28. Pittalis C, Brugha R, Crispino G, et al. Evaluation of a surgical
supervision model in three African countries-protocol for a pro-
spective mixed-methods controlled pilot trial. Pilot Feasibility
Stud. 2019;5:25.
29. Markin A, Barbero R, Leow JJ, et al. Inter-rater reliability of the
PIPES tool: validation of a surgical capacity index for use in
resource-limited settings. World J Surg. 2014;38:2195–2199.
30. Boyatzis R. Thematic Analysis and Code Development: Transforming
Qualitative Information. 1998. doi:10.1177/102831539700100211
31. Nickerson JW, Chikumba E. Access to medicines for improving
access to safe anesthetic care. Anesth Analg. 2018;126:1405–1408.
32. Mcqueen K, Coonan T, Ottaway A, et al. The bare minimum:
the reality of global anaesthesia and patient safety. World J Surg.
2015;39:2153–2160. doi:10.1007/s00268-015-3101-x
33. Bowman KG, Jovic G, Rangel S, Berry WR, Gawande AA.
Pediatric emergency and essential surgical care in Zambian
hospitals: a nationwide study. Journal of Pediatric Surgery.
2013;48:1363–1370.
34. Baxter LS, Ravelojaona VA, Rakotoarison HN, et al. An obser-
vational assessment of anesthesia capacity in Madagascar as
a prerequisite to the development of a national surgical plan.
Anesth Analg. 2017;124:2001–2007.
35. Paoletti X, Marty J. Consequences of running more operating
theatres than anaesthetists to staff them: a stochastic simulation
study. Br J Anaesth. 2007;98:462–469.
36. Henry JA, Frenkel E, Borgstein E, Mkandawire N, Goddia C.
Surgical and anaesthetic capacity of hospitals in Malawi: key
insights. Health Policy Plan. 2015;30:985–994.
37. Stewart BT, Gyedu A, Gaskill C, et al. Exploring the relation-
ship between surgical capacity and output in Ghana: current
capacity assessments may not tell the whole story. World J Surg.
2018;42:3065–3074. doi:10.1007/s00268-018-4589-7
38. Walker IA, Wilson IH. Anaesthesia in developing countries–a
risk for patients. Lancet. 2008;371:968–969.
39. Ulisubisya MM. The critical condition of anaesthesia provi-
sion in low-income and middle-income countries. Lancet Glob
Health. 2016;4:e597–e598.
40. Ozgediz D, Riviello R. The “other” neglected diseases in global
public health: surgical conditions in sub-Saharan Africa. PLoS
Med. 2008;5:e121.