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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.
Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
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.
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... Although ketamine has a large therapeutic window, its use is limited due to low efficacy and huge interindividaul variability in treatment response including ADRs that require cessation of therapy (Kvarnström et al., 2004;Noppers et al., 2010;Laskowski et al., 2011;Hardy et al., 2012;Perez-Ruixo et al., 2020). Ketamine has been associated with increased blood pressure, alteration of speech, muscular discoordination, euphoria, hallucination, loss of consciousness, seizure, nausea, out of body experience, hypothermia, traffic accident or drowning and irrational behavior (Iyalomhe and Iyalomhe, 2014;Lonnée et al., 2018;Gajewski et al., 2020). ...
... Anesthesia care in these countries were performed by non-physician anesthetists, some of whom had no formal training. Shortage of staff, interrupted access to electricity and water for some facilities and lack of functional anesthesia machines were reported (Gajewski et al., 2020). Though ketamine is considered safe, its application by untrained personal might lead to abnormal doses and contribute to adverse effects in these populations. ...
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... It is only with the help of the collective, global anesthesia research community that we will be able to advance anesthesia care, including the practice of sedation and nonphysician anesthesia provision, on the African continent. 27,28 E ...
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BACKGROUND: There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death. METHODS: A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included. RESULTS: Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7-25.6). CONCLUSIONS: The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer. (Anesth Analg 2021;00:00-00)
... It is only with the help of the collective, global anesthesia research community that we will be able to advance anesthesia care, including the practice of sedation and nonphysician anesthesia provision, on the African continent. 27,28 E ...
Article
Background: There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death. Methods: A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included. Results: Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7-25.6). Conclusions: The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer.
... 36 Moreover, many anesthesia providers in LMICs are either nurses or clinical assistants with limited formal advance anesthetic training. 7,37,38 Ketamine use has contributed significantly to improved access to basic surgical and obstetric care in LMICs because its use doesn't require sophisticated equipment for monitoring and expertise. In a survey done in 22 LMICs, availability of ketamine (71.5%) far Disaster Medicine and Public Health Preparedness 3 37 The successful use of ketamine in LMICs was reported by Masaki et al.; the study typified the feasibility and safety of ketamine for essential surgeries where no anesthetic is available. ...
Article
Objectives Although the importance of ketamine in clinical practice and in resource-poor settings and disaster zones, several attempts were made to reschedule it because of the issues around its misuse. Resisting future moves to reschedule ketamine is important for its continuous availability where needed. This scoping review addresses the question of whether ketamine should or should not be banned and the state of preparedness of low resource settings if ketamine petitions become successful in the future. Methods A search was performed using PubMed and Google Scholar to identify articles published in the English language from March 2015 to August 2020. The articles were searched with a wide range of priori search terms related to the research questions. The selection of articles was based on relevance and eligibility. Results Seventy-five articles were selected and grouped into 4 ethical themes. The search revealed that several articles addressed the importance of ketamine, pharmacology, misuse, supply, and consequences of a ketamine ban; however, none addressed how resource-poor countries should prepare for a future without the overreliance of ketamine. Conclusion Four ketamine petitions in about 10 years are an indication that another may resurface soon; therefore, it is important to continue to study the clinical importance of ketamine while discouraging its overreliance for clinical practice.
... 3 Today, in 2021, many hospitals in sub-Saharan Africa still cannot provide safe anesthesia care. 5 Besides restricted access, there are significant shortages of essential equipment, monitors, and trained personnel. 6 The latter is further aggravated by high burnout rates among anesthesia providers. ...
... Rwanda, 51 56 Senegal, 56 Tanzania, 18 Uganda, 40 Zambia 59 and Zimbabwe. 57 60 There are also untrained nonphysician clinicians providing anaesthesia in Liberia, 23 Malawi, 20 28 Rwanda, 51 56 Zimbabwe 57 60 alongside trained personnel. ...
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Objective: To provide a general overview of the reported current surgical capacity and delivery in order to advance current knowledge and suggest targets for further development and research within the region of sub-Saharan Africa. Design: Scoping review. Setting: District hospitals in sub-Saharan Africa. Data sources: PubMed and Ovid EMBASE from January 2000 to December 2019. Study selection: Studies were included if they contained information about types of surgical procedures performed, number of operations per year, types of anaesthesia delivered, cadres of surgical/anaesthesia providers and/or patients' outcomes. Results: The 52 articles included in analysis provided information about 16 countries. District hospitals were a group of diverse institutions ranging from 21 to 371 beds. The three most frequently reported procedures were caesarean section, laparotomy and hernia repair, but a wide range of orthopaedics, plastic surgery and neurosurgery procedures were also mentioned. The number of operations performed per year per district hospital ranged from 239 to 5233. The most mentioned anaesthesia providers were non-physician clinicians trained in anaesthesia. They deliver mainly general and spinal anaesthesia. Depending on countries, articles referred to different surgical care providers: specialist surgeons, medical officers and non-physician clinicians. 15 articles reported perioperative complications among which surgical site infection was the most frequent. Fifteen articles reported perioperative deaths of which the leading causes were sepsis, haemorrhage and anaesthesia complications. Conclusion: District hospitals play a significant role in sub-Saharan Africa, providing both emergency and elective surgeries. Most procedures are done under general or spinal anaesthesia, often administered by non-physician clinicians. Depending on countries, surgical care may be provided by medical officers, specialist surgeons and/or non-physician clinicians. Research on safety, quality and volume of surgical and anaesthesia care in this setting is scarce, and more attention to these questions is required.
Article
Understanding the provision of effective urological management in low-middle income countries (LMICs) is dependent upon the delivery of appropriate and effective care adapted to the needs, capability and resources of the host country. However, a deeper cognisance of the culture, the religious practices and the logistics of healthcare in that environment determines the ability to effectively 'twin', provide a long-term healthcare partnership. Patient beliefs can have profound effects on the understanding of the aetiology of illness, its relevance to their long-term health and the stigmatisation of their family's social status. Consequently, individuals may have a greater willingness to seek help from practitioners of traditional medicine, due to their availability and lower costs by comparison to those demanded by medicine from high-income countries (HICs). This can influence the treatment of many urological conditions as well as late-presenting states such as malignant ureteric obstruction. Social mores, such as cultural paternalism, can also influence many practices that are assumed by HICs to be part of normal healthcare provision, including the delivery of patient information and provision of an informed consent to treatment. Doctor's status, and dress, has greater importance in many countries in sub-Saharan Africa (sSA) than in the UK and the modes of greeting and addressing colleagues and patients can affect the fluency, and effectiveness, of clinical interactions. A local cultural, and religious, knowledge is, therefore, essential to optimise the assimilation of external help. Logistics are perhaps the most important factor that needs to be grasped to provide a sustainable healthcare environment. Limitations in resource allocation are a major factor in planning effective urological treatment in many countries in s-SA, whether the provision of trained personnel, basic infrastructure, a tenable workspace, equipment or drugs. This paper explores all of these factors, and how their recognition assists urologists in providing a twinning process.
Article
Background: Severe anesthetic-related critical incident (SARCI) monitoring is an essential component of safe, quality anesthetic care. Predominantly retrospective data from low- and middle-income countries (LMICs) report higher incidence but similar types of SARCI compared to high-income countries (HIC). The aim of our study was to describe the baseline incidence of SARCI in a middle-income country (MIC) and to identify associated risk for SARCI. We hypothesized a higher incidence but similar types of SARCI and risks compared to HICs. Methods: We performed a 14-day, prospective multicenter observational cohort study of pediatric patients (aged <16 years) undergoing surgery in government-funded hospitals in South Africa, a MIC, to determine perioperative outcomes. This analysis described the incidence and types of SARCI and associated perioperative cardiac arrests (POCAs). We used multivariable logistic regression analysis to identify risk factors independently associated with SARCI, including 7 a priori variables and additional candidate variables based on their univariable performance. Results: Two thousand and twenty-four patients were recruited from May 22 to August 22, 2017, at 43 hospitals. The mean age was 5.9 years (±standard deviation 4.2). A majority of patients during this 14-day period were American Society of Anesthesiologists (ASA) physical status I (66.4%) or presenting for minor surgery (54.9%). A specialist anesthesiologist managed 59% of cases. These patients were found to be significantly younger (P < .001) and had higher ASA physical status (P < .001). A total of 426 SARCI was documented in 322 of 2024 patients, an overall incidence of 15.9% (95% confidence interval [CI], 14.4-17.6). The most common event was respiratory (214 of 426; 50.2%) with an incidence of 8.5% (95% CI, 7.4-9.8). Six children (0.3%; 95% CI, 0.1-0.6) had a POCA, of whom 4 died in hospital. Risks independently associated with a SARCI were age (adjusted odds ratio [aOR] = 0.95; CI, 0.92-0.98; P = .004), increasing ASA physical status (aOR = 1.85, 1,74, and 2.73 for ASA II, ASA III, and ASA IV-V physical status, respectively), urgent/emergent surgery (aOR = 1.35, 95% CI, 1.02-1.78; P = .036), preoperative respiratory infection (aOR = 2.47, 95% CI, 1.64-3.73; P < .001), chronic respiratory comorbidity (aOR = 1.75, 95% CI, 1.10-2.79; P = .018), severity of surgery (intermediate surgery aOR = 1.84, 95% CI, 1.39-2.45; P < .001), and level of hospital (first-level hospitals aOR = 2.81, 95% CI, 1.60-4.93; P < .001). Conclusions: The incidence of SARCI in South Africa was 3 times greater than in HICs, and an associated POCA was 10 times more common. The risk factors associated with SARCI may assist with targeted interventions to improve safety and to triage children to the optimal level of care.
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Background: District-level hospitals (DLHs) can play an important role in the delivery of essential surgical services for rural populations in sub-Saharan Africa if adequately prepared and supported. This article describes the protocol for the evaluation of the Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) project which aims to strengthen the capacity in district-level hospitals (DLHs) in Malawi, Tanzania and Zambia to deliver safe, quality surgery. The intervention comprises a programme of quarterly supervisory visits to surgically active district-level hospitals by specialists from referral hospitals and the establishment of a mobile phone-based consultation network. The overall objective is to test and refine the model with a view to scaling up to national level. Methods: This mixed-methods controlled pilot trial will test the feasibility of the proposed supervision model in making quality-assured surgery available at DLHs. Firstly, the study will conduct a quantitative assessment of surgical service delivery at district facilities, looking at hospital preparedness, capacity and productivity, and how these are affected by the intervention. Secondly, the study will monitor changes in referral patterns from DLHs to a higher level of care as a result of the intervention. Data on utilisation of the mobile based-support network will also be collected. The analysis will compare changes over time and between intervention and control hospitals. The third element of the study will involve a qualitative assessment to obtain a better understanding of the functionality of DLH surgical systems and how these have been influenced by the intervention. It will also provide further information on feasibility, impact and sustainability of the supervision model. Discussion: We seek to test a model of district-level capacity building through regular supervision by specialists and mobile phone technology-supported consultations to make safe surgical services more accessible, equitable and sustainable for rural populations in the target countries. The results of this study will provide robust evidence to inform and guide local actors in the national scale-up of the supervision model. Lessons learned will be transferred to the wider region.
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Background Improvement in the surgical system requires intersectoral coordination. To achieve this, the development of National Surgical, Obstetric, and Anaesthesia Plans (NSOAPS) has been recommended. One of the first steps of NSOAP development is situational analysis. On the ground situational analyses can be resource intensive and often duplicative. In 2016, the Ministry of Health of Tanzania issued a directive for the creation of an NSOAP. This systematic review aimed to assess if a comprehensive situational analysis could be achieved with existing data. These data would be used for evidence-based priority setting for NSOAP development and streamline any additional data collection needed. Methods A systematic literature review of scientific literature, grey literature, and policy documents was performed as per PRISMA. Extraction was performed for all articles relating to the five NSOAPS domains: infrastructure, service delivery, workforce, information management, and financing. Results 1819 unique articles were generated. Full-text screening produced 135 eligible articles; 46 were relevant to surgical infrastructure, 53 to workforce, 81 to service delivery, 11 to finance, and 15 to information management. Rich qualitative and quantitative data were available for each domain. Conclusions Despite little systematic data collection around SOA, a thorough literature review provides significant evidence which often have a broader scope, longer timeline and better coverage than can be achieved through snapshot-stratified samples of directed on the ground assessments. Evidence from the review was used during stakeholder discussion to directly inform the NSOAP priorities in Tanzania.
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The International Standards for a Safe Practice of Anesthesia were developed on behalf of the World Federation of Societies of Anaesthesiologists (WFSA), a nonprofit organization representing anesthesiologists in 150 countries, and the World Health Organization (WHO). The recommendations have been approved by WHO and the membership of WFSA. These Standards are applicable to all anesthesia providers throughout the world. They are intended to provide guidance and assistance to anesthesia providers, their professional organizations, hospital and facility administrators, and governments for maintaining and improving the quality and safety of anesthesia care. The Standards cover professional aspects; facilities and equipment; medications and intravenous fluids; monitoring; and the conduct of anesthesia. HIGHLY RECOMMENDED standards, the functional equivalent of mandatory standards, include (amongst other things): the continuous presence of a trained and vigilant anesthesia provider; continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter; intermittent monitoring of blood pressure; confirmation of correct placement of an endotracheal tube (if used) by auscultation and carbon dioxide detection; the use of the WHO Safe Surgery Checklist; and a system for transfer of care at the end of an anesthetic. The International Standards represent minimum standards and the goal should always be to practice to the highest possible standards, preferably exceeding the standards outlined in this document.
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Background Despite recent advances in surgery and anaesthesia which significantly improve safety, many health facilities in low-and middle-income countries (LMICs) remain chronically under-resourced with inability to cope effectively with serious obstetric complications (Knight et al., PLoS One 8:e63846, 2013). As a result many of these countries still have unacceptably high maternal and neonatal mortality rates. Recent data at the national referral hospitals in East Africa reported that none of the national referral hospitals met the World Federation of Societies of Anesthesiologists (WFSA) international standards required to provide safe obstetric anaesthesia (Epiu I: Challenges of Anesthesia in Low-and Middle-Income Countries. WFSA; 2014 http://wfsa.newsweaver.com/Newsletter/p8c8ta4ri7a1wsacct9y3u?a=2&p=47730565&t=27996496). In spite of this evidence, factors contributing to maternal mortality related to anaesthesia in LMICs and the magnitude of these issues have not been comprehensively studied. We therefore set out to assess regional referral, district, private for profit and private not-for profit hospitals in Uganda. Methods We conducted a cross-sectional survey at 64 government and private hospitals in Uganda using pre-set questionnaires to the anaesthetists and hospital directors. Access to the minimum requirements for safe obstetric anaesthesia according to WFSA guidelines were also checked using a checklist for operating and recovery rooms. Results Response rate was 100% following personal interviews of anaesthetists, and hospital directors. Only 3 of the 64 (5%) of the hospitals had all requirements available to meet the WFSA International guidelines for safe anaesthesia. Additionally, 54/64 (84%) did not have a trained physician anaesthetist and 5/64 (8%) had no trained providers for anaesthesia at all. Frequent shortages of drugs were reported for regional/neuroaxial anaesthesia, and other essential drugs were often lacking such as antacids and antihypertensives. We noted that many of the anaesthesia machines present were obsolete models without functional safety alarms and/or mechanical ventilators. Continuous ECG was only available in 3/64 (5%) of hospitals. Conclusion We conclude that there is a significant lack of essential equipment for the delivery of safe anaesthesia across this region. This is compounded by the shortage of trained providers and inadequate supervision. It is therefore essential to strengthen anaesthesia services by addressing these specific deficiencies. This will include improved training of associate clinicians, training more physician anaesthetists and providing the basic equipment required to provide safe and effective care. These services are key components of comprehensive emergency obstetric care and anaesthetists are crucial in managing critically ill mothers and ensuring good surgical outcomes.
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Objectives: To examine age and gender distribution for the most common types of surgery in Malawi and Zambia. Methods: Data were collected from major operating theatres in 8 district hospitals in Malawi and 9 in Zambia. Raw data on surgical procedures were coded by specialist surgeons for frequency analyses. Results: In Malawi, female surgical patients had a mean age of 25 years, with 91% aged 16-40 years. Females accounted for 85%, and obstetric cases for 75%, of all surgical patients. In Zambia, female surgical patients had a mean age of 26, with 75% aged 16-40. They accounted for 55% of all cases, 34% being obstetric. Male surgical patients in Malawi were on average older (33 years) than in Zambia (23 years). General surgical cases in men and women, respectively, had a median age of 42 and 32 in Malawi and 26 and 30 in Zambia. The median age of trauma patients was 12 in males and 10 in females in both countries. Children aged 0-15 years accounted for 64-65% of all trauma cases in Malawi and 57-58% in Zambia, with peak incidences in 6-10 year-olds. Conclusions: Women of reproductive (16-45 years) mainly undergoing caesarean sections and children aged 0-15 years who accounted for two-thirds of trauma cases are the main patient populations undergoing surgery at district hospitals in Zambia and Malawi. Verification and analysis of routine hospital data, across 10-30% of districts countrywide, demonstrated the need to prioritise quality assurance in surgery and anaesthesia, and preventive interventions in children. This article is protected by copyright. All rights reserved.
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Background Most sub-Saharan African countries struggle to make safe surgery accessible to rural populations due to a shortage of qualified surgeons and the unlikelihood of retaining them in district hospitals. In 2002, Zambia introduced a new cadre of non-physician clinicians (NPCs), medical licentiates (MLs), trained initially to the level of a higher diploma and from 2013 up to a BSc degree. MLs have advanced clinical skills, including training in elective and emergency surgery, designed as a sustainable response to the surgical needs of rural populations. Methods This qualitative study aimed to describe the role, contributions and challenges surgically active MLs have experienced. Based on 43 interviewees, it includes the perspective of MLs, their district hospital colleagues—medical officers (MOs), nurses and managers; and surgeon-supervisors and national stakeholders. Results In Zambia, MLs play a crucial role in delivering surgical services at the district level, providing emergency surgery and often increasing the range of elective surgical cases that would otherwise not be available for rural dwellers. They work hand in hand with MOs, often giving them informal surgical training and reducing the need for hospitals to refer surgical cases. However, MLs often face professional recognition problems and tensions around relationships with MOs that impact their ability to utilise their surgical skills. Conclusions The paper provides new evidence concerning the benefits of ‘task shifting’ and identifies challenges that need to be addressed if MLs are to be a sustainable response to the surgical needs of rural populations in Zambia. Policy lessons for other countries in the region that also use NPCs to deliver essential surgery include the need for career paths and opportunities, professional recognition, and suitable employment options for this important cadre of healthcare professionals.
Article
This is the protocol for a review and there is no abstract. The objectives are as follows: We wish to assess the safety and effectiveness of different anaesthetic providers for patients undergoing surgical procedures under general, regional or epidural anaesthetic. A subsidiary question is to determine whether there are types of procedures or patient groups for which a non-physician anaesthetist is not appropriate. We will consider results from studies within different regions (US, UK, other developed countries and developing countries) initially and then assess whether results are consistent across regions before combining results.
Article
Objective: Capacity assessments serve as surrogates for surgical output in low- and middle-income countries where detailed registers do not exist. The relationship between surgical capacity and output was evaluated in Ghana to determine whether a more critical interpretation of capacity assessment data is needed on which to base health systems strengthening initiatives. Methods: A standardized surgical capacity assessment was performed at 37 hospitals nationwide using WHO guidelines; availability of 25 essential resources and capabilities was used to create a composite capacity score that ranged from 0 (no availability of essential resources) to 75 (constant availability) for each hospital. Data regarding the number of essential operations performed over 1 year, surgical specialties available, hospital beds, and functional operating rooms were also collected. The relationship between capacity and output was explored. Results: The median surgical capacity score was 37 [interquartile range (IQR) 29-48; range 20-56]. The median number of essential operations per year was 1480 (IQR 736-1932) at first-level hospitals; 1545 operations (IQR 984-2452) at referral hospitals; and 11,757 operations (IQR 3769-21,256) at tertiary hospitals. Surgical capacity and output were not correlated (p > 0.05). Conclusions: Contrary to current understanding, surgical capacity assessments may not accurately reflect surgical output. To improve the validity of surgical capacity assessments and facilitate maximal use of available resources, other factors that influence output should also be considered, including demand-side factors; supply-side factors and process elements; and health administration and management factors.