The numbers of trained anesthesia providers are known to be deficient in LMICs. However, no single source of information exists to determine the numbers of practicing anesthesia providers per capita or the numbers of providers being trained in each of these countries. While the WHO tracks the number of physicians per country information about specific numbers of specialized providers are often only known by national ministries of health [20
]. Where physician numbers are very low, assumptions can be made about the even fewer numbers of trained specialists. Therefore, in many LMICs there are often only a few or no anesthesia providers for millions of people.
Traditionally, minimal resources have been allocated for diseases or conditions for which surgical intervention is necessary in LMICs [6
]. The absence of these resources in turn has limited the workforce component, surgical infrastructure and capacity. Public health indicators collected by the WHO clearly document that population health indicators are directly related to the state of the healthcare workforce [22
]. Countries with low physician rates, limited hospital beds, and severely constricted financial resources (percentage of GNI allocated for health) have predictably low average life expectancy, high infant mortality rates, and high under five mortality rates (Table ) Further, countries with limited hospital and healthcare worker resources also have high maternal mortality rates (Table ).
Public health indicators for the United States (USA) and for low and middle income countries (LMICs), by year reported
Public health indicators of medical care providers and hospital beds in the USA and LMICs, by year reported
At present in Uganda there are approximately 14 physician–anesthesiologists for a population of more than 30 million people; 12 of these providers work in government hospitals [6
]. Training positions in the postgraduate programs are unfilled yearly because of the difficulty in recruiting and funding trainees. There are only 10 anesthesia residents in training positions out of a total of 47 possible positions nationwide. The annual cost of training for one surgeon or anesthesiologist is approximately $3,500. Half of this is tuition-fees alone, as the residents have to pay the university to allow them to enter specialist training, which is considered a postgraduate degree. This cost is nearly 10 times the estimated mean annual household income in Uganda.
The problem is similar elsewhere in sub-Saharan Africa. In neighboring Kenya (population 32 million) only 13 of a total of 120 anesthesiologists work in public hospitals. The remainder are in private practice in the capital, Nairobi, with very few serving rural areas. There are a few hundred surgeons at Kenyatta National Hospital, the National referral center and teaching hospital, yet there are only nine anesthesiologists. The problem is similar in rural Kenya, with just 1 anesthesiologist to 13 surgeons [23
To put this in perspective, compared to the ratio of approximately one physician anesthesia provider per 2 million population in Uganda, in the USA the ratio is an estimated 1 anesthetic provider per 4,000 population, with the US workforce of 70,000 anesthesia providers almost equally divided between physician anesthetists and nurse anesthetists (CRNAs). Between them they perform over 40 million surgeries each year on a population of approximately 300 million people [24
]. The UK has one physician–anaesthetist for every patient undergoing surgery—around 12,000 anesthetists for a population of 64 million (approximately 1:5,000) [25
]. It is clear that globally the numbers are not as favorable.
In an attempt to alleviate the workforce problem, several low and middle-income countries including Uganda and Kenya have engaged in a program of utilizing of trained “anesthetic officers” and sometimes “nurse anesthetists” (with up to 300 anesthetic officers practicing in each of these countries). Equally successful programs have been implemented worldwide, most notably in Malawi and Mozambique, Nepal, and Iran [13
]. These officers undertake a limited amount of training (usually 18 months after high school), which qualifies them to perform basic anesthesia and perioperative management. The aim is to alleviate workforce deficiencies due to a lack of physician providers. Anesthetic officers represent a much lower level of training than nurse anesthetists in Europe or CRNAs in the USA but are most likely a key part of solving the anesthesia workforce crisis. In spite of some successes, all are faced with problems related to initial training, maintenance of skills, and oversight. This is not helped by an estimated need for at least 1,000 more anesthetic personnel just to work within the existing infrastructure in each country in sub-Saharan Africa alone [23
While successful in many areas, control of anesthetic officer training programs in some countries has been taken away from mainstream academic or physician-led anesthesia training and oversight. As a result the quality and service provided by anesthetic officers is variable. This variation in quality has proven significantly detrimental to the perception of anesthesia providers by other physicians and patients and has affected recruitment and retention of physician-anesthesiologists. The lack of physician providers in LMICs also limits professional respect, and many report that physician anesthesia providers do not command the same status as other physicians. This negative perception of the profession is also compounded by a significantly high mortality rate associated with anesthesia (as much as 1 death per 144 cases), which is very often ascribed to lack of training and oversight of the anesthesia provider combined with infrastructure and capacity issues [11
Even with evidence of the depth and breadth of the deficiencies in workforce and capacity, solutions are limited, as most LMICs do not have the monetary resources available to recruit, train, and maintain the physician workforce in a sustainable manner. Even where training is available, the migration of healthcare workers to resource-rich environments is a longstanding and ongoing obstacle to sustainability [2
]. Anesthesiologists and other perioperative healthcare workers in low and middle-income countries are very poorly paid. In sub-Saharan African countries, engineers are paid more than doctors, and nurses command about 50% of the salary of teachers. A recent study suggested that the solution was “capital intensive and time consuming: even if the funds materialized, about 600 additional medical and nursing schools and more than two decades would be needed to close the gap” [3
Poor working conditions and limited professional recognition are also a barrier to recruitment and retention in LMICs. This reality is amplified by deteriorating infrastructure and scarce medical supplies, leading to a lack of productivity. Such factors easily dampen morale among health workers. Studies from Tanzania indicated that, in some settings, health workers spend only 50–60% of their time on productive activities. The rest might be spent trying to “fix the system” or to find a part for something that is broken or waiting for it to be repaired or replaced or merely being unable to work due to a lack of other workers (e.g., surgeons but no anesthesiologists or vice versa). Bureaucracy is also reported as a challenge, and it has been reported that some district medical officers in Tanzania spent more than 25 days during any 3-month period writing reports [12
A fundamental lack of infrastructure compounds the workforce issues. A recent study looking at capacity and equipment for the safe delivery of anesthesia in Uganda indicated that only 23% of hospitals reported having a safe environment for adults, only 13% for children, and less than 6% are safe for cesarean section.
Many hospitals also rely on donated equipment rather than on a defined budget. Without sustainable biomedical support not only for existing equipment but also for equipment that is donated, this is neither a reliable nor a sustainable solution. If donations are part of an infrastructure solution, they must meet a specified unmet need in the host country. For this purpose, the WHO produced a comprehensive document on this subject advising donors about appropriate medical donations [31
]. Some recent improvements in anesthesia practices in LMICs, with specific advances in patient safety and improved outcomes offer an example of the impact of anesthesia on morbidity and mortality rates. Anesthesia education and training, research, applied technology, and subsequent changes in the practice of monitoring patients has lead the way in patient safety and improved surgical outcomes over the last 50 years [11
Future programs aimed at addressing the critical shortage of anesthesia providers must address the need for infrastructure by combining capacity building with programs to expand the workforce. A sound physician–anesthesiologist base is an essential requirement for appropriate oversight, training, and recruitment of future physician–specialists, paramedical technicians, and assistants [3
]. To be sustainable, any solution must include appropriate incremental changes to existing infrastructure rather than attempt to impose ideals perhaps originally designed for a more “infrastructure-rich” environment. The utilization and appropriate support of anesthetic officers or similarly trained nurses is a key part of this expansion process. Attracting more medical students and recent medical graduates to apply for specialist training positions also needs addressing [34
]. Incentives are important but do not need to be monetary. Recent study in Uganda has shown that medical providers, trainees, and allied healthcare workers place a very high value on a collaborative effort aimed at education and improving the workplace and learning environment [6
]. These simple interventions have been shown to help recruit as well as retain specialist trainees.