The Lancet Commission on Global Surgery highlights the disparities that currently exist in access to surgical and anesthesia care in low-and middle-income countries (LMICs). It is estimated that nine in 10 people in LMICs are unable to obtain safe surgical care when needed (Lancet 2015;386:569-624). One of the major deficiencies is the lack of anesthesia providers. The World Federation of Societies of Anaesthesiologists (WFSA) workforce map demonstrates how skewed this gap is worldwide. For example, the density of physician anesthesia providers (PAPs) in high-income countries is 17.96 per 100,000, which is in stark contrast to the density of PAPs in low-income countries, which is only 0.19 per 100,000 (Anesth Analg 2017;125:98-90). This disparity exists for both PAPs and non-physician anesthesia providers (NPAPs). In order to provide safe surgical care worldwide, a scale-up of both PAPs and NPAPs is desperately needed.
The solution seems simple: more anesthesia providers need to be trained in LMICs. However, the realities in LMIC settings make this very challenging. First of all, who will train these new providers? If PAP density is so low, then the availability of teachers to train new PAPs is almost non-existent. This then begs the question: what is the experience of anesthesia trainees in LMICs? Is it different from the experience of trainees in high-income countries (HICs)? Is it adequate to ensure quality training of future anesthesiologists and anesthesia educators and leaders in these countries? By understanding the answers to these questions, providers in HICs can recognize how they can best provide support to their colleagues in LMICs.
Comparison of anesthesia training programs in HICs vs. LMICs
Universally, anesthesia residency programs aim to train future anesthesiologists in the provision of safe, high-quality anesthesia care. However, the environments in which this occurs can vary greatly, and the knowledge, skills, and attitudes needed are not universal. Anesthesia residency programs in the United States are all standardized in terms of duration, competencies, and examinations, and monitored for quality by the Accreditation Council for Graduate Medical Education. Thus, a degree of uniformity is ensured across training programs. Trainees are paid a stipend that, while varying between programs, is generally adequate to ensure a comfortable living situation. The experience in the U.S. is just one example of a training paradigm in a HIC. Other HICs have their own models.
In stark contrast, programs in LMICs often lack standardization or a locally developed curriculum. Out of necessity, curricula are often imported or adapted from HICs and may not be relevant or functional in the local context. In addition, there is often a gap between what is written in the curriculum document and its implementation due to a lack of trainers, equipment, supplies, and a strong academic department with subspecialties. Out of necessity, senior residents in LMICs work with insufficient supervision due to the limited number of PAPs. Patients often present late with severe illness, and essential equipment, supplies, and drugs are commonly out of stock (Table 1). Protocols, guidelines, and standards for safe care are often lacking, and those that do exist may have been formulated in HICs and often do not fit the setting.
Challenges and proposed solutions
To remedy the situation, advocates have called on LMICs to establish new anesthesia training programs and to strengthen existing programs (Best Pract Res Clin Anaesthesiol 2012;26:17-21). To do this effectively, it is imperative that we understand the challenges faced by all stakeholders so we can work collaboratively to target feasible solutions.
Trainees lack sufficient supervision, exposure to subspecialties, and adequate financial support. This situation often leads to substandard clinical performance, burnout, insufficient recruitment, and working extra-hours in private clinics to supplement their monthly income, which can be as low as $500 (Anesth Analg 2017;125:2164). HICs can support trainees by helping to identify training gaps and working with local training organizations to address these gaps. For example, develop new local clinical rotations that might not currently exist (i.e., regional anesthesia). Other suggestions include providing supervision for research projects as well as mentorship and guidance for career development, including opportunities for international rotations.
Faculty work under challenging conditions due to low salary, lack of administrative and research support, insufficient equipment and supplies, lack of research funding, and limited opportunities for career growth. They often work at multiple clinics to supplement their salary, which can be as low as $700 per month. Consequently, there is a lack of time for teaching or research, low quality of care, inadequate career growth, poor recruitment and retention, burnout, and migration. HICs can support local faculty by facilitating opportunities for faculty career growth, supporting local research and education capacity by creating centers of excellence, and encouraging local investment by international medical equipment companies.
Anesthesia departments often have limited financial capacity and an insufficient number of faculty, leading to a dearth of equipment and supplies, subspecialties, standard practices, quality care, and quality education for trainees and faculty. Ultimately, the ministry of health, teaching hospitals, and universities should ensure that anesthesia departments have adequate financial and academic capacity. HIC academic institutions can partner with anesthesia departments in LMICs to share knowledge and experiences from working in a variety of resource settings. This bidirectional exchange can help to bridge the knowledge gap seen between high- and low-resource settings.
Anesthesia societies have limited financial capacity due to a small number of members and lack enough authority to influence policymakers. They are often invited by the ministry of health and other partners to provide their input; however, they lack an effective strategy and agenda for better quality of anesthesia delivery. For example, only a few LMICs have their own standards of anesthesia practice, while others rely on the WHO-WFSA Standards (Anesth Analg 2018;126:2047-55). Societies need to be mentored by more established societies, such as ASA and others in their region, to guide them on how best to organize themselves as a society as well as how best to influence policymakers to ensure better quality of anesthesia care and training.
Ministries of health in LMICs may offer universal health coverage, but practically there is often a small health care budget with insufficient funding for the many competing priorities. This results in limited resources for surgical and anesthesia care and training that are not seen as a priority (Anesth Analg 2018;126:2047-55). Advocacy efforts at the ministry of health level to prioritize safe surgery and anesthesia are crucial, including ensuring training programs meet national and international standards, and providing adequate stipends and/or subsidies to trainees and faculty. The Program in Global Surgery and Social Change (“PGSSC”) is an excellent example of an HIC program partnering with local providers to advocate for these changes by developing and implementing National Surgical, Obstetric, Anesthesia and Plans in multiple LMICs (Global Health 2020;16:1).
Examples of ongoing efforts
Collaborative initiatives that include both local and international partners at all levels are important for efforts to expand and improve anesthesia training opportunities in LMICs. At the ministry of health level, they can work with local partners to advocate for more funding for anesthesia training programs as in-country advocates often lack the time, commitment, and financial resources to do so (Best Pract Res Clin Anaesthesiol 2012;26:17-21). One example of a successful model for this type of advocacy work is the Human Resources for Health Program in Rwanda funded by the U.S. through the President's Emergency Plan for AIDS Relief (PEPFAR) (asamonitor.pub/37p95eN).
Anesthesia societies are also providing support, such as the ASA Committee on Global Humanitarian Outreach with its overseas teaching program and the Society for Education in Anesthesia/Health Volunteers Overseas program. Both organizations support developing programs at the department and trainee level by providing volunteer teachers who supplement the local faculty as well as serve as mentors for both faculty and trainees. Other organizations such as the WFSA work at multiple levels. It provides free, online educational resources like the Anesthesia Tutorial of the Week, which supports local curricula, and it organizes a fellowship program that includes 50 programs in various subspecialty areas. The WFSA has also partnered with institutions worldwide to bring short educational courses to LMICs, such as Inspire, SAFE Paediatrics, SAFE Obstetrics, and VAST (asamonitor.pub/37p95eN). The Canadian Anesthesiologists' Society International Education Foundation (CASIEF) has also been instrumental in the past 15 years by supporting the Rwandan residency training program and working with its local partners to develop a comprehensive and locally relevant curriculum, including a strong simulation program (J Grad Med Educ 2019;11:20-1). It is collaborative programs such as these that can help to strengthen local capacity.
Academic partnerships also play an important role in this effort. UCSF's Department of Anesthesia Division of Global Health Equity and their long-term partnership with Makerere University in Uganda has provided mentorship for anesthesia residents and collaborations on research and education projects. In addition, Vanderbilt University Medical Center (VUMC) Department of Anesthesiology has directly partnered with residency programs in Northern Ethiopia (Mekelle University and Bahir Dar University), Ethiopia (MUHAS, CUHAS, KCMC), and are currently developing a residency program in Kenya (Kijabe Hospital). Their efforts include assisting with mentoring, simulation education, data collection, foundation building, and module development with the anesthesiology leaders in these countries in a bidirectional partnership.
In order to address the vast unmet need for surgical care in LMICs, more PAPs must be trained and added to the workforce. Individual countries will need to scale up their training programs, while each of the multiple players involved in the process needs to be supported, strengthened, and reinforced. Furthermore, physicians and institutions from HICs have a responsibility to work with our colleagues in LMICs to advocate for and assist in the strengthening of their anesthesia training programs.
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