Global health and anaesthesia: An exciting time

Five billion of the world’s seven billion people do not have access to safe anaesthesia and surgical care when needed, ¹ and this is in part due to major deficiencies in the global anaesthesia workforce. ² The paper by Burton et al. in this issue highlights many issues relating to the development of the anaesthesia workforce in a low-resource setting and recent rapid developments in anaesthesia in the global health field. ³ The authors have used a model of advocacy, collaboration, partnership and perseverance to support the development of a training programme at Jimma University Medical Centre in Ethiopia. This article follows well from an earlier article in this journal on critical care delivery at Jimma by the same authors. ⁴

Recently, there has been a phenomenal increase in anaesthesia initiatives aimed at improving safety for surgical patients worldwide. At the same time, there has been increasing understanding at the World Health Organization (WHO) and government levels of the impact of surgical disease, estimated to account for 30% of the global burden of disease. ⁵ It is timely to summarise the more recent developments and the roles that anaesthetists and anaesthesiologists have played in the last decade in promoting safe anaesthesia globally.

WHO Surgical Safety Checklist and Lifebox

It is now more than 10 years since the WHO Surgical Safety Checklist was launched, and the Checklist should by now be a routine part of daily practice in every operating room (OR). ⁶ The Checklist is only likely to improve patient outcomes if it is used with the engaged participation of the entire OR team. Unfortunately, use of the Checklist varies widely. Initiatives to improve use of the Checklist can be effective, with a US study in 2015 showing a 20% reduction in mortality in hospitals that improved their adherence to the Checklist. ⁷

It is, however, also necessary to have the basic equipment to provide safe anaesthesia and surgery, notably pulse oximetry. The realisation that many ORs around the world were without this essential monitor ⁸ prompted the inclusion of pulse oximetry in the ‘sign in’ section of the first edition of the Checklist. In 2004, at the World Congress of Anaesthesiologists in Paris, the World Federation of Societies of Anaesthesiologists (WFSA) initiated the Global Oximetry Project to address this problem. This led to the foundation of Lifebox in 2011, and this organisation has now distributed more than 20,000 high-quality, robust and affordable Lifebox oximeters to anaesthesia providers in more than 100 countries. ⁹ Lifebox has extended its work to include other key elements of surgical safety, and is now implementing Clean Cut, a checklist-based surgical infection prevention programme that has been trialled in Ethiopia. ¹⁰

International Standards for a Safe Practice of Anaesthesia

In June 2018, the third edition of the International Standards for a Safe Practice of Anaesthesia, endorsed by the WHO and the WFSA, was published. ¹¹ The endorsement by the WHO of standards of care in anaesthesia sends a powerful signal to both funders and providers about the essential role of anaesthesia in surgical care and has important medico-political implications in every country. The document provides guidance on professional aspects, facilities and equipment, medications and intravenous fluids, monitoring, and conduct of anaesthesia. The WHO does not use the term ‘mandatory’ and so the International Standards utilise the WHO’s terminology, where ‘highly recommended’ is the functional equivalent of mandatory. For example, the Standards state that if an endotracheal tube is used, confirmation of correct placement by carbon dioxide detection (i.e. non-waveform capnography or colourimetry) is highly recommended. The Standards also state that continuous waveform capnography will be highly recommended when appropriately robust and suitably priced devices are available. Capnography is arguably as essential for safe anaesthesia as oximetry, but to date, the monitors have been both more expensive and less robust. ¹² A recent project in Malawi has demonstrated that introduction of capnography is feasible in at least some low-resource environments, ¹³ and the Standards add ‘Equipment manufacturers are encouraged to urgently address this deficiency’.

WFSA

The WFSA vision is ‘universal access to safe anaesthesia’. ¹⁴ It has 135 member national societies and now represents anaesthesiologists in 150 countries, covering 95% of anaesthesiologists worldwide. It has an official liaison role with the WHO and is increasingly becoming the ‘go-to’ organisation on global anaesthesia issues. In 2015, the World Health Assembly unanimously passed Resolution 68.15 calling on all WHO member states to strengthen emergency and essential surgical care and anaesthesia as a component of universal health coverage. This was a landmark resolution for our specialty because it placed anaesthesia and surgery on the global health agenda and highlighted the role of safe surgical care in achieving the United Nations’ 3rd Sustainable Development Goal of ‘good health and well-being’ for all.

During the last four years, the WFSA has played an increasingly active advocacy role at government and WHO levels. In May 2018, at the 71st World Health Assembly, the WFSA reminded governments of their pledge to scale up surgical and anaesthesia capacity to address the needs of the five billion people worldwide who do not have access to essential safe surgery and anaesthesia. ¹⁵ The WFSA also made statements on the anaesthesia workforce, pain management, palliative care and the need to ensure the continuing availability of essential anaesthesia drugs such as ketamine. Ongoing advocacy from the WFSA and other organisations is essential; it has taken a long time for anaesthesia and surgery to get on the global health agenda, and we need to work hard to ensure that the need for safe emergency and essential anaesthesia and surgical care is not ignored.

Anaesthesia workforce and National Surgical, Obstetric and Anaesthesia Plans

The WFSA Global Anaesthesia Workforce Survey published in 2017 ² revealed massive disparities in the anaesthesia workforce worldwide. Many countries in sub-Saharan Africa and parts of Asia have physician anaesthetist/anaesthesiologist densities of less than one per 100,000 population compared to a density of around 20 per 100,000 in Australia and New Zealand. In many countries, it will be necessary to train non-physician anaesthesia providers (e.g. nurse anaesthetists, clinical officers) to address workforce deficits. A shared care model of patient care may be appropriate in many environments, and collaboration with other stakeholders, for example the International Federation of Nurse Anesthetists, ¹⁶ is essential. ¹⁷ The WFSA considers anaesthesia to be a medical specialty and advocates strongly for anaesthesiologist leadership of workforce development and anaesthesiologist supervision of anaesthesia delivery. ¹⁸

Whilst there is increasing recognition that anaesthesia and surgery are essential elements of population health, many current national health plans do not mention surgical care planning, let alone anaesthesia planning. ¹⁹ Improvement in the delivery of surgery, anaesthesia and obstetric care are synergistically essential to achieve the UN’s Sustainable Development Goals, and this has led to several countries developing National Surgical, Obstetric and Anaesthesia Plans (NSOAPs). ²⁰ Ethiopia was the first country to develop such a plan in 2015, and NSOAPs have also been developed in Zambia, Senegal, Tanzania, Rwanda ²¹ and Pakistan. In our region, one is being developed for Papua New Guinea. As a result of Ethiopia’s NSOAP planning, the surgical and anaesthetic workforce was upskilled, 80 operating theatres were renovated, new oxygen plants were obtained, supply-chain management was improved and biomedical engineers were trained. ²² Children constitute up to 40%–50% of the populations of low- to middle-income countries (LMICs). Specific recommendations and guidelines have been made by the Global Initiative for Children in Surgery ²³ relating to requirements for safe paediatric surgery and anaesthesia at all levels of healthcare.^24,25

Research and data

There is a major deficit in both the quantity and quality of research on global anaesthesia and surgery. The 2018 and 2019 SAFE-T Summits in London, held under the auspices of the WFSA and the Anaesthesia Section of the Royal Society of Medicine, provided a forum for focusing on many aspects of this problem, including measurement, and the impact of inequity in global health. More work is needed to establish the universal collection of well-recognised metrics such as perioperative mortality rate ²⁶ and disability-adjusted life years.^27,28 Many major medical and anaesthesia journals now have global health sections to publicise this work, and more research on anaesthesia and surgery in LMICs is beginning to appear, and the paper in this edition of Anaesthesia and Intensive Care is an example. Partnerships between authors from high-income countries and LMICs are increasingly common, and occasionally all authors are from an LMIC. ²⁹ The WFSA now offers several research fellowships to foster the development of research in resource-poor countries. ³⁰

Conclusion

Lack of access to safe anaesthesia and surgery is a major global healthcare issue. Surgical disease accounts for four times as many deaths worldwide every year as the ‘big three’ of HIV-AIDS, tuberculosis and malaria. The data are compelling: recent modelling shows postoperative deaths to be the third most common cause of death in the world, with significant disparities existing between LMICs and high-income countries. ³¹

In our region, representatives of the Australian Society of Anaesthetists, the New Zealand Society of Anaesthetists, the Australian and New Zealand College of Anaesthetists and other organisations such as the Society of Paediatric Anaesthetists of New Zealand and Australia have been playing their part in helping to define global anaesthesia and surgery issues, raise awareness and develop solutions. Australians and New Zealanders are involved in the WFSA, Lifebox and many other international organisations, and together we are making progress.

As anaesthesiologists, we have much to offer in the field of patient safety, and we also have much to offer in the field of global health. Now is an exciting time for our specialty as we continue to work towards universal access to safe anaesthesia.