Anesthesia Workforce Numbers: Only Part of the Story

See Article, pages 4 and 15 Data is like garbage. You’d better know what you are going to do with it before you collect it. ——Mark Twain In 2017, the World Federation of Societies of Anaesthesiologists (WFSA) published its report on the global anesthesia workforce.1 This was the first attempt to delineate a comprehensive description of the numbers of anesthesiologists globally on a country-by-country basis. Some additional data were captured on nonphysician anesthesia providers (NPAPs) but these data were incomplete. After the recommendation of the Lancet Commission on Global Surgery (LCoGS) that there should be a combined total of 20 surgeons, anesthesiologists, and obstetricians per 100,000 population to provide adequate access to care for surgical patients,2 the WFSA determined that there should be a minimum of 5 anesthesiologists per 100,000 population (physician anesthesia provider [PAP] density).1 Data were obtained from 153 of 197 countries representing 97.5% of the world’s population. Seventy-seven countries had a PAP density of <5 per 100,000. NPAPs play an important role in many parts of the world, but even when PAPs and NPAPS were added together, there still remained a total anesthesia provider density of <5/100,000 in almost 50% of the countries reporting. There were marked differences between World Health Organization (WHO) regions, with African (AFRO) and South East Asian (SEAR) regions showing the lowest densities of providers. In this issue of Anesthesia & Analgesia, we have presented a follow-up on the initial WFSA survey: The Global Anesthesia Workforce Survey: Updates and Trends in the Anesthesia Workforce, written by Dr Tyler Law and an international collaboration of colleagues including representation from the NPAP community.3 It is clear that this survey set out to be more comprehensive than the original. So, we need to ask––has any progress been made over the past 5 years in increasing the numbers of anesthesia providers, both physician and nonphysician, so that the LCoGS goals set for 2030 can be met? THE NUMBERS In the current survey, data were obtained from 173 of 197 countries a slight increase over last time. PAP density increased to 7/100,000 from 6.09. NPAP density was 3.1/100,000 with no available comparison due to incomplete data in the previous survey. Seventy-five countries (43%) had a PAP density of <5 and 64 countries (37%) had a total provider density of <5. As expected, huge regional differences continued to exist between high- and low-income countries (LICs) as defined by the World Bank. High-income countries (HICs) had a PAP density of 16 compared to 1.2 for LICs, and an NPAP density of 8 compared to 2 for LICs. Looking at WHO regions, the AFRO and SEAR regions continued to be poorly served, with AFRO having the lowest PAP density of 0.6 and SEAR having the fewest NPAPs at 0.4/100,000. While the aggregate data are important for global advocacy, for explaining the magnitude of the problem, and for demonstrating the disparity that exists between HICs and LICs, it does not tell the entire story nor does it offer insights into how to address these deficiencies. Law et al3 illustrate the workforce data by WHO region. However, these regions are merely for geographical convenience and are often economically diverse. One has to look more closely at the individual countries within them, to appreciate the complexity of the situation (Figure 2, Supplemental Table 2, Supplemental Figures 2.1–2.6). If the WFSA follows its previous practice, it will incorporate all of this data onto interactive maps on its website (https://wfsahq.org), where at the click of button, information on each country’s numbers will be available. The workforce model is often not consistent within a region but can vary widely from country to country. There are some countries with a multitude of cadres providing anesthesia (specialist anesthesiologists, nonspecialist physicians, nurse anesthetists, and other nonphysician providers) and others with only physicians being allowed to do so. This has important implications for the aggregate reporting and target interventions. For example, the SEAR region is reported to have the fewest NPAPs at 0.4/100,000. However, only 4 of the 10 countries include NPAPS as part of their anesthesia workforce. The workforce survey provides very useful information and gathering it on a regular basis is essential. However the information received is not always easy to interpret. For example, recent data derived from the National Audit Project 7 (NAP7) in the United Kingdom suggest that, while there are more anesthesiologists, fewer operations are being performed.4 Why would that be? Pandit et al4 posit that it may in part be related to the coronavirus disease-2019 (COVID-19) pandemic but is much more likely due to other factors such as increasing complexity of cases (patients were older, more obese, and sicker); thus, cases were taking longer to do. In addition, other factors were also identified such as the demand for anesthesiologists to work outside the operating room, for example, in critical care units, in preadmission clinics and on pain services. Anesthesiologists were providing essential services for patients but perhaps not being counted when anesthesia human resources were tallied. Simkin et al5 in their recently published article on the anesthesia workforce in Canada, which incidentally ranks quite low on the PAP density scale (9.7),3 remark on how essential it is to not just count people but to know what they actually do. In their study, they show that while the Canadian anesthesia workforce grew 1.8-fold between 1996 and 2018, the number of nerve block services, as a surrogate for anesthesia activity, increased 7-fold and the number of payments for other anesthesia services increased 5-fold. Thus while the workforce study increases awareness of the huge shortages in human resources that exist in anesthesia, especially in low- and middle-income countries (LMICs), it also raises the question of what services we are expected to provide that must also be taken into account. Do those in a position to effect change understand the context and can they and will they respond appropriately? What other factors are important in our efforts to improve access to safe anesthesia and surgery around the world? THE HARD FACTS The African Surgical Outcomes Study (ASOS)6 told us that, in Africa, surgical patients were twice as likely to die after surgery compared to the global average for postoperative deaths. In-hospital surgical mortality for children in South Africa, a middle-income country, is 10 times that of HICs.7 In Kenya, Newton et al8 found a pediatric peri-operative mortality rate that is 100 times higher than that of HICs. Clearly anesthesia is not the sole cause of these high mortality rates but it certainly has an important role to play. Gajewski et al,9 when attempting to study barriers to improving surgery in Malawi, Zambia and Tanzania, discovered that the major barriers were in fact anesthesia related. They recommended that significant studies be undertaken “to address the critical neglect of anesthesia that is essential to providing surgical responses to the needs of rural populations in sub-Saharan Africa.” Obstetrics is not exempt from these problems either. Sobhy et al10 performed a systematic review and meta-analysis searching for risks of maternal death from anesthesia. They found that anesthesia accounted for 2.8% of all maternal deaths and 13.8% of deaths after Cesarean section. Lack of human resources in anesthesia certainly restricts access to surgery but lack of well-trained, properly equipped, and resourced anesthesia providers restricts access to safe anesthesia and surgery. Both are important and need to be addressed. The essential role of anesthesia is not well understood by those who make decisions on health care, for example in Ministries of Health or hospital administration. Anesthesiologists have an essential role in driving workforce development, in planning, in education and training, in clinical governance as well as in the provision of clinical services.10 It is clear from reviewing available National Surgical Obstetrical and Anesthesia Plans,11 developed at the behest of the LCoGS, that governments are well intentioned. What is not at all clear is whether or not any progress has been made in putting these plans into effective action. Perhaps it is too early to see results and we will need to await follow-up publications. In addition, too rapid expansion of medical schools and training programs can have deleterious effects such as overloading existing facilities and teachers, poor teaching and learning situations, and inadequately planned posttraining placements.12 DIVERSITY Law et al3 found a striking difference between the numbers of women anesthesiologists in high-income (48%) and LICs (32%). With the exception of Europe (54%) and the Americas (48%), all WHO regions showed the percentage of women anesthesiologists to be between 30% and 36%.3 Simkin et al5 note the increasing number of women in anesthesia in Canada but the workforce remains still predominantly male. A second article published this month in Anesthesia & Analgesia relates to this aspect of human resources in anesthesia. Nineteen female African anesthesiologists studied the demographics of women in anesthesia in Africa: Women Anesthesiologists in sub-Saharan Africa in the Pre-Covid Era: a multinational demographic study.13 They gathered data from 13 countries which included information on women medical school graduates, women in anesthesia training programs, and women anesthesiologists in practice. It was a Herculean effort. They found that many more women were graduating from medical school than previously, 41% in 2017 compared to 29% in 1998. However, the percentage of women entering and graduating from anesthesia training programs did not develop in parallel. East Africa was found to be progressing faster than West and Central Africa in terms of women in anesthesiology, 39.4% vs 19.7%. It is not at all clear why this disparity exists. Anesthesia is thought to be a less popular specialty for medical graduates in LICs14 but it may be even less popular for women than for men. This is an issue that needs to be addressed15 if women are to enter the specialty in the numbers that make it very popular in Europe and the Americas. We cannot afford to ignore 50% of graduating medical students if anesthesia is to reach its goals for 2030. CONCLUSIONS Readers looking at this material for the first time might want to throw up their hands in despair. There is no question that the state of anesthesia, the state of safe anesthesia, worldwide is in need of massive support and development to achieve the 2030 goals. However, people who work in the many countries in need, and those who partner with them to assist in development, do see progress even though it may be slow and painstaking. There is a push to include surgical care for children as part of NSOAPs.16 Countries are beginning to review their own resources preparatory to making changes.17 A new low-cost capnograph has been introduced which should make improved patient monitoring available to less well-resourced countries.18 There are increases in numbers of residents training in anesthesia19 and improved access to subspecialty training.20 Driving all these improvements is the increased attention being paid to anesthesia and surgery as a result of the work of the LCoGS.2 Long may it continue. DISCLOSURES Name: Faye M. Evans, MD. Contribution: This author helped write the article. Conflicts of Interest: F. M. Evans is a Lifebox Global Governance Council member, Chair of Education for the World Federation of Societies of Anaesthesiologists, and assistant editor of the Global Health Section of Anesthesia & Analgesia. Name: Angela C. Enright, OC, MB, FRCPC. Contribution: This author helped write the article. Conflicts of Interest: A. C. Enright is a former president of the World Federation of Societies of Anaesthesiologists, and Section Editor of Global Health for Anesthesia & Analgesia. This manuscript was handled by: Zeev N. Kain, MD, MBA.

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