The Anesthesia Workforce Crisis Revisited.

See Article, page 230 The coronavirus disease 2019 (COVID-19) pandemic has focused attention on the anesthesia workforce around the world. In many countries, anesthesiologists have had to work in critical care units as well as the operating room, and deficiencies in the number of anesthesiologists have been laid bare. Anesthesiologists in low-resource environments, already at risk of overwork, stress, and burnout,1,2 are likely to have been hit hard by the effects of the pandemic. The workforce on the African continent is particularly fragile because of insufficient numbers of anesthesiologists. If we are to address the issues in a meaningful way, we first need to understand the problem. The article The Specialist Anesthesiology Workforce in East, Central and Southern Africa: A Cross-Sectional Study by Asingei et al,3 published in this edition of Anesthesia & Analgesia, is an important addition to our understanding of workforce issues in sub-Saharan Africa and the East, Central, and Southern Africa (ECSA) regions in particular. Many of the issues identified in the article are important not just for Africa but also for the global anesthesia community. What are some of the key issues and why are they important? As a specialty, it is vital for us to document anesthesiologist numbers to raise awareness of shortages and to inform workforce planning. Many low-and middle-income countries (LMICs) have disproportionately low numbers of anesthesiologists.4 The minimum recommended number is 4 to 5 per 100,000 population4,5 but the density of anesthesiologists identified in this study was only 0.19 per 100,000 or one-50th of the recommended minimum. In comparison, the United States has a density of >20 per 100,000 population.4 The World Federation of Societies of Anaesthesiologists (WFSA) maintains a global workforce map (available at wfsahq.org/resources/workforce-map), and the ECSA study data will be used to update the map. It is important to note that anesthesiologist numbers do not tell the whole story. We know that many countries in Africa and other parts of the world also rely on nonphysician anesthesia providers.4,6 Workforce models vary from country to country and are determined by economic, cultural, and other factors. Individual countries must determine the model that best suits their needs. Further work is required to understand the contribution of nonphysicians to the provision of anesthesia care.6 We agree with Asingei et al that anesthesiologists have an essential role in driving workforce development, including planning, education, and training, and clinical governance. The development of National Surgical Obstetric and Anesthesia Plans (NSOAPs)7,8 in LMICs has been helpful in identifying anesthesia needs but it is vital that anesthesiologists are at the table with surgeons, ministries of health, and other key stakeholders when planning workforce models and training requirements. The surgical ecosystem needs to be considered as a whole, and long-term planning is required. Distribution of anesthesiologists within a country is critical and an issue in both LMICs and high-income countries. The study by Asingei et al finds that the majority of anesthesiologists, not surprisingly, work in larger cities. In 2015, the Lancet Commission on Global Surgery found that 5 of 7 billion people worldwide do not have access to safe and affordable surgical care and anesthesia when needed, and one of the contributing factors is the geographical distance to the nearest facility where surgical care is provided.9 How can anesthesia services be improved in rural settings where cases may be fewer than in larger centers but the patients may be just as ill? High-income countries, such as Canada and Australia, have to deal with the issue of professional isolation in remote settings.10 Both countries have partially resolved the issue by providing extra training in anesthesia for family doctors. This is done in special training programs designed for the purpose, with the goal of providing the particular skill set required to be successful in a remote and rural community. In addition, strong links are built between the family doctors providing the anesthesia service and the specialists in the training center. With improved communications and technology, distance mentoring, and even real-time management advice, can be available to the practitioner in a remote environment. At the ministry of health and government levels, the role of anesthesiology in overall health care is often poorly understood. There has been improved recognition during the COVID-19 pandemic but intense and ongoing advocacy work is required if our specialty is to have the same standing as surgery or other specialties in LMICs. The WFSA continues to advocate on behalf of anesthesiologists worldwide at the World Health Organization (WHO) and other international fora. There is increasing recognition that the WHO concept of universal health coverage (UHC) will only be possible if anesthesia and surgical care are strengthened as part of a whole-of-system strengthening of health care in individual countries. Unfortunately, in many countries with limited resources, anesthesiology is not seen as an attractive specialty.11 This perception has been reinforced by a worsening of working conditions during the pandemic. Well-developed training programs and career path enhancement are essential to attract and retain people in the specialty. Asingei et al note the development of the College of Anaesthesiologists of East, Central and Southern Africa (CANECSA), and this may provide an important model for training and maintenance of standards in the region. In West Africa, the West African College of Surgeons (WACS) includes a Faculty of Anaesthesia with well-established, graduated training programs.12 In the Pacific region, a training program based in Fiji has helped to develop a critical mass of anesthesiologists throughout the region.13 Asingei et al provide evidence that people trained at home tend to stay at home. Where data were available, over 90% of the anesthesiologists working in the ECSA region had received their first specialist anesthesiology qualification within the region. Comprehensive training programs have been developed in Rwanda and Uganda, and there has been a significant increase in the anesthesia workforce in both countries. The development of “homegrown” training programs must be seen as a priority by governments and external organizations. Such training programs also have the advantage of strengthening local teachers and institutions, and encouraging development of context-sensitive solutions to local problems. Anesthesia training programs need to recognize the breadth of anesthesia practice. In countries with limited resources, anesthesiologists generally take a leading role in critical care medicine, pain management, and other subspecialty areas of practice. There has been little development of critical care medicine as a separate specialty in many LMICs,14,15 and provision of critical care often falls to anesthesiologists. Specific training in critical care should be seen as a core component of training programs in these countries. Anesthesia practice in Africa, and in other parts of the world with severe resource limitations, includes a high proportion of obstetric and pediatric cases. The African Surgical Outcomes Study found that cesarean delivery accounted for 33.3% of the surgical procedures performed in 25 countries over a 7-day period.16 Asingei et al showed that a relatively low number of anesthesiologists in the ECSA region had undergone subspecialty training. Tanzania, for example, did not report any anesthesiologists with either obstetric or pediatric subspecialist training. An argument can be made that it is more important to have true generalists when resources are short, but, alternatively, it can be argued that there should be targeted subspecialty training of a subset of anesthesiologists so that they can provide leadership and training in their subspecialty area. The University of Nairobi-WFSA Paediatric Anaesthesia Fellowship in Nairobi, Kenya, was set up in 2013 to provide subspecialty pediatric anesthesia training for anesthesiologists in the ECSA region. As of 2021, the program had trained 19 pediatric anesthesiologists from 11 African countries, all of whom had returned to their home countries to practice and teach (Dr Faye Evans, personal communication). Worldwide, we are facing an anesthesia workforce crisis. The data from ECSA show that there has been a small increase in anesthesiologists but this has barely kept pace with the overall increase in population. There are some encouraging signs. The workforce is relatively young, and we are seeing a higher proportion of women—let us hope that these young anesthesiologists represent the kernel of a stronger, more sustainable workforce in the ECSA region. Let us also hope that we will continue to see a similar focus on anesthesia workforce development in other parts of the world. DISCLOSURES Name: Wayne W. Morriss, MBChB, FANZCA. Contribution: This author helped write the article. Conflicts of Interest: Current president of World Federation of Societies of Anaesthesiologists. Name: Angela C. Enright, MB, FRCPC. Contribution: This author helped write the article. Conflicts of Interest: Former president of World Federation of Societies of Anaesthesiologists. This manuscript was handled by: Jean-Francois Pittet, MD.