Global Burden of Surgical Disease

Nearly 30% of global morbidity and mortality is surgically treatable, with tens of millions of lives lost each year due to surgical conditions. This burden of surgical disease predominantly affects LMICs and kills 4 times more people than human immunodeficiency virus (HIV), TB, and malaria combined ( Fig. 2.1 ). In addition to negative impacts on health and well-being, there is also significant economic burden associated with surgical morbidity and mortality. By 2030, morbidity and mortality from surgical conditions could reduce annual gross domestic product (GDP) growth by an estimated 2% in LMICs. In the past, similar calculations were used to successfully generate global investment in malaria, but had estimated much lower (1.3%) decreases in GDP due to malaria. Without significant and immediate intervention, surgical disease will produce economic productivity losses of more than US$12 trillion for LMICs between 2015 and 2030. While it is generally agreed that surgical conditions account for a large proportion of global morbidity and mortality, precise data to support this have been lacking. This challenge has been attributed in part to a lack of resources being invested in such research and also to several inherent difficulties in quantifying surgical diseases.

Surgical conditions account for more annual deaths (16.9 million) than HIV/AIDS (1.03 million), TB (1.21 million), and malaria (0.72 million) combined.

AIDS , Acquired immunodeficiency syndrome; HIV , human immune virus, TB , tuberculosis.

Data from Shrime MG, Bickler WS, Alkire BC, et al. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health. 2015;3:S8–S9; and GBD collaborators 2016. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390[10100]:1151–1210.

The term “global burden of disease” (GBD) uses the disability-adjusted-life-year (DALY) as a unit to quantify premature death (years of life lost) and disability (years of life lived in a state of less than full health) ( Fig. 2.2 ). The DALY was originally developed for the seminal GBD 1990 Study to quantify the burden of different diseases around the world and has since become commonly used in public health and health economics. Because the DALY is routinely used to inform resource allocation, it has been utilized to describe surgical and pain disease burdens as well. The global health community has moved away from using terms such as third world, developed, or developing when describing countries’ level of economic development. Leading causes of DALYs are often reported geographically by World Bank income level (see Table 2.1 ) or more recently by socio-demographic index (SDI) ( Figs. 2.3 and 2.4 ). The SDI is a composite average of three indicators predictive of health outcomes: income per capita, average educational attainment (for population >15 years old), and total fertility rate.

The disability-adjusted life year (DALY) .

From Wikipedia. https://en.wikipedia.org/wiki/Disabilityadjusted_life_year#/media/File:DALY_disability_affected_life_year_infographic.svg . Creative commons license: CC BY-SA 3.0.

Socio-demographic Index (SDI) is calculated for each geography as a function of lag-dependent income per capita, average educational attainment in the population older than age 15 years, and the total fertility rate. SDI units are interpretable; a zero represents the lowest level of income per capita and educational attainment and highest total fertility rate observed during 1980–2015, whereas a one represents the highest income per capita and educational attainment and lowest total fertility rate observed in the same period. Cutoffs on the SDI scale for the quintiles have been selected on the basis of examination of the entire distribution of geographies 1980–2015. GBD, Global Burden of Disease.

From GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet . 2016;388[10053]:1459–1544. Copyright © 2017 The Author[s]. Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Leading causes of death and disability-adjusted-life-years (DALYs) , 1990–2016, global versus low Socio-Demographic Index (SDI) . AIDS , Acquired immunodeficiency syndrome; HIV , human immune virus.

From https://vizhub.healthdata.org/gbd-compare/ . Reproduced under Creative Commons Non-Commercial-No Derivatives 4.0 International License.

The 2006 DCP2 publication was one of the first attempts to quantify surgical disease burden and did so by asking 18 surgeons for an educated guess, using convenience sampling and an online survey. Although the reported number (11%) was eye-opening and widely quoted, it was likely a significant underestimation.

In 2015, the DCP3 provided another attempt to assess the public health impact of surgical care by estimating morbidity and mortality averted by scaling up basic surgical and anesthesia services in LMICs (i.e., surgical care for appendicitis, paralytic ileus, intestinal obstruction, hernias, gallbladder and bile duct disease, maternal hemorrhage, obstructed labor, abortion and neonatal encephalopathy, trauma resuscitation, surgical airway, peripheral venous access, suturing, laceration and wound management, chest tube or needle decompression, fracture reduction, escharotomy, fasciotomy, skin grafting, and trauma-related laparotomy and amputation). They concluded that an estimated 1.4 million deaths and 77.2 million DALYs could be prevented each year by scaling up basic surgical and anesthesia services in LMICs.

The LCOGS produced another attempt to estimate global morbidity and mortality from surgical disease by asking 173 surgeons, anesthesiologists, internists, nurses, and public health practitioners from around the world, “What proportion of patients with the following conditions would, in an ideal world, require a surgeon for management?” The result of this survey was 28% to 32% of overall GBD requires a surgeon for management. Based on these results, LCOGS estimated that 30% of GBD is surgically treatable with an estimated 17 million lives lost per year due to surgical conditions.

These reports are consistent with the 1990 GBD Study data, which demonstrate that the morbidity and mortality associated with surgical diseases is significantly larger than that of HIV, TB, and malaria combined. Unintentional injuries are the single largest contributor of DALYs worldwide. The majority of deaths that can be prevented with surgical care are due to injuries (77%), maternal-neonatal conditions (14%), and digestive diseases (9%). Global industrialization and an “epidemiological transition” (i.e., people living longer) in many LMICs have resulted in rising noncommunicable disease and injury burdens (most notably from road traffic crashes) that will likely contribute to increased global surgical disease burden in the coming years.

Each of the methods previously described to estimate surgical disease burden is imperfect. Challenges and limitations include complex methodologies (e.g., Institute for Health Metrics and Evaluation [IHME], GBD Studies), difficulty with measuring and defining surgical diseases (e.g., the same neoplasm in one person may be treated with surgery but in another person may be treated with chemotherapy), and challenges in assigning DALYs to diseases (i.e., disability weighting) and assigning DALYs averted to surgical procedures. To overcome these shortcomings, additional metrics for global surgery and anesthesia have been proposed and include measuring disease prevalence, treatment backlogs for non fatal conditions, morbidity and mortality as a result of delays in care, social benefit, economic benefit, and value of a statistical life (rather than costs per DALY averted).

One significant role for the academic anesthesia community in the global context is working to increase efforts that better quantify the growing surgical disease and pain burdens in order to facilitate appropriate resource allocation and subsequent evaluation of interventions.

Global Burden of Pain

As with surgical disease burden, there is general consensus on the staggering prevalence and incidence of pain worldwide though there are relatively limited data and significant challenges to quantifying pain burden in the global context. Pain is one of the most common reasons for seeking medical attention, is among the top five causes of DALYs worldwide, and directly accounts for four (low back pain, neck pain, musculoskeletal pain, migraine) of the top 10 causes of years lived with disability (YLDs). These statistics do not even account for pain secondary to oncology, injury, or postoperative etiologies, which likely increase these numbers substantially. It is estimated that 10% to 25% of the world’s population suffer from recurring and chronic pain, with increasing numbers caused by intentional physical harm such as war, violence, and torture. Uncontrolled pain has many potential negative impacts on health, well-being, and economic productivity, including increased risk of myocardial infarction and chronic pain.

The 2017 Lancet Commission on Palliative Care and Pain Relief defined serious health-related suffering (SHS) as suffering associated with illness or injury that compromises physical, social, or emotional functioning, and cannot be relieved without medical intervention. Approximately half of all deaths worldwide involve SHS and more than 80% of people who die with SHS are from LMICs. It is estimated that 2.5 million children die with SHS each year. Ninety-eight percent of these children live in LMICs, and more than 90% of these deaths are avoidable. Among the top 10 conditions associated with SHS are HIV, malignancy, and injury. Though not as obvious as injury or cancer, HIV/AIDS is a major source of pain and analgesia need. Pain related to HIV is not routinely managed by anesthesiologists when compared to other more common pain etiologies, however, the relevance of HIV as a rallying point to advocate for greater access to analgesics in LMICs is discussed further in this chapter. In many countries, conditions such as diabetes, sickle cell, and leprosy are also responsible for significant pain burdens. With increasing longevity and industrialization, the disease burden for malignancy and injury are expected to increase significantly in LMICs. As providers with often the most experience administering analgesics, anesthesia providers play an expanded and critical role in pain management, especially in resource-constrained settings.

Disparities in Access, Affordability, and Safety

The exact level of disease burden attributable to surgical disease or pain is a focus of ongoing debate and research, yet it is generally accepted that the surgical, anesthesia, and pain crises are massive, largely avoidable, and disproportionately affect LMICs. Of the roughly 300,000 maternal deaths worldwide, 99% occur in low-resource settings (66% in sub-Saharan Africa) and the majority are preventable with relatively basic surgical, anesthesia, and perioperative care. Approximately 70% of global cancer deaths occur in LMICs, with the majority requiring surgical, anesthesia, or analgesia services. Scaling access to basic surgical and anesthesia services in LMICs could avert 77 million DALYs and 1.5 million deaths per year. Injury represents the majority (77%) of this avoidable morbidity and mortality, followed by maternal and neonatal conditions (14%). Approximately 90% of deaths and DALYs that are lost due to road traffic accidents occur in LMICs.

Based solely on the inequitable distribution of operating theatres, more than two billion people have no access to surgical services. When also accounting for timeliness, facility capacity, safety, and affordability, nearly 5 billion people—the majority of the world’s population—lack access to surgical and anesthesia care. The Global Initiative for Children’s Surgery (GICS) estimates that 1.7 billion children lack access to surgical care. [CR] It is estimated that approximately 143 million additional surgeries are required each year. Of the 234 million major surgical procedures performed annually, only 3% to 6% of them are estimated to occur in LIMCs. Disparities in access disproportionally affect lower-income areas like sub-Saharan Africa or South Asia, where more than 95% of the population do not have access to surgical and anesthesia care. In some higher-income areas like North America and Europe, access varies considerably, but generally more than 95% of the population has access ( Fig. 2.5 ). Even in HIC like the United States, access to anesthesia, surgical, and analgesia care can be limited for rural and underserved populations. It is estimated that universal access to “essential” surgical procedures (which include treatments for injury, obstetric complications, abdominal emergencies, cataracts, and congenital anomalies) would prevent approximately 1.5 million deaths per year or 6% to 7% of all preventable deaths in LMICs.

The proportion of population without access to surgery.

From Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3:e316–e323. doi: 10.1016/S2214-109X(15)70115-4. Epub 2015 Apr 27. Copyright © 2015 Alkire et al. Open Access article distributed under the terms of CC.

Inadequate access to analgesia is among the most neglected and inequitable global public health challenges. The global burden of pain disproportionately affects the world’s poor due to the high-burden conditions associated with pain (e.g., HIV, malignancy, and injury) in LMICs, and the general lack of access to analgesics. Although pain is the most common reason for seeking medical attention, and analgesia is considered a basic human right, gaps in access to analgesia are significant and among the most striking global health disparities worldwide. Injury and malignancy, two conditions with significant analgesia needs, represent a significant proportion of surgical disease burden in LMICs, yet the vast majority of LMIC populations have limited or nonexistent access to opiate analgesia. Six HICs account for 80% of the world’s opiate consumption, and countries that contain 17% of the world’s population (Canada, United States, Western Europe, Australia, and New Zealand) are responsible for 92% of the world’s opiate consumption ( Figs. 2.6 and 2.7 ). Pain and palliative care remain relatively neglected by the global health community and disproportionately affect vulnerable populations in LMICs. In recent decades, access to opiates has improved in some LMICs, but not all (e.g., consumption in Africa and South Asia has declined). Inequitable access to analgesia is not unique to LMICs and has been repeatedly described in many HICs, including the United States. Reasons for the inequitable distribution of analgesia are discussed further in the next section of this chapter.

Mean availability of opioids for pain management in 2011–2013.

S-DDD , Defined daily doses for statistical purposes.

From Berterame S, Erthal J, Thomas J, et al. Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study. Lancet . 2016;387:1644–1656. https://doi-org.easyaccess2.lib.cuhk.edu.hk/10.1016/S0140-6736[16]00161-6 . Copyright © 2015 Berterame et al. Open Access article distributed under the terms of CC.

Distributed opioid morphine-equivalent (morphine in mg/patient in need of palliative care, average 2010–2013), and estimated percentage of need that is met for the health conditions most associated with serious health-related suffering.

From Knaul FM, Bhadelia A, Rodriguez NM, et al. The Lancet Commission on Palliative Care and Pain Relief—findings, recommendations, and future directions. Lancet Glob Health . 2018;6:S5–S6. Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY 4.0 license.

For the proportion of the world’s population that has access to surgical and anesthesia care, they must confront significant disparities in safety. In the last half-century perioperative patient safety has improved by more than 10-fold, though the majority of the gains have been seen in HICs. In the United States during the 21st century, anesthesia-related mortality decreased from 1:1560 around 1950 to less than 1:13,000, and is significantly better than this in healthy patients. Worldwide, approximately 32 million people per year receive anesthesia without adequate monitoring, and more than 77,000 operating rooms (19%) worldwide lack pulse oximetry. In some regions, more than 70% of operating rooms lack pulse oximetry. Data on surgical outcomes in LMICs remain limited but have expanded significantly in the early part of the 21st century. Reports of perioperative mortality rates (POMRs) from low-income countries (LICs) have varied widely in both methodology and results, ranging from 0.2% to 6% overall, with significantly higher mortality for emergent procedures (10% overall, 20% for typhoid intestinal perforations). One international, prospective, observational cohort study of adults undergoing inpatient surgery in 247 hospitals from 25 African countries reported a 30-day in-hospital mortality rate (2.1%) that was twice the reported global average, despite a significantly younger and lower American Society of Anesthesiologists (ASA) physical classification patient population. In several African countries, anesthesia-related mortality has been reported to be in the 1:100s (Malawi 1:504; Zimbabwe 1:482; Nigeria 1:387 for C-sections; Togo 1:133 to 1:250). In one report of 24-hour surgical outcomes in Togo, 30 deaths occurred (total cases 1464), 22 were deemed avoidable, and 11 were due to avoidable anesthesia complications. Another report from Togo reported a mortality rate of 1:250 and found less than half of the 26 facilities surveyed had pulse oximetry, and none had capnography. In a national report on maternal mortality in South Africa, nearly 2.35% of recorded maternal mortalities were anesthesia related, and the majority (93%) were deemed avoidable. One of the most common causes of anesthesia death in this report was the provision of spinal anesthesia without skills necessary to manage an airway or convert to general anesthesia. Other commonly cited causes of avoidable anesthesia mortality in resource-constrained settings include inadequate staffing, monitoring, and drug overdose. A recent meta-analysis of anesthesia-related maternal mortality in LMICs found the risk of death from anesthesia for women undergoing obstetric procedures to be 1.2 per 1000 (vs. 3.8 per million in the United States), with higher risk reported if general anesthesia was used or if anesthesia was provided by a nonphysician . In this analysis, anesthesia was the cause in 2.8% of maternal deaths in LMICs and 13.8% of all deaths during or after C-section in LMICs. To state this differently, anesthesia-related maternal mortality is 300-fold higher for neuraxial and 900-fold higher for general anesthesia than is reported in the United States.

It is important to note that the relationship between hospital-based perioperative morbidity and mortality and surgical disease morbidity and mortality must be interpreted with caution in settings where patients lack access to hospitals. In other words, in an HIC a patient’s chances of dying from a ruptured viscous are roughly the same as the chances of dying from surgery for a ruptured viscous because more than 95% of the population has access to care. However, in an LIC, while the perioperative mortality for a ruptured viscous may be 10%, the majority of patients with this condition never make it to surgery and have mortality rates that are dramatically higher.

Affordability is another significant barrier to accessing surgical and anesthesia services. Each year, approximately 33 million people face catastrophic out-of-pocket expenditure due to payment for surgery and anesthesia ( Fig. 2.8 ) with an additional 48 million people facing catastrophic expenditure related to non medical costs of accessing surgical care (e.g., transportation, lodging, and food). Nearly half (3.7 billion) of the world’s population is at risk of catastrophic expenditure if they were to have surgical and anesthesia care. The majority of those at risk live in sub-Saharan Africa, and South and Southeast Asia. The issue of affordability applies not only to surgery itself but also to components of perioperative care including analgesia and transfusions. For example, in South America, a monthly prescription of opiate for chronic pain may cost 200% of annual income. In India (where nominal gross national income per capita is $1670), a unit of blood often costs up to $247 despite a legal limit of $25. Global health and development leaders including the WHO and World Bank prioritize financial risk protection as a key component of achieving universal health coverage goals for all countries. Despite relatively high out-of-pocket costs at the individual level for some procedures, surgery is a highly cost-effective public health intervention as discussed further in the following sections.

Risk of catastrophic expenditure for surgical care in 2014 (% of people at risk).

Data from http://databank.worldbank.org.easyaccess2.lib.cuhk.edu.hk/data/home.aspx . Originally printed: http://blogs.worldbank.org.easyaccess2.lib.cuhk.edu.hk/opendata/africacan/pt/comment/reply/2341. Copyright © 2018 The World Bank. Reproduced under CC BY 4.0 license.

Misperceptions and Limited Data

Two common misperceptions about surgery and anesthesia have contributed to the delayed recognition of these fields as global public health priorities: (1) the scope and scale of surgical disease and pain burdens were vastly underestimated; and (2) surgical and anesthesia care were erroneously assumed to be too expensive and technology dependent to be done safely or cost-effectively in resource-constrained environments. In this section we discuss reasons why the surgical disease and pain burdens are historically poorly characterized. Misperceptions about cost-effectiveness and feasibility of safe surgery and anesthesia care also have roots in a historical data void, especially from LMICs.

Several innovative service delivery models in the public and private sectors of LMICs (e.g., Indus hospital, Aravind Eye Hospitals, and Narayana Hrudayalaya Heart Hospital) have demonstrated that it is feasible to provide cost-effective, safe, and affordable surgical and anesthesia care in resource-constrained countries.

Recent data have consistently demonstrated that surgical services are among the most cost-effective public health interventions ( Fig. 2.9 ). There are several methods to define cost-effectiveness thresholds, each with pros and cons. One of the most commonly cited methods uses GDP-based thresholds. This approach was suggested by the WHO Commission on Macroeconomics and Health and has been defined by authors from the WHO’s Choosing Interventions that are Cost–Effective project (WHO-CHOICE) as, “interventions that avert one DALY for less than average per capita income for a given country or region are considered very cost–effective; interventions that cost less than three times average per capita income per DALY averted are still considered cost–effective; and those that exceed this level are considered not cost–effective.”

Cost-effectiveness of surgery in low-income and middle-income countries compared with other public health interventions. Data points are medians, error bars show range. Surgical interventions are denoted by the diamonds and solid lines, public health interventions by the circles and dashed lines. BCG, Bacillus Calmette–Guérin; DALY , disability-adjusted life-year; HIV , human immune virus.

Source: Chao TE, Sharma K, Mandigo M, et al. Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis. Lancet Glob Health . 2014;2:e334–e345. Copyright © 2015 Elsevier Ltd. Creative Commons Attribution License [CC BY].

In 2003 in Bangladesh, one of the earliest cost-effectiveness studies on surgical care reported the cost of emergency obstetric care at less than $11 per DALY averted. This was 3 times more cost-effective than the measles vaccine (in 2003 dollars). The DCP2 and DCP3 demonstrated cost-effectiveness of the first-level surgical hospital, with essential surgical services all being highly cost effective and many costing $10 to $100 per DALY averted. This is comparable to the cost-effectiveness of other public health interventions such as immunizations ($13-$26 per DALY) or bed nets for malaria prevention ($6-$22 per DALY), and much more cost-effective than other high-priority public health interventions such as HIV treatment ($500 per DALY). A recent analysis of the cost-effectiveness of a pediatric operating room in Uganda found a cost of $6.39 per DALY averted and $397.95 per life saved, with a net economic benefit of over US$5 million per year (cost of $41,000 per year).

In a 2012 forum hosted by the Copenhagen Consensus, five leading health economists, including four Nobel laureates, were asked how best to spend US$75 billion over 4 years to “advance global welfare,” especially in LMICs. The leading priority identified by the group was the expansion of surgical care capacity (US$3 billion per year).

In the past 5 years the global surgery and anesthesia communities have expanded the volume of data that dispel prior misconceptions and support prioritization of surgical and anesthesia care in the global health agenda. During this timeframe, there has also been an explosion of articles that expand available data on a wide range of global anesthesia and surgical topics. The majority of these articles have been published in the surgical journals though recently anesthesia publications have begun to actively support global anesthesia research. The global anesthesia community must increase research productivity in global health and also invest in advocacy, policy, and implementation sciences in order to ensure impact.

Advocacy and Policy

There are many reasons why surgery, anesthesia, and pain have historically not been prioritized by national health systems, donors, or the broader global health community. Although surgical disease accounts for 30% of global disease burden, less than 1% of development assistance for health supports delivery of anesthesia and surgical care. Imbalance between resource allocation and disease burden is found in many health conditions, though the degree of this disparity for surgical disease and pain is particularly striking.

As discussed previously, lack of disease burden data and misperceptions about safety and cost-effectiveness have significantly hindered advocacy efforts for global anesthesia and surgery. In a qualitative analysis of factors that have hindered political prioritization for global surgery, several additional factors were identified including: fragmentation of the global surgery community, lack of leadership and consensus, and inadequate political strategy (e.g., not capitalizing on opportunities such as the MDGs). In another analysis to determine why certain disease-specific global health networks are relatively more or less effective than others, four common challenges were highlighted, each with relevance to global anesthesia and surgery: (1) defining the problem and how it should be addressed; (2) positioning the issue in a way to inspire action by external audiences; (3) building coalitions that include stakeholders outside the healthcare sector (coalitions are too often dominated by HIC providers); and (4) creating governance institutions that facilitate collective action ( Fig. 2.10 ). Another study that examined factors influencing prioritization of surgery in national health systems concluded that sustained advocacy, effective framing of problems and solutions, robust country-level data, and support from regional and international partners were critical for success but often lacking.

Four challenges that global health networks face.

From Shiffman J. Four challenges that global health networks face. Int J Health Policy Manag. 2017;6[4]:183–189. Copyright © 2018 The Author[s]. Published by Kerman University of Medical Sciences. This is an open access article under the CC BY 4.0 license.

Advocacy efforts for surgery, anesthesia, and pain face a few additional and relatively unique challenges. Unlike infectious diseases such as HIV or Ebola, surgical disease and pain are not pandemic and do not incite similar action by the HIC donor community. Furthermore, most surgical conditions and pain are difficult to advertise and are not disease specific. While select pediatric conditions (e.g., cleft lips) are easily marketable, other conditions like trauma, hernias, and cesarean section are more difficult to compassionately portray in media in attempts to improve public awareness.

The WHA resolution 68.15 emphasized advocacy and resource development in five key focus areas for global surgery (workforce, essential medicines, information management, service delivery, and advocacy). The LCOGS provided clear framing of problems (see Box 2.2 ), outlined priorities for country-level data collection, and helped to provide frameworks for national surgical, obstetric, and anesthesia plans (NSOAPs) in LMICs. As more NSOAPs are produced, they have the potential to serve as key rallying points for national advocacy efforts.

Anesthesia, surgery, and pain need global champions. Only recently has advocacy by leading global organization (e.g., the World Bank, WHO) and select local governments in LMICs focused attention on anesthesia and surgery in the global context. This is in part due to advocacy efforts by several relatively recent initiatives (e.g., LCOGS, The Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care [G4 Alliance], WFSA, GICS, and several more). These multidisciplinary efforts must be expanded and sustained in order to reach the critical mass needed to overcome prior misperceptions and affect change. It is essential that advocacy efforts for surgery, anesthesia, and pain be consistent with the key messages of LCOGS, the Global Health 2035 Report, WHA resolution 68.15, and the SDGs, and emphasize that anesthesia, surgery, and analgesia are indispensable components of “universal health coverage.” No longer can surgery be seen as a vertical (i.e., disease-specific) program.

One key objective for advocacy efforts will be to identify new streams of funding from global donors, national budgets, private sectors, and innovative models. Similar to the large-scale funding initiatives to combat HIV/AIDS and other infectious diseases (e.g., the U.S. President’s Emergency Plan for AIDS relief, Gavi Vaccine Alliance, The Global Fund), surgery and pain require comparable attention and support. In addition to domestic and international financing mechanisms to support health system scale-up, public-private partnerships and innovative patient-level financial risk protection strategies must be integral components to advocacy efforts.

As leaders in safety, pain, perioperative care, and more, the global anesthesia community must actively engage in policy, research, and innovative global initiatives to expand access to quality care. Academic institutions from all countries can play a significant role in supporting a coordinated research agenda, creating a global voice for advocacy, sharing information, and harmonizing educational standards and opportunities. Anesthesia must follow the lead of other medical disciplines to not only cultivate but also support faculty and trainees with interests in global public health careers. Such advocacy will likely require coordination and partnership with multiple disciplines, including nonphysician provider cadres who perform a significant proportion of anesthesia services, especially in LICs.

Workforce Shortages and Strategies for Expansion

The critical shortage of trained anesthesia providers in resource-constrained settings is one of the most significant barriers to expanding access to safe surgical, anesthesia, and pain services for billions of people worldwide. Although shortages of many key members of the surgical workforce exist (including surgeons, obstetricians, pathologists, radiologists, laboratory technicians, nurses, biomedical engineers, and more), anesthesia provider shortages in LMICs are particularly striking and relatively neglected. Countries like the Central African Republic have no physician anesthesiologists and only 24 nonphysician anesthesia providers (NPAPs) for a population of nearly 5 million. Ethiopia, with a population of over 100 million people, has only 35 physician specialist anesthesiologists. A survey of emergency obstetric care capacity at facilities in Uganda found that lack of staff had the greatest correlation with observed mortality rates. In a survey of 64 public and private hospitals in Uganda, 84% did not have a physician specialist anesthesiologist, and 8% had no trained anesthesia providers at all. In another survey of anesthesia providers from five main referral hospitals in East Africa (Uganda, Kenya, Tanzania, Rwanda, and Burundi), only 7% reported adequate anesthesia staffing. In settings where providers exist but in small numbers, the workforce shortage is compounded by heavy administrative burdens and non-clinical duties.

While the anesthesia workforce shortage is most severe in LICs and particularly pronounced in sub-Saharan Africa, regional workforce shortages also exist in HICs and can significantly limit access to care for rural populations. In one survey of rural hospitals in the United States, 36% reported delay or cancellation of surgery due to a lack of anesthesia providers. Data from HICs demonstrate differences in trauma mortality are significantly worse starting at five miles from a trauma center in a major urban city. One can only imagine outcome differences in settings where there may be no surgical or anesthesia provider for tens or even hundreds of miles.

The optimal number of specialist surgical, anesthetic, and obstetric workforce (SAO) providers needed to give access to safe surgery is unknown and likely to vary significantly based on local resources and needs. The SAO density correlates with life-expectancy and in one study, as SAO providers increased from 0 to 20 per 100,000 population, maternal mortality decreased by 13.1% for each 10 unit increase in provider density ( Fig. 2.11 ). These benefits were also observed with workforce expansion beyond 20, though with less magnitude beyond 30 and 40 providers per 100,000 ( Fig. 2.12 ). Based on these findings, the LCOGS recommended prioritizing expansion of the SAO workforce to 20 per 100,000 population by 2030, with anesthesia-specific targets of 5 to 10 anesthesia providers per 100,000.

Life expectancy tends to be higher in countries with a surgical workforce larger than 20 workers per 100,000 people.

Data source: http://databank.worldbank.org.easyaccess2.lib.cuhk.edu.hk/data/home.aspx . Originally printed: http://blogs.worldbank.org.easyaccess2.lib.cuhk.edu.hk/opendata/africacan/pt/comment/reply/2341. Copyright © 2018 The World Bank. Reproduced under CC BY 4.0 license.

Specialist surgical workforce density and maternal survival.

A surgical workforce density of less than 20 per 100,000 specialist surgeons, anesthesiologists, and obstetricians correlates with lower rates of maternal survival. Maternal survival per 100,000 livebirths = 98,292 × ln (workforce density) + 99,579.

From Meara JG, Leather AJ, Hagander L, et al . Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624. Data from Holmer H, Shrime MG, Riesel JN, et al. Towards closing the gap of the global surgeon, anaesthesiologist and obstetrician workforce: thresholds and projections towards 2030. Lancet . 2015;385(suppl 2):S40. Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY 4.0 license.

The density of SAO providers has been estimated at 0.7 per 100,000 population for LICs as compared with 56.9 per 100,000 population for HICs. Worldwide, 77 countries report an anesthesia provider density less than 5 per 100,000, with a 90-fold difference between the average physician workforce density in HICs as compared to LICs. The anesthesia workforce crisis is most severe in sub-Saharan Africa, where most countries have approximately 1.0 physician anesthesiologist per 100,000 population as compared to approximately 19 in Europe or 21 per 100,000 in the United States ( Fig. 2.13 ). Twenty-six countries in sub-Saharan Africa reported less than 0.5 physician anesthesia providers (PAPs) per 100,000. In many LICs, NPAPs provide the majority of anesthesia care. When NPAPs are included in calculations of total anesthesia provider density, 16 countries in sub-Saharan Africa still report less than 1 anesthesia provider per 100,000, and worldwide 70 countries still report less than 5 anesthesia providers per 100,000 population. Estimates from the WHO Global Surgical Workforce database demonstrate that 12% of the SAO workforce provides care for approximately a third of the world’s population. Worldwide, LICs and LMICs have 48% of the world’s population but only 20% of the SAO workforce.

World Federation of Societies of Anaesthesiologists Workforce Map.

Image accessed at https://www.wfsahq.org/workforce-map

Data published: Kempthorne P, Morriss WW, Mellin-Olsen J, et al. The WFSA Global Anesthesia Workforce Survey. Anesth Analg . 2017;125[3]:981–990. Copyright © 2018 The WFSA. This image is reproduced under the CC BY 4.0 license.

Multiple factors have contributed to the ongoing surgical and anesthesia workforce crises in LMICs, including limited training infrastructure, relatively low professional status, lack of career advancement (especially for NPAPs), perceived limited job opportunities relative to other professions (e.g., infectious disease in LMICs), cost of training, inefficient hiring mechanisms, provider burnout, as well as internal (e.g., private practice in urban settings) and external brain drain (e.g., leaving the country). Lack of consensus on anesthesia practice models and polarized views on who should provide anesthesia care (i.e., physician versus nonphysician, supervised versus independent) are additional factors limiting a clear path for rapidly scaling the global anesthesia workforce ( Table 2.3 ). Task-sharing is a prominent and controversial component of many surgical workforce expansion efforts.

Each of the aforementioned challenges must be addressed as part of any national or international effort to expand the anesthesia workforce. The long-term goal of building robust training infrastructures in low-resource settings requires locally led plans for national advocacy, implementation, and evaluation. Such efforts can benefit from international investment and collaboration.

Significant heterogeneity in anesthesia care models exists worldwide. Although the varied anesthesia practice and training models have evolved to address different local needs and challenges, excess heterogeneity and lack of consensus on anesthesia workforce strategy may provide an additional challenge to global workforce expansion. For example, within sub-Saharan Africa, formal nonphysician training programs range from 3 to 72 months in duration with widely different entry requirements, no standardized curricula or assessment tools, and different scopes of practice. For countries seeking to increase anesthesia provider numbers, no clear roadmap exists. In most of these countries, task-sharing with NPAPs will likely play a key role in workforce expansion efforts. Collaborative efforts involving stakeholders from different countries and different anesthesia provider cadres can support anesthesia workforce expansion efforts by offering frameworks for anesthesia training, competency assessments, and potential practice models that are feasible with local resources and that meet local needs. Initiatives that ensure quality (e.g., education programs, credentialing bodies, and licensing exams) are as important as those that focus on increasing absolute numbers. The global anesthesia community can play a significant role via advocacy, research, education, and partnership to address many of the challenges that have created the current global anesthesia workforce crisis.

Infrastructure Challenges

The provision of surgical and anesthesia care requires infrastructure that is often lacking in many LMICs. As discussed elsewhere in this chapter, such infrastructure does not necessarily need to be high-cost or based on advanced technologies to provide safe care. In addition to the provider shortages already discussed, additional infrastructure challenges that frequently limit surgical and anesthesia service delivery include: underdeveloped patient referral and prehospital systems, medication and equipment shortages, and inadequate supply chains and facility resources.

In maternal health, and more recently for surgery and anesthesia, a “three delays framework” has been used to describe factors delaying timely access to safe healthcare services. The “first delay” in this model (delay in seeking care) may occur due to financial, cultural, education, or other patient factors. Anecdotally, fear of bad surgical outcomes (whether true or not) and more specifically a fear of anesthesia may also contribute to the “first delay.” The second and third delays are more directly linked to infrastructure limitations. The “second delay” (delay in reaching care) occurs when health facilities cannot be reached in a timely manner and may be due to geographic distance or challenges with transportation (e.g., bad road conditions, no access to a car, no money for public transport). Although efforts to improve healthcare infrastructure often focus on facility-based interventions, emphasis on infrastructure that minimizes this “second delay” is underappreciated despite evidence of cost-effectiveness. For example, the lack of prehospital care systems in many LMICs is a significant source of avoidable morbidity and mortality. The DCP3 estimates that 4.7 million deaths in LMICs each year are due to surgical conditions that are potentially addressable through prehospital and emergency care systems. In Uganda, less than 25% of the population lives within 2 hours of a surgical facility, and worldwide approximately 2 billion people lack access due to this second delay.

When discussing infrastructure limitations, most people think of the “third delay” (delay in receiving care), which occurs when patients reach a facility but may not receive adequate care because of limitations in facility resources. Data from 800 first-level health facilities in LICs demonstrate that relatively few first-level hospitals could provide C-sections (64%), laparotomies (58%), or open fracture repairs (40%), and most did not have reliable electricity (31%), running water (22%), oxygen (24%), or Internet access. Without reliable utilities, standard equipment like monitors, ventilators, anesthesia machines, and autoclaves are often not functional, assuming they are even present at all. In recent years, the number of surgical and anesthesia capacity assessment tools increased significantly, although most tools have focused on surgical care with limited ability to assess anesthesia or analgesia capacity.

The WHO Surgical Safety Checklist includes requirements for pulse oximetry, anesthesia machine check, and confirmation of instrument sterility, yet these may not currently be feasible in many LMIC health facilities. As the consensus on what constitutes “essential” or “standard” anesthesia and surgical safety equipment is evolving, it is universally agreed that far too many health facilities face routine shortages of even the most basic anesthesia equipment.

Inadequate access to indicator strips, maintenance support, power, and distilled water result in low compliance with the 2016 WHO/Pan American Health Organization (PAHO) standards for cleaning, disinfection, and sterilization in most LMICs. In a survey of 28 district hospitals in Zambia, 35% did not have a laryngoscope. A study from Nigeria found that most facilities could not provide general anesthesia (53%); another survey in the Democratic Republic of Congo demonstrated 40% of hospitals lack suction, and in Guatemala only 17% of facilities surveyed had capnography. In Uganda, a 2014 survey of health facilities that offer emergency services and surgical care revealed only 22% had pediatric airway equipment, 41% adult airway equipment, and 28% a pulse oximeter. In one survey about obstetric operating room capacity in the five main referral hospitals in East Africa (Uganda, Kenya, Tanzania, Rwanda, and Burundi), only 4% of the providers surveyed reported the presence of electrocardiograph (ECG), pulse oximetry, continuous blood pressure monitoring, capnography, thermometer, stethoscope, difficult airway cart, suction machine, recovery room, and intensive care unit (ICU) facilities. Access to reliable oxygen is a common problem in resource-constrained health systems. In such settings, oxygen is rarely available through central pressurized gas lines and more often provided via tanks or oxygen concentrators, the latter of which has been shown to offer long-term cost savings and increased reliability. (Further discussion of oxygen supply challenges in resource-limited settings is provided in the section, Essentials for Practice in Resource-Constrained Settings of this chapter)

Equipment donations are common in LMICs, however, they often have limited long-term impact and multiple unintended consequences. Donations are frequently made with limited understanding of local needs, lack of communication between donor and recipient, and absence of ongoing technical support or access to consumables. Well-intentioned donors are often unaware of WHO Guidelines for Medical Device Donation, or of the fact that purchase costs account for only 20% of total lifetime costs for a piece of equipment. As a result, up to 30% of donated equipment may only transiently or never become operational, and commonly accumulates in equipment graveyards because of a sense of obligation by recipients to not throw anything away. For example, donations of modern anesthesia machines from HICs is commonly encountered in many LMICs. Without reliable power, pressurized gas supplies, biomedical support, or access to disposables (e.g., carbon dioxide absorbent, humidity filters, circuit tubing), it is sometimes hard to argue in favor of these machines.

Reliable access to medications and blood are two additional common infrastructure challenges limiting access to safe surgery and anesthesia services worldwide. The WHO Essential Medicines List includes medications to safely perform general anesthesia, monitored anesthesia care (MAC), neuraxial, regional, local anesthesia, as well as acute and chronic pain management ( Box 2.3 ). Despite the existence of the list for more than 40 years, critical shortages of many medications persist. A WHO survey of all health facilities in Uganda examined availability of twelve anesthetic drugs (atracurium, bupivacaine, halothane, isoflurane, desflurane, sevoflurane, ketamine, lidocaine 2%, lidocaine 5% heavy spinal injection, midazolam, nitrous oxide, and suxamethonium) and found that only 2% of the surgical health facilities had all of these medications and only 19% had half. The same WHO survey in the Democratic Republic of Congo found that only 33% of hospitals had bupivacaine, 21% thiopental, and 16% halothane. Factors specifically affecting access to analgesics are discussed further in the next section, though supply chain, cold storage, and cost are common challenges that limit availability for many drugs. Drug quality is also a factor in some LMICs where variable manufacturing quality and fraud (i.e., counterfeiting) are commonly encountered. It is estimated that 1 in 10 medical products (e.g., medications) found in LMICs are substandard or falsified and result in hundreds of thousands of deaths each year.

The WHO Essential Medicines List also includes blood products. Despite more than four decades of global advocacy (1975 WHA28.72) for universal access to safe blood, limited transfusion capacity significantly impacts the ability to provide safe surgery and anesthesia care, especially for rural and LMIC populations. Most rural surgical facilities are unable to provide consistent access to safe blood. Patients lack timely access to safe blood as a result of several common challenges including inadequate blood supply, distribution networks, rural blood banking capacity, safety protocols, workforce (e.g., pathologists, laboratory technicians), testing supplies, and policy implementation, as well as high costs of blood and high prevalence of infectious diseases. The whole blood donation rate is used as an indicator of blood availability. The LCOGS recommends a minimum of 15 blood donations per 1000 people per year, yet this rate is 4.6 per 1000 people per year in LICs (compared with 32.1 per 1000 people per year in HICs). Most LMICs cannot maintain adequate supply from voluntary non-remunerated donors (VNRDs) alone (as advocated by WHO), and the use of paid donors or family donors poses numerous logistic and safety concerns. According to WHO data, 71 countries collect the majority of their blood supply from family or paid donors, 50% lack capacity to separate blood components, and 23.5% of countries have less than 100% screening for at least one of these transfusion-transmissible infections: HIV, hepatitis B, hepatitis C , or syphilis. For many LMICs, investment in transfusion infrastructure, expansion of transfusion research, and advocacy (including rethinking of well-intentioned but context-limited policies such as VNRD-only mandates, requirements for onsite pathologists, and mandatory replacement units) are critical areas for engagement by anesthesia providers in the greater global health community.

There is an evolving consensus on global standards for anesthesia equipment, medications, and other infrastructure. As a result, most assessments of facility or national capacity capture different data that may over- or underestimate current infrastructure limitations. For example, lack of access to rocuronium, sevoflurane, or propofol does not necessarily indicate inability to safely perform anesthesia if suxamethonium, halothane, isoflurane, or thiopental are available. Currently efforts are underway by the WFSA, GICS, and other organizations to develop anesthesia-specific research tools to assist LMICs in monitoring and evaluation of anesthesia capacity. The global anesthesia and surgical communities are likely to benefit from continued collaboration and harmonization of efforts that assess global anesthesia infrastructure.

Inequities in Analgesia

Five billion people worldwide have little or no access to analgesia. As with the surgical disease crisis, inequities in analgesia access are in part a result of the limited availability of data that quantify the problem. Unlike most traditional global health metrics that focus on extending healthy life and productivity, alleviating pain may not always target these same goals (e.g., acute surgical pain relief and palliative care), thus adding to the complexity of quantifying pain burden. Massive inequities in access to analgesia are also attributed to several additional factors including advocacy challenges (pain is not disease specific or easy to associate with a “face”), limited training opportunities for healthcare professions, fear of addiction and diversion, financing, supply chain limitations, cultural attitudes, and regulatory and legal barriers ( Box 2.4 ). In the ensuing discussion, we consider some of these barriers and potential areas for intervention by the global anesthesia community.

Limited financial resources and infrastructure hinder the ability of healthcare systems to deliver analgesia (i.e., effective supply chains) and limit the ability of patients to afford such care. Countries with a lower GDP or human development index have less access and use of opiates. Opiate prices in LMICs are often significantly higher relative to GDP. In the recent past in Argentina and Mexico, the monthly cost of an opioid prescription for oncologic pain was reported to be more than 200% the average monthly income. In Rwanda, the reported price of injectable morphine is 6 times the lowest cost reported in the International Drug Price Indicator Guide. Drivers of these inflated prices include import costs, taxes, licensing fees, storage and sales restrictions, and limited public finance programs. International regulations and misconceptions about pain treatment and addiction form the basis for many of these interventions.

Misinformation about analgesia has biased knowledge and attitudes among providers, patients, and policymakers, and has resulted in significant undertreatment of pain. Several studies have demonstrated that the risk of addiction associated with appropriate analgesic administration is significantly exaggerated and especially low for acute, oncologic, or end-of-life pain. Nonetheless, widespread and excessive fears over diversion and addiction have resulted in unnecessarily onerous regulatory barriers that often confuse tolerance and dependence, users and addicts, and disproportionately affect poor and marginalized populations. In China, for example, a domestic ketamine abuse problem has led to repeat lobbying of the International Narcotics Control Board (INCB) by the Chinese government to reschedule ketamine as a schedule I drug for all countries. Such regulation would effectively remove the nearly ubiquitous access to ketamine in LMICs, and further exacerbate the ongoing global pain crisis. Ketamine is inexpensive, accessible, and safe, and as a result has become a critical resource for the provision of safe and accessible anesthesia and analgesia services worldwide. Fortunately, attempts to restrict ketamine have been promptly recognized as heartless and a violation of international regulatory policies.

Tramadol is another analgesic with frequently misunderstood pharmacology that is commonly found in LMICs. Tramadol is not controlled by international regulations, which has led to its widespread availability for analgesia but also to its abuse. Abuse is widely reported in many HICs (e.g., Canada) and LMICs (e.g., many countries in Africa and the Middle East) and is so severe that in countries like Cameroon, it can literally be found in the groundwater as a result of human excretion. Tramadol is not considered an adequate substitute for opiates and is not included in the WHO Essential Medicines List.

Contemporary legal and regulatory/policy frameworks have significantly exacerbated disparities in access to analgesia care. In the wake of several key events in the 1800s that fueled skyrocketing opioid abuse, including the Opium Wars and invention of the hypodermic syringe, the beginning of the 20th century produced several of the first national and international efforts to restrict and regulate narcotics. This included the first international conference on narcotics in 1909 (International Opium Convention in Shanghai) and the first multilateral drug treaty in 1912 (The Hague Opium Convention). One of the most notable regulations of the 20th century is the 1961 UN Single Convention on Narcotic Drugs. The opening sentence of the “Single Convention” recognizes, “…that the medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering and that adequate provision must be made to ensure the availability of narcotic drugs for such purposes…” The Single Convention set out to control the use and trade of plant-based drugs (opium, cannabis, and cocaine) while also assuring availability for medical purposes. This regulation mandated government participation (reporting national estimates of narcotic needs, meticulous record keeping), regulated drug cultivation, restricted trade to authorized international parties, and created the INCB. The INCB was tasked with monitoring UN drug convention implementation and required each country to designate an enforcement office (e.g., the Drug Enforcement Administration [DEA] in the United States). While most countries adopted this onerous regulation, most poor countries did not have the extensive resources needed to enact all of these changes. The Single Convention’s “global estimates” system has been particularly difficult for many countries to implement. This system requires all countries to provide an estimate of opiate need (for medical purposes) in order to inform global production goals and limit excess opiate supplies that are at risk for illicit use. Accurate estimates require significant resources, and for many LMICs, inability to provide accurate estimates translates directly to inadequate supply. For example, 2017 opiate estimates for Chad (population 14.5 million) predicted 341 g fentanyl, 249 g morphine, and 105 g codeine. When compared to estimates from Canada (population 36.3 million: 150,000 g fentanyl, 4,750,000 g morphine, 40,020,000 g codeine, and 70 other controlled substances) the disparity and gross underestimation is apparent. By approving such gross underestimates, the INCB effectively is legally prohibiting patients from having access to opiates. In times of humanitarian crisis, the Single Convention impedes the ability to emergently augment local analgesia capacity as became evident in the wake of the 2010 Haiti earthquake.

Global regulations to curb illicit use have dominated efforts to ensure access to analgesics for medical purposes (or to ensure access to substance abuse treatment). In 1985, the Parliament of India passed the Narcotic Drugs and Psychotropic Substances Act to enforce international drug policy (e.g., the Single Convention). The Act’s onerous regulations and extreme penalties (including the death penalty for certain drug-related crimes) resulted in more than a 90% decrease in the medicinal use of morphine. This imbalance, referred to by some as “collateral damage from the war on drugs,” disproportionately affects LMICs and continues to cripple access to analgesics for the majority of the world’s population. Such bias has also impaired scaleup of addiction treatment initiatives. For example, addiction treatment (methadone and buprenorphine) was not added to the WHO Essential Medicines List until 2006, approximately 100 years after the passage of the earliest narcotic regulations and 40 years after the list’s creation.

The prohibitory biases of prior international drug policy has resulted in numerous national regulatory barriers that include limitations on who can prescribe, dispense, or administer opiates, as well as limitations on indications (e.g., postoperative but not cancer pain), dosages, or duration of therapy. For example, in Armenia only oncologists with the approval of multiple providers can prescribe outpatient opiates, whereas in the Ukraine, healthcare providers must travel to the patients’ homes to administer outpatient opiates. In Jordan, the maximum duration of an opiate prescription for oncologic pain is 10 days, and only three days for all other conditions. These myriad regulations create an additional barrier by inducing fear of prosecution for noncompliance among health professionals, thereby reducing provider willingness to prescribe. Lack of adequate training opportunities for healthcare providers, especially in LMICs, coupled with the rare use of analgesics in clinical practice, create a cycle whereby fewer and fewer providers feel comfortable prescribing opiates.

Several amendments to the Single Convention have been enacted including the 1971 Convention of Psychotropic Substances, the 1988 UN Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, the inclusion of morphine in the first WHO Essential Medicines List in 1977, and introduction of the WHO Pain Ladder in 1986. Despite these efforts most of the world’s population remains without reliable access to analgesia. Nearly 60 years after the Single Convention, the number of drug abusers in many countries is near all-time highs while 150 countries still lack reliable access to analgesia. Even the UN’s SDGs, which aim to set development priorities for the world, reflect the prohibitory bias of prior international policies. SDG 3.5 calls for improved prevention and treatment for substance abuse, including narcotics, but fails to mention pain or palliative care anywhere else in the SDGs.

Advocacy and education efforts by the global stakeholders, including the anesthesia community, as well as rethinking of international analgesic policy (including the Single Convention) are essential for progress in addressing the global pain crisis. Education for healthcare providers, policymakers, and the public can play a significant role in expanding access to analgesia. Such efforts should focus on pharmacologic treatment strategies, but should also emphasize better understanding and management of causes and contributors to pain, including social and economic determinants. Efforts by numerous Ministry of Health agencies have had small successes. In Vietnam and India, grassroots- and civil-society-led policy initiatives to allay opiophobia and reduce institutional licensing regulations have significantly increased access to analgesia without an increased diversion. In Uganda, advocacy efforts by the nongovernmental organization Hospice Africa Uganda helped convince the Uganda Ministry of Health in 1993 to import morphine powder and to provide domestically made morphine liquid free to all cancer or HIV/AIDS patients. In 2004, the Uganda Ministry of Health legalized opioid prescribing by nurses and clinical officers with palliative care training, which significantly expanded access to analgesia especially in rural communities. The import and domestic packaging of oral morphine for palliative care has translated into greater access to oral morphine for the anesthesia and surgical communities. A similar model is currently being adopted in Rwanda, Nigeria, Kenya, Swaziland, and Malawi.