Group
Injuries
Infectious disease
Cancer
Pregnancy-related complications
Disasters and emergencies
Congenital disease
WHO GIEESS [7]
Optimal management starts at first-referral facility
EESC works to strengthen essential surgical care
High-HIV transmission risk in Africa
EESC works to improve safety of clinical procedures
EESS works for early detection
1/3 of all pregnancy-related complications can be treated with surgery
Timely access reduces death rate and disability
EESC works with partners to provide guidance for disaster preparedness and response
50 % of congenital abnormalities can be treated with surgery
EESC promotes cost-effective and disability-preventative measures
Médecins Sans Frontières [8]
Chagas
Cholera
Leishmaniasis
Malaria
Measles
Meningitis
Tuberculosis
Trypanosomiasis
Women’s health
Obstetric fistulae
Natural disasters
Armed conflicts
Debas (author) four Sig. types of surgery [91]
Provision of competent care to injury victims
Reduce preventable deaths
Decrease personal dysfunction
Decrease burden on families
HIV
Handling of obstetric complications:
– Obstruction of labor
– Hemorrhage
Elective care of simple surgical conditions:
– Hernia
– Clubfoot
– Cataract
– Hydrocele
– Otitis media
5,000,000 deaths per year due to injuries
1,200,000 deaths per year due to road accidents
50,000,000 injured due to road accidents
287,000 deaths per year due to pregnancy-related complications
800 deaths per day
2,000,000 obstetric fistulae per year
100,000 children born annually with club feet
These definitions do require some care, however. Certain conditions that should be classified as surgical—for example long bone traction—may not be so classified because no anesthetic or operating suite is involved. Conversely, other conditions that do not require a surgical incision but are also on the spectrum of surgical care—fluid resuscitation and emergency airway management—may also be misclassified [9].
While surgery does require significant input in terms of skilled labor (e.g., surgeons, anesthetists, and nurses) and is technologically intensive (surgical and anesthetic equipment, dedicated operating room space), the presented evidence suggests that the return in quality life years for selected patients can exceed the expenditure. For example, emergency obstetric care at a rural hospital in Bangladesh was calculated to be US$10.93 per DALY averted [10–12].
Disparity in Access to Surgical Care
Before analyzing discrepancies in surgical care between HIC and LMICs, the framework utilized to make these comparisons must be understood. The WHO classifies member countries depending on both Gross National Income and Region, based on World Bank criteria [13].
WHO Member States are grouped into six regions (2012) including the African Region, the Region of the Americas, the Eastern Mediterranean Region, the European Region, the South-East Asia Region, and the Western Pacific Region. WHO Member States are grouped into four gross annual income groups (GNI) per capita (low, lower middle, upper middle, and high) based on the World Bank list of economies for the year 2011 (released July 2012) (Table 4.2).
Table 4.2
World Bank categories of countries by income group
Gross income groups | Criteria (per capita) |
---|---|
Low income (LI) | Less than $1,035 |
Lower middle income (LMI) | $1,036–$4,085 |
Upper middle income (MI) | $4,086–$12, 615 |
High income (HI) | Greater than $12,616 |
In the USA, annual per capita healthcare spending (2011) is on the order of $8,608 [14, 15]. Of this, roughly US$4,400 is spent by the government. At the other extreme Eritrea, Ethiopia, Central African Republic, Madagascar, the Democratic Republic of the Congo and Niger all spend less than $20 USD per capita annually on health care (Table 4.3), which is extremely low, even when calculated in terms of purchasing power parity (PPP).
Table 4.3
Purchasing power parity, total healthcare expenditure, and healthcare expenditure as a percentage of GDP, 2012 data (World Bank)
Rank | Country | Region | $PPP | THE | % GDP |
---|---|---|---|---|---|
3 | Qatar | a | 80,470 | 1,707 | 1.9 |
8 | Singapore | a | 60,110 | 2,787 | 4.6 |
USA | a | 52,610 | 8,608 | 17.9 | |
140 | Mongolia | East Asia and Pacific | 5,020 | 251 | 5.3 |
168 | Nigeria | Sub-Saharan African | 2,450 | 139 | 5.3 |
170 | Yemen, Republic | Middle East and N. African | 2,310 | 152 | 5.5 |
186 | Zambia | Sub-Saharan African | 1,590 | 99 | 6.1 |
187 | Afghanistan | South Asia | 1,560 | 50 | 9.6 |
187 | Tanzania | Sub-Saharan African | 1,560 | 107 | 7.3 |
191 | Nepal | South Asia | 1,470 | 68 | 5.4 |
194 | Rwanda | Sub-Saharan African | 1,320 | 135 | 10.8 |
196 | Haiti | Latin American and Caribbean | 1,220 | 94 | 7.9 |
199 | Uganda | Sub-Saharan African | 1,120 | 128 | 9.5 |
200 | Ethiopia | Sub-Saharan African | 1,110 | 52 | 4.7 |
207 | Togo | Sub-Saharan African | 900 | 80 | 8.0 |
208 | Niger | Sub-Saharan African | 760 | 39 | 5.3 |
209 | Malawi | Sub-Saharan African | 730 | 77 | 8.4 |
210 | Liberia | Sub-Saharan African | 580 | 112 | 19.5 |
211 | Burundi | Sub-Saharan African | 550 | 52 | 8.7 |
211 | Eritrea | Sub-Saharan African | 550 | 17 | 2.6 |
213 | Congo, D.R. | Sub-Saharan African | 390 | 32 | 8.5 |
Data from the World Bank [16]. PPP is used in international comparisons based on currencies to estimate what market basket of goods a currency could purchase. They are used in economics to eliminate distortions that can occur when comparisons are made on the basis of market exchange rates.
As the above tables show, there are dramatic funding disparities from country to country. However, even if funding were to be increased in sub-Saharan Africa—the most concentrated, impoverished region—there would be major issues of healthcare delivery because there is no established infrastructure coupled with a large deficit of healthcare providers here and in other LMICs. In Table 4.4, we also see the significant variation in the distribution of physicians, nurses, and available hospital beds when countries are ranked by PPP. Regional variation again is striking, with sub-Saharan Africa having the greatest shortages in all categories.
Table 4.4
Physicians, nurses, and hospitals beds
Rank | Country | Region | Physicians per 1,000 | Nurses+ per 1,000 | Hospital beds per 1,000 |
---|---|---|---|---|---|
3 | Qatar | a | 2.80 | 7 | 1.2 |
8 | Singapore | a | 1.90 | 6 | 2.7 |
13 | USA | a | 2.40 | 10 | 3.0 |
140 | Mongolia | East Asia and Pacific | 2.80 | 4 | 6.8 |
168 | Nigeria | Sub-Saharan African | 0.40 | 2 | – |
170 | Yemen, Republic | Middle East and N. African | 0.20 | 1 | 0.7 |
186 | Zambia | Sub-Saharan African | 0.10 | 1 | 2.0 |
187 | Afghanistan | South Asia | 0.20 | 0 | 0.4 |
187 | Tanzania | Sub-Saharan African | 0.00 | 0 | 0.7 |
191 | Nepal | South Asia | – | – | 5.0 |
194 | Rwanda | Sub-Saharan African | 0.10 | 1 | 1.6 |
196 | Haiti | Latin American and Caribbean | – | – | 1.3 |
199 | Uganda | Sub-Saharan African | 0.10 | 1 | 0.5 |
200 | Ethiopia | Sub-Saharan African | 0.00 | 0 | 0.4 |
207 | Togo | Sub-Saharan African | 0.10 | 0 | 0.7 |
208 | Niger | Sub-Saharan African | 0.00 | 0 | – |
209 | Malawi | Sub-Saharan African | 0.00 | 0 | 1.3 |
210 | Liberia | Sub-Saharan African | 0.00 | 0 | 10.8 |
211 | Burundi | Sub-Saharan African | – | – | 1.9 |
211 | Eritrea | Sub-Saharan African | – | – | 0.7 |
213 | Congo, D.R. | Sub-Saharan African | – | – | 0.8 |
As seen in Table 4.4, LMICs have fewer physicians, nurses and midwives, and hospital beds per capita compared to more affluent countries. Exacerbating this discrepancy however is the fact that compared to population growth rates, most-sub-Saharan African nations have an actual negative annual growth rate in the number of physicians produced [17]. Because of the hardships of practice in these locations, better reimbursement for competing professions (engineering) and the employment opportunities in countries which spend more money per capita on healthcare, many individuals in LMICs either choose alternative professions or if they do enter medicine, they are induced to migrate elsewhere for better wages and living conditions.
A study of healthcare workers in Ghana revealed a marked preference for migration to ODEC countries [95]. For healthcare workers, this was of particular concern because their training is generally publically funded. One model found that for the United Kingdom, the country had a net overall gain by the importing of foreign physicians, the exact opposite was seen in the exporting country. Although only 1.91 % of the total population migrated, this was reflective of 8.07 % of the total expenditure on education of the current population.
Access to surgery, operating suites, and trained anesthesia personnel is even more starkly imbalanced between HI countries and those of sub-Saharan and other LI countries. Weiser et al. [18] found that the global volume of major surgery was between 187 and 281 million cases, which is equivalent to one operation for every 25 people living in 2004. These researchers further found that countries spending less than USD $100 (2004) per person only had 295 major surgeries per 100,000 people. In contrast, countries spending more than USD $1,000 (2004) per person had surgical incidences of 11,110 per 100,000 people.
Weiser et al. also showed that MI and HI countries accounted for 30.2 % of the world’s population but received 73.6 % of the surgical operations, whereas poor expenditure countries (less than or equal to USD $100 per person) accounted for 34.8 % of the global population and received only 3.5 % of all surgical procedures. This striking difference is not primarily due to nonessential surgical care. For example, in the USA in 2010 there were 51.4 million procedures performed on inpatients. Some of these procedures were endoscopies and cardiac catheterizations, but for the most part the procedures are those typically associated as “surgical” [19]. The number of aesthetic surgical procedures performed in the USA in 2012 was 289,000 [20]. Consequently, it can be seen that even with cosmetic and other procedures, the bulk of surgical interventions in the USA and other HI countries is not solely the result of nonessential intervention. Rather, what these data emphasize is that the extremely low volume of surgery performed in LMICs underscores a lack of access to surgical services in these locations. With this large, unaddressed surgical disease burden worldwide, measurement of surgical outcomes and public health evaluations in surgical disease are warranted.
In HI countries, mortality from anesthesia was found to be on the order of 6.4 deaths per 10,000 anesthetics by Beecher and Todd in 1954. By 1980, the mortality rate from anesthesia had decreased to 2 deaths per 10,000 anesthetics and current data indicates that anesthetic mortality is on the order of 1 death per 100,000–200,000 [21]. Major morbidity occurs in 3–16 % of cases. In contrast, in developing countries, the death rate remains 5–10 %, which is 500–1,000 deaths per 10,000 administered anesthetics [22] (Table 4.5). These data suggest that while affluent portions of the world have benefited from advances in anesthesia over the past six decades, with risk from dying from anesthesia being on the order of 1:200,000 anesthetics, LMICs have not seen any improvement. Anesthetic-related mortality in these environments is worse than experienced in the developed world since the inauguration of the age of anesthesia in the nineteenth century [23].
Table 4.5
Current comparative mortality rates in the UK and selected LMICs
Study | Mortality rate | Reference(s) |
---|---|---|
UK confidential enquiry for perioperative death | 1:185,000 | |
University teaching Hospital, Zambia | 1:1,925 | [87] |
Central Hospital, Malawi | 1:504 | [88] |
District Hospital, Zimbabwe | 1:482 | [9] |
Teaching Hospital, Nigeria | 1:387 | [89] |
Teaching Hospital, Togo | 1:133 | [90] |
Differences in frequency of surgical procedures could perhaps be explained by availability of surgical resources. Funk et al. [24] noted that there are more than 14 operating theaters per 100,000 people in high-income countries and 1–25 per 100,000 in middle to low-income countries. Moreover, almost 20 % of operating rooms worldwide were not equipped with pulse oximeters and this was not the case in high-income countries. Pulse oximeters are not the only equipment-related resources missing in LMICs. As seen below, simple things such as functional operating table are frequently not available. And, basic infrastructure requirement—such as electricity and water—cannot be guaranteed (Table 4.6).
Table 4.6
Unavailability of requirements for administration of anesthesia
% Unavailable | Anesthesia specific |
74 | Pulse Oximeter |
59 | No spinal solutions available at all times |
23 | Tilting operating room table |
22 | Oxygen source |
21 | Appropriately sized endotracheal tubes |
Facility Specific | |
80 | Electricity not always available |
44 | Running water not always available |
30 | Fluids not always available |
Workforce
Differences in the availability of human resources are also striking. In the USA (2011), there were approximately 35,000 anesthesiologists, an equal number of certified registered nurse anesthetists (CRNA), and 1,300 anesthesia assistants (AA) actively practicing in the USA [25]. This yielded a trained anesthesia provider for every 4,295 individuals in the USA. In the UK, the ratio is on the order of 1 anesthetist for every 5,333 persons (2007) [26].
In contrast to high-income countries, in a 2006 study in Uganda [27], questionnaires were distributed to attendees at a national anesthesia refresher course sponsored by the Ugandan Society of Anaesthesia, the Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the World Federation of Societies of Anesthesiologists (WFSA). Of the 91 attendees, only one was a physician anesthetist in the group (all called anesthetists in this study). The vast majority of providers had attended a course in the administration of anesthesia of 1–2 years duration. Fewer than half had their own textbooks of anesthesia. In the UK, for 60 million people, there are roughly 12,000 anesthetists while in Uganda with a population of 27 million, there are 13 medical anesthesiologists and 330 nonphysician anesthesia providers. These figures are also seen in Afghanistan, with nine physician anesthetists for a population of 32 million and Bhutan with eight for a population of 700,000 [28].
In this study, only 23 % of the Ugandan anesthesia providers had the minimum requirements in their facilities for the safe administration of general anesthesia, only 13 % of anesthetists were able to provide safe anesthesia to children, and only 6 % of anesthetists in this study could provide safe anesthesia for a C-section with either a general or spinal anesthetic.
Dubowitz et al. provides some explanation of a relationship between economic rank and anesthesia availability [94]. Using a descriptive questionnaire mailed to the LMICs from the WHO, ministries of health, the following significant findings emerged:
1.
Most LMICs surveyed had ratios of 1 or less physician or nonphysician anesthesia provider per 100,000 populations.
2.
Inadequate nursing and surgical staff and limited hospital beds are also critical issues.
3.
These discrepancies translate into low average life expectancy, high infant mortality, and high under-five mortality rates.
4.
Again, as noted above, anesthesia-related mortality is extremely high.
Lack of funds and training are not the only problems, however. Even if appropriate funding were available, other problems for the provision of healthcare services–especially anesthesia service–remain. There is poor infrastructure, inadequate equipment or equipment that is frequently in disrepair, long and harsh working conditions, bureaucratic roadblocks [29] and lack of professional recognition. There are also incentives for trained personnel to migrate to urban settings or transnationally [30].
Within LMICs, most surgical and anesthesia providers cluster in urban environments, especially treating patients with the financial resources to pay for care [31]. For example, if one looks at the statistics for the entire country of Haiti before the 2010 earthquake, low-end estimates of maternal mortality are 523 per 100,000 live births. Community-based surveys have placed this number for the country as a whole at 1,400 per 100,000 live births [32]. This is in stark contrast to the much lower C-section rates and maternal mortality rates seen in Haitian cities, which approach those seen in the US. The maternal mortality ratio in other LMIC countries is 240 per 100,000 births versus 16 per 100,000 in HI countries with large disparities within countries, between people with high and low income, and between people living in rural and urban areas [33].
Delivery of Anesthesia Care
In general, three types of clinical personnel administer anesthesia globally: anesthesiologists, anesthesia assistants, and nurse anesthetists or surgical nurses. Anesthesiologists are medical professionals who have received medical degrees and appropriate training. Anesthesia assistants are trained professionals that specifically assist anesthesiologists. Nurse anesthetists are nurses who receive specialized training related to anesthesia, which may include drug administration. In certain countries, surgical nurses are trained to administer and/or monitor anesthesia. Thus, the specialty of nurse anesthetist does not exist. Each country has various restrictions that govern the practice of each type of clinical personnel.
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