Anesthesia in Low-Resource Settings

Surgery and anesthesia are essential health services, but they are unavailable in many parts of the world.¹ An estimated one third of the world’s population does not have access to essential surgical resources, and even more people are exposed to unsafe anesthesia practices.¹ Low- and middle-income countries face shortages in human resources, technical resources, education systems and other utilities that prevent them from achieving the same standards of anesthesia care as high-income countries.² When anesthesiology practitioners from high-income countries travel to low-resource settings to provide care, they are often confronted by a lack of resources and different health issues among their patients.³ Anesthesia providers should consider the low anesthetic capacity in low- and middle-income countries, the importance of safe anesthesia and future strategies to approach global anesthesia care.¹

Anesthesia is necessary for the management of a variety of situations, including obstetric surgery,⁴ childbirth,⁵ abdominal surgery,⁶ injuries⁵ and other surgical conditions. However, providers in low-resource settings are unable to give proper anesthesia care to patients due to shortages of personnel, drugs, equipment and training.⁷ For example, a study by Hodges et al. found that in Uganda, only 23 percent, 13 percent and 6 percent of anesthetists had the facilities to deliver safe anesthesia to an adult, to a child and for a Cesarean section, respectively.⁷ Additionally, many educated clinicians in low-income settings emigrate to places with more opportunities for growth and better resources.⁸ As a result, anesthesia providers in low-resource areas have few role models, low wages, inadequate equipment and limited professional development opportunities.^5,8 Overall, an insufficiency of technological supplies, medications and training combined with a small workforce makes anesthesia care low in quality, if existent at all, in low-resource settings.

Yet anesthesia care is highly important to health care and general success of low-income regions.¹ Conservative estimates show that conditions requiring surgery and anesthesia contribute to 11 percent of the global burden of disease, and poor anesthetic care could result in further morbidity or mortality.⁹ For example, the inability to provide safe anesthesia for women in childbirth, whether for Cesarean section or vaginal delivery, contributes to high fetal and maternal mortality rates in low-resource settings.¹⁰ Anesthetic shortages also contribute to disparities in global mortality rates from injuries, as 90 percent of deaths from injuries occur in low- or middle-income countries.¹¹ The Global Burden of Disease Study estimates that by 2030, injuries will be the fifth leading cause of death in low- and middle-income countries, ahead of HIV, tuberculosis and malaria.¹² This is especially concerning given the role anesthesia and surgery play in preventing injury-related deaths. Evidently, anesthesia is crucial to preventing issues such as maternal, fetal and injury-related morbidity and mortality, all of which are common in low-resource regions.¹

Anesthesiology professionals and other health providers can work towards better anesthesia care in low-resource settings. Walker et al. suggest that nurses or clinical officers be provided with effective anesthesia training programs in settings without anesthesiologists.⁸ Hodges et al. encourage local structural changes, such as improvements in local management, finances and logistics.⁷ In their review, Bharati et al. mention that use of local or epidural anesthetics may lower risk of mortality in cases where resuscitation equipment, vital signs monitors and mechanical ventilators are unavailable.² The authors also make a variety of suggestions for enhancing anesthesia provision in low-resource settings, including continuous education for nurse anesthetists, simulation training for medical students, adequate resuscitation equipment, changes in prescription practices and development of transportation infrastructure.² However, these improvements all require contributions by high-income countries and global organizations.² Education and local infrastructure changes may be helpful in low-resource settings, but these advances—along with technological development, proper equipment and improved transportation—may be difficult to achieve without a global effort.

Anesthesia and surgery are crucial to maintaining a healthy population. However, safe anesthesia care is sorely lacking in low-resource settings. A lack of supplies, technology, infrastructure and health professionals makes anesthesiology extremely difficult in low-resource regions. This can contribute to obstetric, injury-related and other surgical complications and mortality. Global health policymakers should shift focus and funding to anesthesia provision in low-resource regions to work toward a healthy global population.¹

1.         Li V, Neuen BL. Access to safe anesthesia: A global perspective. The Journal of Global Health. April 1, 2014.

2.         Bharati SJ, Chowdhury T, Gupta N, Schaller B, Cappellani RB, Maguire D. Anaesthesia in underdeveloped world: Present scenario and future challenges. Nigerian Medical Journal. 2014;55(1):1–8.

3.         University of Oxford Nuffield Department of Clinical Neurosciences. Anaesthesia in Developing Countries. Continuing Professional Development 2020; https://www.ndcn.ox.ac.uk/study-with-us/continuing-professional-development/anaesthesia-in-developing-countries.

4.         Grady K. Building capacity for anaesthesia in low resource settings. BJOG: An International Journal of Obstetrics & Gynaecology. 2009;116(s1):15–17.

5.         Cherian M, Choo S, Wilson I, et al. Building and retaining the neglected anaesthesia health workforce: Is it crucial for health systems strengthening through primary health care? Bulletin of the World Health Organization. May 10, 2010;88:637–639.

6.         Khan FA, Merry AF. Improving Anesthesia Safety in Low-Resource Settings. Anesthesia & Analgesia. 2018;126(4):1312–1320.

7.         Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA, Wilson IH. Anaesthesia services in developing countries: Defining the problems. Anaesthesia. 2007;62(1):4–11.

8.         Walker I, Wilson I, Bogod D. Anaesthesia in Developing Countries. Anaesthesia. 2007;62(s1):2–3.

9.         Ozgediz D, Riviello R. The “other” neglected diseases in global public health: Surgical conditions in sub-Saharan Africa. PLoS Medicine. 2008;5(6):e121.

10.       Dyer RA, Reed AR, James MF. Obstetric anaesthesia in low-resource settings. Best Practice & Research Clinical Obstetrics & Gynaecology. 2010;24(3):401–412.

11.       Bae JY, Groen RS, Kushner AL. Surgery as a public health intervention: Common misconceptions versus the truth. Bulletin of the World Health Organization. 2011;89(6):394.

12.       Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet (London, England). 2012;380(9859):2095–2128.