Special Article - SAGE Journals

Anaesth Intensive Care 2016 | 44:3

M. G. Cooper et al

Special Article Global safe anaesthesia and surgery initiatives: implications for anaesthesia in the Pacific region M. G. Cooper*, P. B. Wake†, W. W. Morriss‡, P. D. Cargill§, R. J. McDougall**

Summary

In 2015 three major events occurred for global anaesthesia and surgery. In January, the World Bank published Disease Control Priorities 3rd edition (DCP 3rd edition). This volume, Essential Surgery, highlighted the cost effective role of anaesthesia and surgery in global health. In April, the Lancet Commission on Global Surgery released its report “Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development”. The report focuses on five key areas to promote change including: access to timely surgery, surgical workforce and procedural capability, surgical volume, data collection such as perioperative mortality rate, and financial protection. In May, the 68th World Health Assembly (WHA) voted in favour of Resolution A68/31: Strengthening emergency and essential surgical and anaesthesia care as a component of universal health coverage. The resolution was passed unanimously and it is the first time that surgery and anaesthesia have received such prominence at WHA level. These three events all have profound implications for the provision and access of safe anaesthesia and surgery in the Pacific region in the next 15 years. This article considers some of the regional factors that affect these five key areas, especially with regard to anaesthetic specialist workforce density in different parts of the region. There are many challenges to improve anaesthesia access, safety, and workforce density in the Pacific region. Future efforts, initiatives and support will help address these problems.

Key Words: global, anaesthesia, surgery, Pacific In this article we would like to draw the attention of anaesthetists in the Pacific region to three major events in 2015, making it a momentous year for global anaesthesia and surgery. We would like to discuss the implications of these reports and resolutions, and highlight the role of anaesthetists in Australia and New Zealand in promoting access to safe anaesthesia and surgery in the Pacific region.

* MBBS FANZCA FFPMANZCA, Chair, Overseas Aid Committee, Australian & New Zealand College of Anaesthetists, Adjunct Professor of Anaesthesiology, University of Papua New Guinea, Papua New Guinea, Senior Anaesthetist, Department of Anaesthesia, The Children’s Hospital at Westmead and St George Hospital, Sydney, New South Wales † MBBS DA MMed (Anaesthesiol), Lecturer, Discipline of Anaesthesiology and Intensive Care, School of Medicine and Health Sciences, University of Papua New Guinea, Papua New Guinea ‡ MBBCh DipObs FANZCA, Chair, Education Committee, World Federation of Societies of Anaesthesiologists, Consultant Anaesthetist, Department of Anaesthesia, Christchurch Hospital, Christchurch, New Zealand § BA(Hons) MDevPract, Policy Officer, Australian & New Zealand College of Anaesthetists, Melbourne, Australia ** MBBS FANZCA, Honorary Clinical Associate Professor, The University of Melbourne, Chair, Overseas Development and Education Committee, Australian Society of Anaesthetists, Anaesthetist, Department of Anaesthesia and Pain Management, Royal Children’s Hospital, Melbourne, Victoria Address for correspondence: Dr Michael G Cooper. Email: [email protected] Accepted for publication on February 18, 2016

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The three major events are as follows: firstly, in January, the World Bank published the first of nine volumes on Disease Control Priorities 3rd edition (DCP 3rd edition). This volume, Essential Surgery, highlighted the cost effective role of anaesthesia and surgery in global health1. Secondly, in April 2015, the Lancet Commission on Global Surgery released its report “Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development”2. The report focuses on five key areas to promote change including: access to timely surgery, surgical workforce and procedural capability, surgical volume, data collection such as perioperative mortality rate (POMR), and patient financial protection. Thirdly, in May, the 68th World Health Assembly (WHA) voted in favour of Resolution A68/31: Strengthening emergency and essential surgical and anaesthesia care as a component of universal health coverage3. The resolution was passed unanimously and it is the first time that surgery and anaesthesia have received such prominence at WHA level. These three events all have profound implications for the provision and access of safe anaesthesia and surgery in the Pacific region. Much work will be required if we are to make Resolution A68/31 a reality. A recent survey estimates that in Australia and New Zealand, 9% of anaesthetists are engaged in overseas teaching and clinical work in resource-poor countries in the Pacific region and


beyond4. This equates to approximately 430 anaesthetists and this number includes those who are involved in education only and are not providing clinical expertise. The Lancet Commission report is essential reading for any anaesthetist, surgeon or obstetrician working in healthcare in resource-poor countries in our region. The report lists five key findings: • Five billion people out of the world’s population of seven billion do not have access to safe, affordable anaesthesia and surgical care when needed. • 313 million surgical procedures are currently performed worldwide. An additional 143 million procedures are needed in low and middle income countries (LMICs) to save lives and prevent disability. • 33 million individuals face catastrophic health expenditure in these countries due to payment for surgery and anaesthesia care each year. • Investing in surgical services in LMICs is affordable, saves lives and promotes economic growth. • Surgery is an indivisible, indispensable part of health care. During recent decades, anaesthesia and surgery have been given relatively low priority in LMICs despite advances in many other global health areas. Globally in 2010, an estimated 16.9 million lives were lost (32.9% of all deaths worldwide) as a result of conditions needing surgical care. This figure was three times the combined number of deaths from HIV/AIDS (1.46 million), tuberculosis (1.20 million), and malaria (1.17 million)2. Global Surgery 2030 recommends monitoring of a number of indicators to assess development of anaesthetic and surgical services worldwide2. These indicators assess preparedness (access, workforce density), delivery (surgical volume, perioperative mortality) and impact (impoverishing or catastrophic expenditure). What information do we have about these indicators in the Pacific region?

Access Access is measured by the proportion of the population that can access, within two hours, a facility that can perform Caesarean delivery, laparotomy and treatment of an open fracture (the bellwether procedures). The target is 80% coverage in LMICs by 2030. The ability to perform bellwether procedures is used as an indicator of a system that can provide a much broader range of basic surgical care2. In many parts of the Pacific, there is very limited healthcare outside the capital cities. There are specific challenges in our region due to remote geographical considerations. Some island nations have small populations on islands remote to the one or two main hospitals for the country e.g. Vanuatu and the New Guinea Islands, where patients must travel by small boat and occasionally light plane and are dependent on finances and weather, or countries like mainland Papua New

Global anaesthesia and the Pacific

Guinea (PNG) where 80% of the population lives remote to main provincial towns with a hospital and may be one to two days away by foot or truck to reach basic medical services. Obviously local pre-hospital care in these communities is important at a health centre level, but many of these centres are not functional or are poorly supplied. One-third of aid posts in PNG are closed and only 50% of those remaining have adequate supplies of essential medicines5. Health workers, if present, are professionally very isolated. Such geographical constraints obviously have an impact in any country and data from India in 2010 shows that patients had a nine-fold increase in mortality from acute abdominal conditions if they lived only 50 km or more from a wellresourced district hospital. This equates to 50,000 deaths in India annually from acute abdominal conditions6. In the pooled population of the Pacific (excluding Australia and New Zealand), this would equate to over 450 deaths per annum for an estimated population of approximately eleven million in the LMICs of the Pacific.

Surgical specialist workforce density This is defined as the number of surgical, anaesthetic and obstetric physicians (SAOs) per 100,000 population. The Lancet Commission conservatively estimates that 20 SAOs per 100,000 are required in a LMIC to provide basic surgical care. Of this, approximately 7 per 100,000 should be specialist anaesthetic physicians. Currently, the anaesthetic physician workforce in the Pacific is much lower (see Table 1). PNG is the most populous LMIC in the Pacific and currently has 0.25 anaesthetists per 100,000. Timor Leste, the second most populous country, has 0.42 per 100,000. Using these figures, the density of anaesthetists in Australia and New Zealand is currently 75 times that of PNG and 45 times that of Timor Leste. In comparison, Australia and New Zealand combined have approximately 5,350 anaesthetists for 28 million people which equates to 19.1 per 100,000—nearly three times the desired goal of the Lancet Commission for a LMIC7,8. Approximately 4,780 are active Fellows of the Australian & New Zealand College of Anaesthetists (ANZCA) (see Table 2). In the Pacific LMICs, additional physician anaesthetists will need to be trained to overcome the current deficit and to match population growth. To achieve the target of 7 per 100,000 in 2030, over 760 anaesthetists will need to be trained in the region, or 50 per year. These figures do not take into account population growth in the region. For example, PNG is predicted to double its population by 2030 and this would mean that 700 more trained anaesthetists would need to be in place by that time. This is not achievable with current medical school graduation in the region. Pacific countries with very small populations (100,000 or less) e.g. Kiribati and the Federated States of Micronesia, may appear reasonably staffed but the disparity lies in population access

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Table 1 Anaesthetic physician workforce in the Pacific Country

Population

Current number of anaesthesia providers working in 2015

Numbers needed by 2030 (approx. number to be trained per annum)

Papua New Guinea (LMI)

7,476,000

Consultant 19 Training 10 NPA 80

523 (35)

Timor Leste (LMI)

1,200,000


84 (6)

Fiji (UMI)

887,000


62 (4)

Solomon Islands (LMI)

572,865


40 (3)

Vanuatu (LMI)

258,301


18 (1)

Samoa (LMI)

191,831


13 (1)

Tonga (UMI)

105,800


5

Kiribati (LMI)

103,900


5

Federated States of Micronesia (LMI)

103,903


5

TOTAL

10,899,600


761 (50)

LMI = Lower middle income country (gross national income per capita US$1,000 to $4,125), UMI = Upper middle income country (gross national income per capita US$4,125 to $12,746), populations based on World Bank from www.data. worldbank.org. Training = physician anaesthetists in a formal training program, NPA–nonphysician anaesthetists e.g. nurse anaesthetist, anaesthetic scientific officer. These numbers exclude other doctors without a specialist anaesthetic qualification who may give anaesthetics in the short term e.g. a service registrar.

to one or two hospitals. A new trainee in these countries may only occur every three to four years which does not allow for sudden staff movement, retirement or death. There is now an urgent need to closely track the number of trainees in anaesthesia in the region in the next 15 years. In 2016, five medical candidates are potentially sitting the Masters of Medicine (Anaesthesiology) final examination in PNG—the highest number ever since training started in 1992, but there have been many years in the interim when there was no trainee graduating. The Solomon Islands have only one potential trainee for 2016 but currently no funding and they will need to have two anaesthetists per annum finishing their training if this country is to achieve its goal by 2030. A very important contributing factor is the relatively small

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number of doctors trained in the Pacific region. The two main medical schools—University of Papua New Guinea (Port Moresby) and Fiji National University (Suva)—each produce fewer than 40–50 graduates per year. A small number of doctors are also being trained in Samoa and a new medical school is being developed in Madang, PNG, but there will need to be a dramatic increase in basic medical graduates in order to increase the output of specialists. The Lancet Commission target and the figures above refer to specialist physician anaesthetists. In many LMICs, non– physician providers perform a large proportion of anaesthetic services. In PNG, about 90% of all anaesthesia procedures are provided by Anaesthetic Scientific Officers (ASOs). ASOs


Global anaesthesia and the Pacific

Table 2 Density of anaesthetists in Australia and New Zealand Country

Population

Medical specialist anaesthesia providers*

Australia

23, 490,000

4485

4163

1236

4,510,000

867

624

262

28,000,000

5352

4787

1498

New Zealand TOTAL

Fellows of the Australian & New Zealand College of Anaesthetists#

Registered trainees with ANZCA for 2015+

Populations based on World Bank from www.data.worldbank.org for 2014. * From Medical Board of Australia, December 2014; Medical Council of New Zealand, June 30 2014.# From Australian & New Zealand College of Anaesthetists (ANZCA) Dec 31, 2014.+ From ANZCA for 2015.

undertake at least one year of training through the University of PNG and Port Moresby General Hospital and many have a nursing background. Longer term, it may be possible to train more physician anaesthetists to staff remote areas in PNG and elsewhere, but this will depend on leadership and resources in individual countries. Currently, in the Pacific LMICs there are over twice as many non–physician anaesthetists as physician anaesthetists (Table 1). Task shifting or task sharing of physician anaesthetists to non–physician anaesthetists—has developed through necessity and has been shown to be effective while countries make long-term investments in building surgical and anaesthesia workforces1. Other cultural factors also contribute e.g. higher numbers of non–physician anaesthetists in countries with more links to the United States, including Federated States of Micronesia and Palau. There is often a disparity in training numbers between anaesthetists and other medical specialties. A provincial hospital in PNG may have one or two general surgeons, an obstetrician and possibly a subspecialty surgeon, but there may only be a few non–physician anaesthetists (ASOs). Physician anaesthetist training needs to increase to address this deficit and maintain relativity as more surgeons are trained.

Surgical volume Surgical volume is defined as the number of procedures done in an operating theatre per 100,000 population per year. The Lancet Commission states that a minimum of 5000 procedures per 100,000 is required to meet basic surgical need. Operative volumes in LMICs are usually well below this target and are often not recorded accurately, if at all. Anecdotal surgical volume for PNG is 30,000 operations per annum for a population of 7.5 million which equates to 400 procedures per 100,000 (personal communication, Dr Osborne Liko). Surgical cancellation rates are often very high in these countries for both elective and emergency surgery and may range from 25–40%. This is usually due to lack of staff and resources. Australia and New Zealand have approximately 25 times this surgical volume.

Paediatric conditions will account for a large proportion of unmet surgical need. Bickler et al estimated that, in LMICs, 10% of children per year need a surgical procedure by the time they are 15 years old9. In many Pacific LMICs, children account for up to 50% of the total population. Neonatal anaesthesia and surgery is challenging in any environment, but especially in low resource settings. New World Health Organization recommendations for mothers where preterm birth is inevitable may improve preterm neonatal survival rates and so impose a new challenge of higher risk neonates needing surgery and anaesthesia10.

Perioperative mortality rate Perioperative mortality (POMR) is defined as the number of hospital deaths from any cause in patients who have undergone a procedure in an operating theatre, divided by the total number of procedures. Reliable mortality data for anaesthesia is nonexistent in LMICs in the Pacific region. Data from LMICs in other parts of the world have shown avoidable anaesthetic mortality rates 100 to 1,000 times higher than high income countries like Australia and New Zealand11. This is especially relevant in the obstetric and paediatric populations12,13. The only available data for PNG shows the mortality rate at Port Moresby General Hospital in 2002 to be 0.3% within 48 hours14.

Financial protection Financial affordability of services is vital and was highlighted as part of the 2015 World Health Assembly resolution passed “in the context of universal health coverage”. The Lancet Commission advises that 33 million individuals face catastrophic health expenditure in order to pay for anaesthetic and surgical services annually2. In the Pacific, many governments are committed to providing public health systems with a focus on minimising direct costs to patients.

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Conclusion The World Bank, the Lancet Commission on Global Surgery and the World Health Assembly resolution have all highlighted the massive disparity between provision of anaesthesia and surgery between LMICs and high-income countries. Our closest Pacific neighbours fit squarely in the LMIC group and have much more limited access to safe anaesthesia and surgical care than we enjoy in Australia and New Zealand. Many Australian and New Zealand anaesthetists are already involved with healthcare delivery in the Pacific region and ongoing help will be required if the goals set out by the Lancet Commission are to be achieved—improved patient access, increased specialist workforce numbers, increased surgical volume and improved data collection. Organisations and individuals can help at many levels including: formal agreements to assist development of training programs, assistance with data collection, clinical support and remote advice about clinical problems using low cost efficient modern communications. There will be an ongoing need for inter-government dialogue and support. In Australia, the Department of Foreign Affairs and Trade (DFAT) has preserved some existing commitments within the Pacific despite significant overall reductions in its commitment to foreign aid in the past two years15. However, there are no guarantees that this will be maintained. Through our professional and educational bodies we are already educating, advocating and providing collegiate support in the region. We must assist anaesthesia providers of whatever level of training and background in the Pacific countries, and maintain the long-term support for continuing education and professional development well beyond 2030. Through our professional and educational bodies we are already educating, advocating and providing collegiate support in the region. We can assist anaesthesia providers of whatever level of training and background in the Pacific countries, and maintain the long-term support for continuing education and professional development well beyond 2030.

Acknowledgements Dr Jack Puti, Solomon Islands; Dr Dennis D. Agapito, Federated States of Micronesia; Drs Harry Aigeeleng and Nora Dai, Papua New Guinea; Dr Eric Vreede, Timor Leste; Dr Kenton Biribo, Fiji; Dr Duncan Dobunaba, Chief Anaesthetist, Papua New Guinea; Dr Osbourne Liko, Chief Surgeon, Papua New Guinea. Some data is based on the WFSA Global Manpower Survey for an individual country.

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