Building and retaining the neglected anaesthesia health workforce: is it crucial for health systems strengthening through primary health care?

Background The world health report 2008 emphasizes "that putting people at the centre of service delivery" is not only about service delivery models from a short-term perspective, but rather about long-term commitment to health care. (1) Given the critical shortage of the health workforce, investments in training, retaining and sustaining them are necessary. Sub-Saharan Africa is a prime example of uneven distribution of health-care personnel. The subcontinent carries 24% of the global burden of disease in 11% of the world's population, but has as little as 3% of the world's health workers. (2) The concern for countries in sub-Saharan Africa and other nations was recognized by the World Health Assembly resolution WHA59.23 that urged for rapid scaling up of health workforce production. (3) Addressing the situation should take into account the four reforms (universal coverage, people-centred service delivery, leadership and public policies) towards refocusing health systems through primary health care. Importance of anaesthesia workforce The contribution of surgical conditions to the global burden of disease and the potential impact of the provision of basic surgical services at the first referral level facility is widely under appreciated. It is estimated that 11% of the world's disability-adjusted life years (or years lost from healthy lives) are from conditions that are very likely to require surgery. (2) Adequate surgical care as a primary care strategy can address and greatly alleviate this burden. (4) Increasing evidence is beginning to emerge that maternal and infant survival is proportionately correlated to the number of health workers providing obstetric care that includes anaesthesia. (5,6) The delivery of surgical (including obstetrics and trauma) care is highly dependent on the availability and retention of a trained anaesthesia healh workforce. The United Kingdom Confidential Enquiry for Perioperative Death in 1987 reported one death per 185 000 anaesthetic procedures; whereas in Zambia (University teaching hospital), it was one death per 1925. The avoidable anaesthesia-mortality rate in Malawi (central hospital) was one death per 504; in Nigeria (teaching hospital) for Caesarean sections, one death per 387 anaesthetic procedures; in Togo (teaching hospital), one death per 133; and in Zimbabwe (district hospital), one death per 482. (7) Many of these unnecessary deaths were a result of airway problems and hypovolaemia in healthy young patients. (7) Though the common perception is that anaesthesia services are only required at the level of secondary and tertiary health-care facilities, the availability of basic services at the first referral level facility can contribute significantly to a reduction in death and disability. At the district and sub-district level, health personnel are expected to provide a range of anaesthesia services (local, intravenous ketamine, spinal and general anaesthesia) for the management of pregnancy-related complications, unsafe abortion, injuries (road traffic accidents, domestic violence, burns, falls, rape), complications of female genital mutilation, congenital anomalies as well as other surgical conditions. To safely deliver anaesthesia in emergency and surgical procedures, investments for appropriate training are required. The role of anaesthesia extends beyond the operating room, and is necessary in postoperative monitoring, intensive care units, for co-existing medical conditions, as well as providing pain relief (particularly in children and women in labour). A workforce trained in basic anaesthetic techniques at the primary health care level can also resuscitate critically ill patients or those with severe trauma and stabilize their condition, before transfer to a more specialized facility. The anaesthesia services required at the first referral level facilities can mostly be delivered by trained nonphysician anaesthetists. Current situation Physician anaesthetists are scarce in many developing countries and not available at first referral level health facilities. …