Reimagining Global Outreach

Number of Anesthesia Providers per 100,000 in Population

This map shows the global distribution of anesthesia providers. For reference, here in the United States (dark green) there is approximately one anesthesia provider per 4,000 people in population, and the US is considered to have an anesthesia provider shortage... The countries seen in red have less than one anesthesia provider per 100,000 in population, and the countries in orange have one to three anesthesia providers per 100,000 in population. You can see the most need in Africa, Central America, India, and Southeast Asia.

Historically, what efforts have been made to address this global disparity?

Image from: https://journals.lww.com/anesthesia-analgesia/fulltext/2017/09000/the_wfsa_global_anesthesia_workforce_survey.39.aspx

What about Medical Missions?

Several years ago researchers conducted a large-scale literature review that examined 230 medical mission publications over a 25 year period to better understand the impact these missions have on health systems in low- and middle-income countries.

They discovered that there are several Pros to medical missions, such as reducing individual suffering, providing temporary relief on the healthcare system, feelings of personal gratification for the volunteers, and missionary providers being reminded of the reason they chose a career in healthcare. Although these are positive outcomes, It is important to understand that some of these positive outcomes are more beneficial for the missionary provider themselves, and not necessarily for the people in the receiving country.

Healthcare providers are faced with several barriers to participation in medical missions, such as the cost of the trips (approximately $2,000-$3,000 per provider), ability to get enough time off work, family obligations, potential health risks associated with traveling to low-income countries, language barriers, and the need to acquire specialized skills for providing care in low-resource environments.

Image from: https://www.eakc.net/about-us/medical-missions/

Common Critiques of Medical Missions

Are medical missions the solution? The literature also shows several common critiques of medical missions. Individuals and organizations that have participated in medical missions and critically evaluated their effectiveness have discovered multiple shortcomings of these trips.

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Common Critiques of Medical Missions

One of the most common critiques of medical missions is their unsustainability. They only offer temporary, short-term relief on the healthcare system. Medical missionaries travel to the destination country, provide care for a short period of time, and then they leave…

To quote one participant, who went on a medical mission to Honduras:

“Even though we really helped many of the people, for others all we really did was put a bandaid on a gaping wound. Now that we are gone will the wound just grow larger and larger?”

The cost-effectiveness of these missions is also commonly called into question in the literature. These missions can cost anywhere from $12,000-$84,000, with an average cost of $34,000, or around $2,000-$3,000 per provider.

To quote a medical missionary who went on a surgical mission to Ghana:

“What business did our team of 10 members, have spending approximately $30,000 toward travel and hotel costs when the entire cost to build a new 30-bed hospital wing was $60,000?"

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Common Critiques of Medical Missions

Many medical missionaries are intimately connected to their mission groups, either through religious affiliations, schools, or places of employment. This emotional connection to the mission makes it extremely difficult for them to objectively evaluate its success. This has often led to a misconception that, in low-income countries, any healthcare is good healthcare, regardless of the quality. 

The literature also raised concerns with the preparedness of medical missionaries and their ability to provide culturally appropriate care, emphasizing that medical missionaries were not familiar with the local health needs or limitations of the healthcare system. Nor were they familiar with the social, cultural, and political contexts of the country where they were providing care. Because of this, they had minimal understanding of the follow-up care, or lack thereof, that their patient’s would receive once they left.

An emphasis was also placed on how surgical intervention requires a multidisciplinary, long-term, team approach that cannot be met by short-term medical missions, and that sending a surgical team of medical missionaries to a remote region of the world without consideration of multidisciplinary care needs was “Perhaps irresponsible or, at best, purely an aesthetic rather than functional undertaking.”

Investing in Educating Local Providers

Much of the literature highlights the importance of providing educational opportunities for local healthcare providers in low-and middle-income countries as a potentially superior solution to address the provider shortage, as opposed to medical missionaries traveling to provide care themselves.

Education-Focused Organizations

There are multiple non-profit organizations that prioritize educating healthcare providers in low- and middle-income countries. Some of these organizations go on education-focused medical missions where they provide education to local healthcare professionals, and some provide free online educational resources. Some of these organizations focus on anesthesia education, and other have a more broad spectrum of surgical education.

These organizations are making a significant impact by educating current providers, helping them become more proficient. However, their efforts are not increasing the overall number of providers in these low- and middle-income countries.

Number of Anesthesia Providers per 100,000 in Population

Remember, the primary concern causing insufficient access to anesthesia care is the limited quantity of anesthesia providers! These countries need more providers.

To illustrate this point and suggest an alternative way to increase the number of providers in these countries, the following sections will focus on the region of the world with the greatest need for anesthesia providers, Sub-Saharan Africa.

Image from: https://journals.lww.com/anesthesia-analgesia/fulltext/2017/09000/the_wfsa_global_anesthesia_workforce_survey.39.aspx

Anesthesia Provider Shortage in Sub-Saharan Africa

Sub-Saharan Africa claims 25% of the global disease burden, but they only possesses 3% of the world’s healthcare workers. Their lack in anesthesia personnel has shown to cause long wait times for emergency and life-saving procedures, resulting in increased morbidity and mortality. Because of this, Sub-Saharan Africa is the destination for twice as many short-term medical missions than any other region of the world. However, it is recognized that medical missions have their limitations.

Have there been any attempts, other than medical missions, to increase the number of anesthesia providers in Sub-Saharan Africa? Have there been efforts to educate more local providers? What initiatives have been taken in the past?

Image from: https://en.wikipedia.org/wiki/Sub-Saharan_Africa#/media/File:Sahara_Sahel_sub-Saharan_Africa.svg

Physician Anesthesiologists

What about training more Physician Anesthesiologists in Sub-Saharan Africa?

The Physician Anesthesiologist community has attempted to, and has been unsuccessful. The issues they face in Africa are multifaceted.

Their first problem is often described as "Brain Drain." This term refers to the phenomenon where locally-trained African Physicians choose to emigrate to wealthier countries in pursuit of more lucrative economic opportunities after they complete their education. Unfortunately for Africa, up to ⅓ of their locally-trained physicians emigrate to higher-income countries. 

Additionally, anesthesia ranks as one of the least preferred specialties among African medical students, with fewer than 1% of students expressing interest in choosing anesthesia as their specialty.

Another issue the Physician Anesthesiologist community faces is that nearly 100% of their physician anesthesiologists are concentrated in major metropolitan areas, creating a massive disparity in access to anesthesia care between urban and rural communities. In response to this anesthesia access gap, the physician community introduced a "mid-level" anesthesia provider program for Bachelor of Medicine graduates. These students were enrolled in a 12-18 month program that awarded them a diploma in anesthesia practice. This program aimed to increase the number of rural anesthesia providers.

Nonetheless, the "mid-level" program also proved to be unsuccessful, as over 90% of participants eventually left the “mid-level” career to pursue further medical training, and a significant proportion of them emigrated.

The researchers who evaluated the outcomes of the “mid-level” program came to the conclusion that perhaps recruiting a more stable group, such as nurses, into appropriate anesthesia training programs may be more successful at increasing access to anesthesia in rural African communities.

Is training nurses to administer anesthesia even an option in these Sub-Saharan African countries? Are there nurse anesthetists in other countries around the world?

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~ 100 Countries Around the World with Nurse Anesthetists

According to most recent surveys from both the International Federation of Nurse Anesthetists and the World Federation of Societies of Anesthesiologists, there are approximately 100 countries around the world, that we know of, that have nurse anesthetists who provide surgical anesthesia in some capacity.

Those countries can be seen in purple on this map. Most of the areas that we know have the highest need such as Sub-Saharan Africa, Central America, and Southeast Asia, all have some form of nurse anesthetists.

37 African Countries with Nurse Anesthetists

In Africa, 37 of the 54 countries utilize Nurse Anesthetists. They provide up to 90% of all anesthesia services in Sub-Saharan Africa, and up to 100% of anesthesia services in rural areas. 

One of the most promising aspects of these African Nurse Anesthetists is their high rate of provider retention. These nurse anesthetists stay and continue practicing anesthesia in their native countries, making them promising candidates to address the anesthesia provider shortage. African Nurse Anesthetists have the potential to be the long-term solution to expand access to anesthesia in Sub-Saharan Africa.

Nurse Anesthetists’ Education & 

Training in Sub-Saharan Africa

Nurse Anesthetists in Sub-Saharan Africa can be trained in a variety of different post-graduate nurse anesthesia training programs. Historically, these programs have been diploma programs, similar to the diploma programs seen in the United States during the early days of the nurse anesthetist profession. However, these diploma programs are being phased out and replaced by bachelors degree programs, and even some masters degree programs. The duration of these post-graduate programs is typically around two years.

Before becoming eligible to apply to one of these nurse anesthesia schools, a Registered Nurse is typically required to attain a minimum of 2-3 years of RN work experience. 

Image from: https://krna.org/investing-in-anesthesia-workforce-a-case-for-non-physician-anesthetists/

Ridge Regional Hospital’s School of 

Anesthesia & Critical Care in Ghana

Ridge Regional Hospital's School of Anesthesia and Critical Care in the West African country of Ghana is an example of one of these Sub-Saharan African nurse anesthesia schools. This is a two-year nurse anesthesia program that was established back in 2009 by a non-profit organization out of North Carolina, Kybele Inc. They worked with the Ghana Health Service organization and a group of Certified Registered Nurse Anesthetists and Physician Anesthesiologists from Duke and Wake Forrest Universities to develop the curriculum and establish the program. 

Although this program was initially established with the help of Americans, it is now entirely self-sustaining. The only support it receives from the United States is in the form of occasional guest lecturers who present on a topic that is assigned to them by the Ghanaian administrators. 

Ridge Regional Hospital's School of Anesthesia and Critical Care is one of three nurse anesthesia schools in Ghana, and it provides the country with new anesthesia providers every year.

The total cost of this two-year program is approximately $2,000. This cost may not seem like much, but to put it into perspective, the yearly salary for a Registered Nurse in Ghana is approximately $2,100. The cost of a Ghanaian Registered Nurse to attend anesthesia school is approximately equivalent to a full year's salary. The financial obligations of anesthesia school are a significant barrier that can prevent Ghanaian nurses from pursuing a career in anesthesia.

The number of students that this program produces each year is not limited by its capacity for students, but by the number of students who apply. Also there are times when students are unable to complete the program due to financial limitations. Essentially, a nurse anesthesia school of this nature could potentially produce more students annually if it were not for the financial constraint faced by the students.

Image from: https://www.frontiersin.org/articles/10.3389/fpubh.2017.00078/full

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Our Hearts Your Hands

Our Hearts Your Hands (OHYH) is a non-profit global anesthesia support community that takes tax-deductible donations to allow nurses in low- and middle-income countries to go to anesthesia educational programs. They are one of, if not the only organization that focuses specifically on utilizing the nursing profession to produce more anesthesia providers in low- and middle-income countries. 

OHYH was founded by five Certified Registered Nurse Anesthetists, and their president, Dr. Jackie Rowles, also serves as the President of the International Federation of Nurse Anesthetists (IFNA). OHYH and the IFNA are similarly aligned in values and focus on supporting nurses around the globe in obtaining high-quality anesthesia education.

The IFNA has multiple member countries around the world where nurse anesthesia schools can apply to be recognized and accredited by the IFNA. This recognition from the IFNA indicates that a school's curriculum has been reviewed and they have proven to demonstrate substantial compliance with the IFNA's educational standards. It basically puts the IFNA's stamp of approval on the program, indicating that it has proven to provide nurses with high-quality anesthesia training.

There are currently 11 IFNA member countries in Sub-Saharan Africa

Nurse Anesthesia Global Scholarship - Africa

Recognizing the significant demand for anesthesia providers in Africa and the promising results of African nurse anesthetists in addressing this need, Our Hearts Your Hands has established a new, dedicated scholarship fund exclusively for nurse anesthesia students in Africa. This new scholarship is the Nurse Anesthesia Global Scholarship - Africa.

Scholarships will be awarded to students enrolled in nurse anesthesia programs within any of the 11 African member countries of the IFNA. The selection of scholarship recipients will be carried out by the OHYH Board of Directors, who will evaluate applicants based on a specified grading rubric. This rubric takes into account factors such as the student's financial need, academic achievements, dedication to the field of anesthesia, and intentions to work in rural or underserved areas.

This scholarship fund provides an opportunity for individuals interested in global outreach an easy opportunity to get involved in a meaningful way by helping sponsor a student.

Advantages of Sponsorship

This chart illustrates the advantages of sponsoring a nurse anesthesia student over embarking on a medical mission. 

Participating in a medical mission typically costs around $2,000-$3,000 per provider, covering expenses like travel, housing, equipment, and more. Conversely, fully funding an entire two-year anesthesia education for one student would cost $1,500-$2,000.

While a medical missionary may offer anesthesia care in Ghana for a few weeks to a few months, a sponsored nurse anesthesia student can go on to provide anesthesia care throughout their entire career, potentially spanning over 20 years.

A medical missionary will likely be unfamiliar with the local culture, healthcare system, equipment limitations, country's needs, prevalent diseases, and more. In contrast, a locally trained nurse anesthetist possesses in-depth knowledge and understanding of these aspects. 

Engaging in a medical mission demands time away from work and family, and may entail health risks due to potential exposure to foreign pathogens. These concerns, however, do not apply to supporting a student financially.

This alternative method of aiding through student sponsorship effectively circumvents many common barriers that might hinder meaningful participation in global outreach. Additionally, it is likely to yield more sustainable benefits for the country in the long run.

Balancing Immediate Need & Long-Term Solutions

Although medical missions have their flaws and shortcomings, it may be argued that the care they provide might be the best potential care that exists for a patient in a particular location, at a particular time. They serve an important role in addressing the immediate healthcare needs in low- and middle-income countries.

Nevertheless, more forward thinking and investment into more-sustainable long-term solutions to the anesthesia provider shortage is imperative.