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Development of Education and Research in Anesthesia and
Intensive Care Medicine at the University Teaching Hospital in
Lusaka, Zambia: a descriptive observational study
Dr Anna Janowicz MD FRCA, Visiting Lecturer in anesthesia, University Teaching
Hospital, Lusaka, Zambia (principle investigator), [email protected]
Dr Tuma Kasole, anesthesia MMed 3, University Teaching Hospital, Lusaka,
Zambia, [email protected]
Emily Measures, Zambia Country Manager, Tropical Health and Education Trust,
Meg Langley MPH, Senior Programme Manager, Tropical Health and Education
Trust, [email protected]
Dr Fastone M Goma, Dean University of Zambia School of Medicine, Lusaka,
Zambia [email protected]
Dr Feruza Ismailova, Head of Department of Anaesthesia, University Teaching
Hospital, Lusaka, Zambia, [email protected]
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Professor John Kinnear, Lead of the University of Zambia Master of Medicine
anesthesia program, Postgraduate Medical Institute, Anglia Ruskin University, UK,
Dr M Dylan Bould, Visiting Lecturer in anesthesia, University Teaching Hospital,
Lusaka; Associate Professor, The Children’s Hospital of Eastern Ontario, The
University of Ottawa, Ottawa, ON, Canada [email protected]
Corresponding author:
Anna Janowicz
Postal address: 24 Amsterdam Rd, London E14 3JB, UK
E-mail: [email protected]
Phone number: +44 79311 08461
Funding
Dr Janowicz’s involvement in this project was funded through the Health Partnership
Scheme, which is funded by the UK Department for International Development
(DFID) for the benefit of the UK and partner country health sectors.
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Competing interests
AJ, EM, ML, FI, JK and MDB are all contributors to the global health partnership that
is described in this paper. TK is an anesthesia trainee on the residency program
supported by this partnership.
Ethics approval
ERES Converge IRB, 33 Joseph Mwilwa Road, Rhodes Park Lusaka, Zambia
Approval date: 10th April 2014
Approval No. 2015-Mar-008
Consent to participate
Not applicable
Consent for publication
Not applicable
Availability of data and material
Data is available from the authors on request.
Authors’ contributions
AJ performed data collection and analysis and contributed to methods and results
sections of the manuscript. TK contributed to data collection and analysis. EM and
ML contributed to writing discussion and conclusion sections of the manuscript. FG
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reviewed the manuscript. FI contributed to data collection and reviewed the
manuscript. JK was a major contributor in writing the manuscript. MDB supervised
data collection and analysis and was a major contributor in writing the manuscript.
Number of words
Abstract 350
Introduction 357
Methods 325
Results 2516
Discussion 1354
Abbreviated title
Anesthesia practice, education & research in Zambia.
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Abstract
Background
Data from 2006 show that the practice of anesthesia at the University Teaching
Hospital in Lusaka, Zambia was underdeveloped by international standards. Not only
was there inadequate provision of resources related to environment, equipment and
drugs, but also a severe shortage of staff, with no local capability to train future
physician anesthetic providers. There was also no research base on which to
develop the specialty. This study aimed to evaluate patient care, education and
research to determine whether conditions had changed a decade later.
Methods
A mix of qualitative data and quantitative data was gathered to inform the current
state of anesthesia at the University Teaching Hospital, Lusaka, Zambia. Semi-
structured interviews were conducted with key staff identified by purposive sampling,
including staff who had worked at the hospital throughout 2006-2015. Further data
detailing conditions in the environment were collected by reviewing relevant
departmental and hospital records spanning the study period. All data were analyzed
thematically, using the framework described in the 2006 study, which described
patient care, education, and research related to anesthetic practice at the hospital.
Results
There have been positive developments in most areas of anesthetic practice, with
the most striking being implementation of a postgraduate training program for
physician anesthesiologists. This has increased physician anesthesia staff in Zambia
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six fold within four years, and created an active research stream as part of the
program. Standards of monitoring and availability of drugs have improved, and
anesthetic activity has expanded out of operating theatres into the rest of the
hospital. A considerable increase in the number of cesarean sections performed
under spinal anesthetic may be a marker for safer anesthetic practice.
Anesthesiologists have yet to take responsibility for the management of pain.
Conclusions
The establishment of international partnerships to support postgraduate training of
physician anesthetists in Zambia has created a significant increase in the number of
anesthesia providers and has further developed nearly all aspects of anesthetic
practice. The facilitation of the training program by a global health partnership has
leveraged high-level support for the project and provided opportunities for North-
South and international learning.
Keywords
Anesthesia, development, education, training, research, partnership
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Introduction
Zambia has a population of approximately 14.5 million 1 and is ranked 141 out of 187
countries on the Human Development Index 2. It is classified as one of the Least
Developed Countries by the United Nations 3 and has a gross national income per
capita of $2,898 (US) with 74% of the population living on less than $1.25 (US) a
day1. The University Teaching Hospital (UTH) is a referral centre for Zambia as well
as serving the entire Lusaka area with an estimated population of 1.7 million 4. It has
an inpatient capacity of approximately 1,655 beds, but demand often outstrips
capacity. UTH is also the main teaching site for the University of Zambia School of
Medicine (UNZASoM) and serves as the clinical training hospital for undergraduate
and postgraduate specialties.
The Lancet Commission on Global Surgery has defined the challenges facing
resource-poor countries if they are to improve their perioperative outcomes in the
next decade 5. One of these challenges is the consistent provision of safe anesthesia
services to underpin a robust ‘surgical ecosystem.’ Data from 2006 indicate that
anesthesia services at the largest referral hospital in Lusaka, Zambia, the University
Teaching Hospital (UTH), suffered from poor infrastructure, inadequate staffing, poor
access to equipment to support anesthesia practice, absence of a postgraduate
anesthetic teaching program and no research activity within the specialty in the
previous 5 years 6.
The situation in anesthesia has changed significantly over the last nine years, mainly
owing to investment in the specialty by the UK Department for International
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Development (DFID) and the Zambian Ministry of Health, and the development of
effective partnerships to support post-graduate training in anesthesia by the Tropical
Health and Education Trust (THET) 7,8. The primary aim of this study was to evaluate
precisely what progress has been made over the past nine years and the current
state of anesthesia in Lusaka, Zambia, which will inform efforts to further develop the
specialty in support of the aspirations of the Lancet Commission on Global Surgery.
A secondary aim of the study was to assess the extent to which international health
partnerships have contributed to the successful growth.
Methods
This study was granted ethics approval from the ERES Converge Research Ethics
Board. Data were collected at the University Teaching Hospital, Lusaka, Zambia
between April 11 and May 15, 2015. The data collection form was based on the
previous study by Jochberger and colleagues so that the current status of clinical
practice, education and research in anesthesia at UTH could be directly compared
with findings from 9 years ago 6.
Purposive sampling was used to recruit participants who could authoritatively
represent key professions and specialties in perioperative care. We aimed to include
participants who had been at UTH throughout the 9-year period covered in the study.
Eight participants were identified and all of them have consented to participate in the
study (two consultants anesthesiologists, two Master of Medicine (MMed) anesthesia
trainees, consultant radiologist, consultant hematologist, consultant pathologist and
an intensive care nurse). Qualitative data collection was by semi-structured
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interviews lasting between 10 and 40 minutes conducted by two of the authors (A.J.
and T.K.). The same questionnaire was used for all the participants (available as
additional online material). Notes were taken during the interviews and all
information was subsequently entered into the data collection form. Supporting data
were collected from a document review that included departmental and hospital
records and documents from relevant training programs. Hospital statistics were
obtained with permission from the hospital superintendent who granted permission to
access all data sources, covering the years from 2012 to 2015. Cross verification
was used whenever possible during data collection process. All data were analyzed
thematically using the framework described in the 2006 study so that the historical
situation could be directly compared with the current state. The themes were based
on what was proposed by Jochberger and colleagues to be the three major functions
of a major teaching hospital: patient care, undergraduate and post-graduation
education, and research. Patient care was further divided into anesthesia, intensive
care and supporting disciplines.
Results
Patient Care
Anesthesia
The workload of the Department of Anaesthesia has increased only slightly since
2006. There are still 17 operating theatres, of which 15 are now in regular use
compared with 13 in 2006. A little fewer than 20,000 procedures are performed every
year, up from 16,000 in 2006, with a substantial increase in the number of major
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cases performed (table 1). There have been significant changes to anesthetic
techniques most commonly used since 2006, in particular, techniques for airway
management and the use of neuroaxial (spinal) anesthesia. Whereas previously
most general anesthesia (GA) cases were managed with endotracheal tubes (ETT)
or mask anesthesia, now laryngeal mask airway (LMA) is the predominant method
owing to its ubiquitous availability. This is aligned with practice in high resource
environments.
The rate of spinal anesthesia for cesarean sections has risen from 20% to 86.2%,
which represents a significant advance towards safer anesthesia for pregnant
women, and this appears to be due to better education of anesthesia providers.
There is a wider choice of anesthetic and analgesic agents available compared with
2006 (Table 2), with propofol and fentanyl, previously unavailable, now standard
agents for GA. Although halothane remains the most commonly used inhalational
agent, isoflurane has also become available.
In 2006 there was no electronic or automated monitoring, with a reliance on clinical
skills known to be inaccurate (e.g. estimation of cyanosis) or distracting (e.g. manual
blood pressure measurement). In 2015 there is automated electronic monitoring that
more closely reflects the standards considered to be mandatory in modern practice
(electrocardiogram, non-invasive blood pressure, oximetry), with the exception of
respiratory CO2 and anesthetic gas measurement, which are still unavailable.
Although the postoperative recovery room is now equipped with pulse oximeters
(Lifebox, from http://www.lifebox.org/) , non-invasive blood pressure machines and
occasional availability of ECG monitors, regular staffing by nurses with specific
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recovery training remains an issue.
Basic supplies
There is no 2006 data on oxygen availability, but we present data about the current
status here for any future comparisons. As in 2006, oxygen is provided by a central
oxygen unit, provided by in-house oxygen concentrators but both concentration (70-
80%) and pipeline pressure (less than 4 Bar) are erratic. However, supply by oxygen
cylinder provides more predictable pressures, notwithstanding at low oxygen
concentrations (50-60%). The oxygen cylinders are also filled from in-house oxygen
concentrators. Air conditioning that was non-existent in 2006 is now available in all
theatres, but the use is intermittent due to the lack of patient warming devices. The
electricity supply appears to be the same quality as in 2006, with occasional
unexpected (usually up to 15min) and planned (up to 6 hours) power cuts.
Availability of water is also unchanged at around 16 hours a day with only stored
water being used overnight.
Drugs and consumables
Data from 2006 are limited and no direct comparison can be made. However, there
is a good supply of dressing materials and basic airway equipment, but supply of
consumables for the ICU is donor driven and is erratic. In 2014 endotracheal tubes
were available in a wide variety of sizes, but UTH is still very much reliant on re-use
of endotracheal tubes designed to be single use, after cleaning with 0.5% chlorine.
Laryngeal masks were also reused and available in a wide variety of sizes.
Intravenous cannulae, needles and syringes were available and single use in 2014.
This situation seems to be essentially unchanged from 2006.
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For anesthesia there is a broader range of induction agents, muscle relaxants,
benzodiazepines, analgesic agents, antibiotics and emergency drugs available and
commonly used (table 2). Inotropic agents such as epinephrine are now readily
available, with norepinephrine frequently available from donations. However,
invasive arterial monitoring is only available in exceptional cases.
Medical Equipment
In 2006 all anesthetic machines were over 20 years old, had no facilities for positive
pressure ventilation or any monitoring. There has been a significant improvement in
the quality of anesthetic machines and monitoring for theatres, which are modern
and of adequate standard. Twenty new Aeon 8300A (Aeonmed, Beijing) anesthetic
machines (Figure 1) have recently been supplied by the Ministry of Health and are
equipped with volume/pressure controlled ventilators and integrated monitoring. The
availability of maintenance provided by the hospital-based engineering department
remains variable.
Intensive care unit (ICU)
The ICU has remained a ten bed mixed medical/surgical unit, and continues to be
run by the Department of Anaesthesia. In contrast to the 354 admissions in 2005,
there were 793 in 2015, but poor records make it impossible to provide a breakdown
of the most common diagnoses. Surgical causes accounted for 62% of admissions
and medical for 38%. Of the surgical admissions 36% were following trauma and
around 10% were obstetric. Mortality rate based on the best available data was
46.2% in 2014, compared with 55.9% in 2006, but there is not enough robust data to
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explain the improvement. Nursing provision has improved in terms of both number
(35 versus 28) and skill (Table 3), with a critical care nursing training program,
implemented by THET, being a major contributor.
Monitoring equipment
The ICU is currently equipped with 10 ventilators, 8 infusion pumps and 8 IntelliVue
MP20 monitors (Philips, Amsterdam) which provide integrated monitoring of patient’s
ECG, heart rate, oxygen saturation and blood pressure. Not all of the above were
functional at the time of data collection. Availability of transducers for central venous
pressure monitoring is very limited and there is only facility for invasive arterial blood
pressure monitoring in ICU in exceptional cases. This is a distinct improvement on
the situation with monitoring in 2006 when there were 3 pulse oximeters and 9 ECG
monitors (with no information on how many of them were functional). The current
range of routine nursing observations remains much the same as 2006 and include
non-invasive blood pressure, oxygen saturation, heart rate, respiratory rate, Glasgow
Coma Scale and urine output measurement if requested.
Staffing
There has been a substantial increase from the five physician and eight clinical
officer anesthetists (COA) available in 2006. The Department of Anaesthesia has a
current complement of 30 physician anesthetists comprising seven consultants and
23 residents (postgraduate anesthesia trainees), with only 6 COAs (Figure 1).
Staffing is such that all elective theatres now have assigned physician
anesthesiologists and the ICU is covered by anesthesia residents for 24 hours per
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day. The ICU is further staffed by five consultants (including three physicians not
counted above) who provide daytime cover four days of the week.
In addition to local staff, the anesthetic department has also been supported by
visiting clinicians from the UK and Canada who are attached as honorary consultants
(attendings) or visiting residents. This is the main form of support provided by the
global health partnership. These visiting faculty are supported by THET’s grant
through DFID and their primary role is to deliver all the classroom teaching for the
MMed anesthesia program 7 as well as most of the clinical supervision. These
visiting faculty also conduct specified quality improvement initiatives including
working with local trainees to support audits, improvement in the organization and
storage of anesthesia equipment, the introduction of the WHO surgical safety
Checklist, the development of clinical protocols and the institution of mortality and
morbidity meetings. In 2014 these additional visiting faculty included 9 consultants
on short term visits of between 2 weeks and 3 months each. From 2013 there has
also been one consultant anesthetist employed full time by UNZASoM as a lecturer
and academic lead for the postgraduate training program who remained in country
for 2 years. There were also 5 visiting senior residents (with 4-5 years of anesthesia
training in the UK or Canada) and 3 junior residents (with 2-3 years of postgraduate
anesthesia training in the UK) in Zambia for between 1 and 6 months. Consultant
short-term visiting faculty were funded by the UK Department of International
Development, via a grant administered by THET. Trainees have had funding from a
variety of sources including grants from THET, the Association of Anaesthetists of
Great Britain and Ireland and the Beit Trust, but in many cases these visits have
been largely or entirely self-funded.
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Supporting disciplines
Laboratory
A more comprehensive range of blood tests was routinely available in 2014 (full
blood count, electrolytes, renal function, liver function, clotting profile, arterial blood
gases and cardiac enzymes) than in 2006 (full blood count, electrolytes and serum
glucose), but as then, reagents are not always available and the service is only
available during daytime hours. There is also no efficient system for delivering blood
samples to the laboratory, with delays in obtaining results. There are a limited
number of devices for bedside hemoglobin measurement in cases of acute
hemorrhage.
Transfusion service
As in 2006, the blood transfusion service was able to issue a range of products
including whole blood, packed red cells, platelets, fresh frozen plasma and
cryoprecipitate, which were all routinely tested for infectious diseases and
transfusion compatibility. Blood product shortages did occur and occasionally
emergency Group O blood was out of stock. Recent developments have been the
formation of a Hospital Transfusion Committee and the implementation of a massive
hemorrhage protocol, these being examples of quality improvement initiatives by a
THET supported volunteer and clinical faculty.
Radiology
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Limited data from 2006 indicate very poor radiological support for ICU, with no X-ray
or sonography available in the intensive care unit, which has improved considerably.
Routine X-rays are available at any time, but are not always achieved on the same
day due to organisational delays. There is a dedicated portable X-ray machine
situated on the ICU, and radiographers are on site for 24 hours a day. Ultrasound
examinations are available up to 16.00 hours and both CT and MRI scans are
available on the hospital site. However, when the hospital CT scanner is not
functional, critically ill patients may need be transferred to other hospitals for
investigations.
Emergency medicine
Anesthesiologists or clinical officer anesthetists (non-physician anesthesia providers)
are regularly requested to attend critically ill patients in the Emergency Department
(ED), in sharp contrast to the situation in 2006 when the anesthesia department did
not undertake any patient management outside theatres and ICU. The Emergency
Department now has a dedicated defibrillator. Anesthesiologists also occasionally
provide urgent treatment to critically ill patients on the wards where they have access
to emergency trolleys with a limited supply of epinephrine, atropine and occasionally
a self-inflating bag. A surgical emergency room also provides basic monitoring,
airway equipment and emergency drugs for use by anesthesiolgists.
Pain management
Although there is a growing awareness of the importance of postoperative pain
control, anesthesiolgists are not yet formally responsible for pain management
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outside theatres and ICU. This situation has not changed since 2006, possibly owing
to the still limited number of anesthesiolgists available to provide such a service.
Education and training
In 2006, undergraduate anesthesia was taught as a sub-speciality of surgery, but
there is no report of the curriculum content. Structured teaching now exists for
anesthesia and medical students complete a two-week module in the specialty. This
includes tutorials comprising the history of anesthesia, pharmacology of anesthetic
agents, neuraxial anesthesia, obstetric anesthesia, pediatric anesthesia and
anesthesia for a shocked patient. Informal teaching is also delivered on a daily basis
in the operating theatres by residents and consultants.
There was complete absence of any postgraduate training program for anesthesia in
2006, although programs existed for the specialties of surgery, obstetrics, internal
medicine and pediatrics. In 2011 the UNZASoM Master of Medicine anesthesia
Program was initiated, with support from THET, and by 2015 the course had 23
residents over four years of training 7. The syllabus is delivered by a combination of
formal small group teaching sessions, simulation, and workplace-based supervision
delivered by visiting faculty from the UK and Canada. Direct clinical supervision is
also provided by local consultants, with distant supervision out of hours. Curriculum
delivery and assessment are based on the UK model of postgraduate anesthetic
training, with residents participating in annual reviews for training progress at the end
of each year and compulsory exams at the end of the first and fourth years. The
structure of the exams is aligned to those of the UK Royal College of Anaesthetists,
although there is no formal link between the two. The program had its first graduates
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in October 2015, the first physician anesthetists to complete training in Zambia since
independence in 1964. At the time of this study a proposal was submitted and under
consideration by UNZA to recognize an independent academic Department of
Anaesthesia.
Non-physician anesthetic training was not mentioned in the previous study, but a
clinical officer training program has been in place since the 1960s, with an Advanced
Diploma program since 1996. This is a two-year program based in Lusaka and
comprises practical experience in the hospital and structured teaching in the
classrooms. This program is run by clinical officers at the Chainama College of
Health Sciences (CCHS), a public institution under the Ministry of Health.
In 2006 the only continuing professional development provided for anesthetists was
through a biennial anesthesia conference held in Lusaka. This conference is still
held, but there are now several other opportunities for professional development that
have been initiated to support the postgraduate anesthesia training program. These
include the Safe Obstetric Anaesthesia course (3 courses to date including 70
anesthesia clinical officers) 9 and Primary Trauma Care course (one course to date
including 7 clinical officers) 10, supported by THET and the Lifebox course (which
provides oximeters and teaching on the World Health Organization surgical safety
checklist) 11, supported by the Lifebox Foundation. All these courses are supported
by the MMed trainees, and the reach is beyond Lusaka, to include COAs stationed in
rural districts and includes a “train the trainers” element that aims to embed training
capacity locally.
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Research
The report by Jochberger and colleagues noted that in 2006 there had been no
research activities by the division of anesthesia for the previous 5 years. Since 2011
every postgraduate anesthesia trainee has been expected to lead their own research
project for the dissertation required to pass the Masters of Medicine anesthesia
degree. To date, three of these projects have been completed, seven have been
granted research ethics approval, with the other proposals at earlier stages of
development. The completed projects were on (i) anesthetic related perioperative
complications during caesarean deliveries at UTH, (ii) a validation of pain
assessment tools for the patient population at UTH, and (iii) a comparative study of
diclofenac with wound infiltration to additional ilio-inguinal/ hypogastric nerve block
for pain relief in children undergoing groin surgery. These research dissertations
have been supervised by visiting faculty from the UK and Canada through a
combination of in-person visits and remote research mentorship using electronic
communication. Other scholarly activities from 2011-2015 include collaborative
research undertaken by local and visiting residents, and visiting faculty of the
Department of Anaesthesia, as well as co-investigators in the Departments of
Surgery and Obstetrics 12-15.
Discussion
Page 20 of 32
There have been significant positive changes in anesthesia at UTH in the past nine
years. Progress has been marked in the three areas of patient care, education and
research as defined by Jochberger’s study. Although these areas are
interdependent, our study suggests that the primary driver for development has been
the initiation of the postgraduate training program in anesthesia and intensive care
which has had the multiple effects of increasing the number of capable anesthesia
providers, increasing advocacy for an undervalued profession, strengthening
processes for procuring drugs and equipment, embedding quality improvement as an
expected professional activity and driving scholarship through mandated research
activity.
The Department of Anaesthesia at UTH is no longer a subdivision of the Department
of Surgery and has expanded its zone of activity beyond the operating theatre to
encompass care of critically ill patients in the ICU and across the hospital. This is in
keeping with the international recognition of the anesthesiologist as ‘perioperative
physician’ rather than theatre technician. The ICU is now covered by anesthesia for
24 hours per day, with significantly increased consultant input during the day.
However, Zambian anesthesiolgists have yet to assume responsibility for pain
management, which is an integral function of the anesthetist’s extended role.
Although evaluating patient safety and better operative outcome was not the direct
aim of this study, it is likely that the observed improvements in the processes,
equipment and drugs for anesthesia has had a beneficial effect on surgical
outcomes. The strongest indicator for such improvement is the huge increase in the
number of spinal anesthetics for cesarean section since 2006, rising from 20% to
Page 21 of 32
86%. This is a major achievement in obstetric anesthesia since it is well recognized
that spinal anesthesia is a safer alternative to general anesthesia and has been
advocated as a first choice for the conduct of cesarean sections worldwide. Further
enhancement in this high risk area has been the successful delivery of several SAFE
Obstetric courses, which not only train anesthetists to better manage acute problems
for pregnant women, but also embed the capacity for further training locally.
Additionally, the Lifebox and Primary Trauma Care courses provide important
sources for continuing professional development, and adopt the same philosophy of
embedding training capacity locally so that the courses become self-sustaining over
time.
The growth in educational and research activities in the department have been of
sufficient quality for the university to consider forming a self-standing Academic
Department of Anaesthesia within UNZASoM. If this development comes about it will
likely give greater impetus to further growth to the specialty and raise its profile.
which in turn will promote recruitment and retention in this undervalued discipline.
If, as our study suggests, the observed improvements since 2006 are directly
attributable to the development of a postgraduate training program in anesthesia with
an increased number of physician anesthetists, it begs the question of how the
program has been successfully implemented. The answer may offer a solution to
other countries facing similar challenges. In the case of Zambia the central vehicle
for development has been through global health partnerships enabled by THET. A
full description of how this partnership was put together can be found elsewhere,7
but the necessity to train specialist physician anesthesiologists was identified by the
Page 22 of 32
Zambian Ministry of Health, who have had a previous formal partnership with the UK
government. THET have sourced funding from the UK Department for International
Development (DFID) to support the initial requirement for overseas faculty. It is
difficult to give a precise amount for start-up costs as they included the anesthesia
program as one of three Masters of Medicine programs that were started at the
same time, and included support of nursing training and biomedical engineer training
in Zambia, which were all supported by THET. There were some shared costs
between these programs, but we estimate that start up and ongoing costs for the
anesthesia program were around £100,000 ($123,000 USD) per year. THET also
leveraged cooperation and support from high-level stakeholders such as the Ministry
of Health. Without such high-level buy-in it would have been difficult to negotiate the
many hurdles presented when instituting a major change from afar. In addition, the
ties to institutions in the UK have helped to develop a base of expertise to support all
aspects of program development; curriculum design and review, research and
quality improvement.
Funding has since been renewed by DFID for the anesthesia program on the basis
of 3-year funding cycles. The current funding cycle ends in late 2017 and it is not yet
clear if there will be ongoing funding from the DFID or other funding agencies. We
are now in the second phase of the partnership. Phase 1 (2010-2015) was called
“building capacity”, phase 2 (2016-2020) is called “embedding the program locally”.
The goals of the current phase are to mentor graduates of the program into
leadership roles in administration, education, research and quality improvement both
at the University of Zambia/University Teaching Hospital, where the training program
is situated, but also nationally. The goal is to have the program entirely run by
Page 23 of 32
Zambian anesthesiologists and self-sustaining by the end of this phase of the
partnership as well as to broaden support to all anesthesia providers to ensure
adequate supply of trained providers across Zambia.
This study has limitations, in particular we did not collect data, nor had previous data
for comparison, on many factors relating to anesthesia care that are likely to affect
the outcome of perioperative care. Areas for future evaluation should include surgical
and nursing factors such as the number and sub-specialty availability of surgeons,
constraints in nursing staffing, sterilization processes, and available surgical
equipment.
Conclusions
Jochberger and colleagues made several recommendations for improving
anesthesia in Zambia. We would concur with their recommendations for ‘Improved
staff training … promotion of anesthesia to improve its image as a postgraduate
specialty, and… the creation of a local postgraduate training scheme’ 6. We believe
that these elements have been critical to the observed growth of anesthesia at UTH
in the last nine years. Their other recommendations for reliable supply of basic
amenities and drugs, functional medical equipment, improved anesthesia systems
(such as procurement), and introduction of clinical audit and governance procedures
naturally follow since the primary interventions create a ‘pull’ on the rest of the
system through enhanced advocacy, influence and understanding. However, their
recommendations offer no guidance as to how the necessary changes were to be
Page 24 of 32
achieved, and our study has offered insights into how major change has been
facilitated. Global health partnerships and the concept of co-development16 have
been key enablers to progress and have demonstrated how effectively this model of
support can work. This advance in anesthesia capability has coincided with the
recent launch of the Lancet Commission on Global Surgery, which has placed
surgical outcomes and development of the surgical care environment at centre stage
internationally 5. Central to achieving the Commission’s goals are developing
anesthetic capacity in countries with high perioperative mortality in order to support
safe surgery.
There needs to be continuing investment in infrastructure, equipment and drugs, but
these are likely to continue to be driven by further developing training and research
capacity to create an established profession of anesthesia in Zambia who can
advocate for patient safety. Although the profiles of anesthesia and perioperative
care are rapidly evolving, sub-specialty areas will require significant enhancement of
expertise. For Zambian anesthetists to develop these skills it will be essential for
them to be exposed to practice in a high-resource environment so that they can
return with the expertise. This can be achieved by supporting fellowship schemes in
neighbouring and overseas countries. Some examples already exist in Uganda,
Malawi, Zimbabwe, Namibia, Tanzania, who access fellowships in South Africa,
Canada, America and Asia. Furthermore, regional collaboration will be important in
setting uniform standards for anesthesia practice and training and the anesthesia
community has followed the example of the College of Surgeons of East, Central
and Southern Africa (COSESCA) collaborative17 by founding the College of
Anaesthesia of East, Central and Southern Africa (CANECSA) in 2014.
Page 25 of 32
Acknowledgements
Not applicable
References
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Figure 1: Anesthesia staffing
In additional file “Figure 1 anesthesia staffing”.
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Table 1: Data on surgical cases from UTH records from 2014 (with permission from the
Hospital Superintendent) compared with historical data
2005 2014
Major 5,012 (31%) 10,084 (55%)
Intermediate 1,415 (9%) 464 (2%)
Minor 9,702 (60%) 8,409 (43%)
Total 16,129 (100%) 19,697 (100%)
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Table 2: Drugs availability
TYPE OF DRUG DRUG MOST COMMONLY USED 2006
AVAILABLE DRUGS 2006
DRUG MOST COMMONLY USED 2015
AVAILABLE DRUGS 2015
Inhalational agent Halothane Halothane Isoflurane
Induction agent Thiopental Ketamine Thiopentone Ketamine, propofol
Neuromuscular blocking agent
Suxamethonium Pancuronium Suxamethonium Pancuronium
Opioid analgesic Pethidine Morphine Fentanyl, Morphine (IV)- in theatre
Pethidine (IM/IV)- on the wards
Pethidine (IM/IV) Morphine (oral), tramadol- theatres and wards
Non-opioid analgesic
Metamizol Paracetamol
Diclofenac
Diclofenac (IV- im preparation used)- theatres
Paracetamol (oral)- wards
Ibuprofen, Diclodenac (oral/ IM)
Local anesthetic Lidocaine Bupivacaine 2% Lidocaine- local infiltration
Heavy bupivacaine- spinal
Heavy bupivacaine, plain bupivacaine (occasionally from donations)
Reversal Neostigmine Neostyimine (+atropine)
Cardiovascular active drugs
As needed Dopamine Adrenaline
Dopamine
Dopamine, Dobutamine, Noradrenaline (from donations)
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Table 3: ICU staffing
Grade 2006 2015
Critical care nurses
(one year post graduate critical care training)
0 14
Registered nurses 11 11
Enrolled nurses/ Bedside nurses 17 10
Total: 28 35
