The need for a global perspective on task-sharing in Anesthesia

Abstract

Worldwide, patients are suffering due to a critical shortage of anesthesia providers. Five billion people lack access to safe surgical and anesthesia care with 143 million surgical procedures not performed each year due to inadequate access to care.1 A large proportion (approximately one third) of the global burden of disease requires surgical and anesthesia services, yet many countries have < 1 anesthesia provider per 100,000 or even per million citizens. By comparison, in the United States, there is 1 anesthesia provider per 4300 citizens. How best to rectify this global anesthesia workforce crisis is a challenge that needs urgent, productive dialogue and action, especially by the anesthesiology community. It cannot be left to happenstance, to whimsical government decisions, or to nonanesthesiologists alone. Furthermore, it cannot be left in the hands of individuals or organizations that ignore the global perspective and either categorically oppose independent nonanesthesiologist provision of care or demand complete nonanesthesiologist autonomy as the optimal strategy for increasing access to safe anesthesia care worldwide. Task-sharing is widely utilized to expand access to care and address workforce shortages for many disciplines, including anesthesia, primary care (eg, community health workers), obstetrics (eg, midwives), and surgery (eg, physicians’ assistants). However, the topic of task-sharing in anesthesia is arguably more complex than for other disciplines primarily for 2 reasons: (1) the relative shortage of physician anesthesia providers in many low- and middle-income countries (LMICs) is orders of magnitude worse than for other specialties; and (2) anesthesia is perhaps the only specialty where formal, nonphysician cadres practice in some settings with full scope of practice. The former makes task-sharing all the more important and the latter factor makes task-sharing more contentious. For the purposes of this article, we use the word “anesthesiologist” to mean a graduate of a medical school who has undergone a period of postgraduate clinical training in an accredited anesthesia education program with documentation of training and the ability for independent practice. A nurse anesthetist is a graduate of nursing school who has completed an accredited clinical anesthesia training program. In the United States, a certified registered nurse anesthetist (CRNA) has completed a Bachelor’s degree in nursing (or other appropriate degree), holds a Registered Nurse licensure, and has had a minimum of 1 year of critical care experience. We define an anesthetic assistant, an anesthetic/clinical officer, or an anesthesia technician as a health care provider with a varied background who has undergone clinical anesthesia training. For the purposes of this article, we use the term nonphysician anesthesia provider (NPAP) to collectively describe all nonphysician providers. Current models of anesthesia care delivery worldwide include anesthesiologists working alone, anesthesiologists supervising NPAPs (care team), NPAPs working independently, and surgery providers performing surgery while concurrently administering some form of anesthesia. In many countries worldwide, it is also common practice for physicians with little or no formal anesthesia training to administer anesthetics. Due to the massive global anesthesia workforce shortage and inequitable access to surgical and anesthesia services in low-, middle-, and high-income countries, the fact of the matter is that a universal model based on service provision by a single-handed anesthesiologist is untenable.2,3 The duration and cost of anesthesiologist training, coupled with limited existing training capacity worldwide, prohibit sufficient scale-up of anesthesiologists to meet growing global needs. The only globally viable model is a flexible, team-based approach that includes both anesthesiologists and nonanesthesiologist providers.