Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia

1 September, 2020

Dear HIFA-Zambia and HIFA colleagues,

This paper highlights major shortcomings.

Citation, abstract and key points below. Full text:

The full text ends with the following comment: 'Global policy makers and funding bodies need to prioritize anesthesia and surgical care, ensuring that skilled staff, infrastructure, and supplies are in place, because injury and surgically treatable conditions kill more humans currently than tuberculosis (TB), human immunodeficiency viruses (HIV), and malaria together, while the latter 3 receive the majority of funding.'

CITATION: Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia: A Mixed-Methods Study

Gajewski, Jakub et al.

Anesthesia & Analgesia: April 2020 - Volume 130 - Issue 4 - p 845-853

doi: 10.1213/ANE.0000000000004363



District-level hospitals (DLHs) are the main providers of surgical services for rural populations in Sub-Saharan Africa (SSA). Skilled teams are essential for surgical care, and gaps in anesthesia impact negatively on surgical capacity and outcomes. This study, from a baseline of a project scaling-up access to safe surgical and anesthesia care in Malawi, Tanzania, and Zambia, illustrates the deficit of anesthesia care in DLHs.


We undertook an in-depth investigation of anesthesia capacity in 76 DLHs across the 3 countries, July to November 2017, using a mixed-methods approach. The quantitative component assessed district-level anesthesia capacity using a standardized scoring system based on an adapted and extended Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) Index. The qualitative component involved semistructured interviews with providers from 33 DLHs, exploring how weaknesses in anesthesia impacted district surgical team practices and quality, volume, and scope of service provision.


Anesthesia care at the district level in these countries is provided only by nonphysician anesthetists, some of whom have no formal training. Ketamine anesthesia is widely used in all hospitals, compensating for shortages of other forms of anesthesia. Pediatric size supplies/equipment were frequently missing. Anesthesia PIPES index scores in Malawi (M = 8.0), Zambia (M = 8.3), and Tanzania (M = 8.4) were similar (P = .59), but an analysis of individual PIPES components revealed important cross-country differences. Irregular availability of reliable equipment and supply is a particular priority in Malawi, where only 29% of facilities have uninterrupted access to electricity and 23% have constant access to water, among other challenges. Zambia is mostly affected by staffing shortages, with 30% of surveyed hospitals lacking an anesthesia provider. The challenge that stood out in Tanzania was nonavailability of functioning anesthesia machines among frequent shortages of staff and other equipment.


Tanzania, Malawi, and Zambia are falling far short of ensuring universal access to safe and affordable surgical and anesthesia care for district and rural populations. Mixed-methods situation analyses, undertaken in collaboration with anesthesia specialists — measuring and understanding deficits in district hospital anesthetic staff, equipment, and supplies — are needed to address the critical neglect of anesthesia that is essential to providing surgical responses to the needs of rural populations in SSA.


Question: Considering the lack of published country-specific empirical studies comparing anesthesia capacity across countries using standardized and validated methods, what is the current state of anesthesia care at district hospitals in Malawi, Zambia, and Tanzania?

Findings: None of the surveyed hospitals met international minimum safety standards for anesthesia, and an in-depth investigation brought to light major cross-country differences in the availability of essential anesthesia personnel, equipment, and supplies.

Meaning: Country-specific interventions are urgently needed to improve anesthesia care at the district level if the surgical needs of rural populations are to be addressed.


Best wishes, Neil

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages in collaboration with WHO. Twitter: @hifa_org FB: