In Response

Abstract

We welcome and wish to endorse the points made by Sund1 in his commentary on our article “Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia: A Mixed-Methods Study.”2 The importance of our article lies to a great extent in the size of the evidence gap and the paucity of research on anesthesia capacity at district hospitals, which are best placed to address the bulk of unmet population need. Sund1 has highlighted some of the obstacles, including lack of funding and capacity to conduct such research. We wish to commend Anesthesia & Analgesia for publishing our article, despite its shortcomings, not least being the lack of anesthesiologists among the authors. We are not the first—and sadly, we may not be the last—to come to the realization that lack of anesthesia capacity is often the rate-limiting step to delivering essential and life-saving surgery to rural populations in much of Sub-Saharan Africa. The positive development is that our study has produced hard evidence from 76 district-level hospitals across 3 such countries, which the anesthesia and public health communities can use in advocating for resources from global and national policy makers and funding bodies. We suggest that those in the anesthesia community, who are committed to building on this modest platform of population-level research on anesthesia capacity, need to work with a broader coalition of stakeholders who share their commitment. At the global level, this will include global public health and global surgery communities, so as to build synergies of effort. Even more important, we believe, is the national commitment in countries with the greatest need, which is essential to the future sustainability of the interventions we are currently testing, where anesthesia as well as surgical and nursing specialists are working together in building capacity at district level.3 This national-level commitment needs to translate into the availability of local and international funding to improve surgical services. There is also an important need to extend the focus beyond national surgery, anesthesia, and obstetric specialists, who are leading the development of national plans in several Sub-Saharan African countries, to include frontline district health care providers—doctors, nonphysician clinicians, nurses, managers, and support staff. District level health care, although of crucial importance, has not been the main focus for most researchers, academics, and implementers working in global surgery. Its importance is also not adequately reflected at the policy level. The prioritization of district-level surgery is currently missing in 4 of 5 published national surgery, obstetric, and anesthesia plans. Therefore, an inclusive approach is needed in both research and interventions to ensure the perspectives of all members of the surgical team (surgical providers, anesthesia providers, and nursing) are taken into account to best serve patients where the need is the greatest. In our current study, our focus is on the teams and teamwork needed to deliver these essential services. This requires moving out of the professional silos that can otherwise impede the collective effort that is needed. Our research has contributed a further brick to build evidence that the availability of quality-assured safe anesthesia is the critical and common underlying determinant of countries’ abilities to deliver essential surgery and emergency obstetric care. Hence, we wish to join in Sund’s1 impassioned call to—and we look forward to working with—the global anesthesia research community in building on this platform. Global access to safe surgical and anesthesia care in the developing world will not be possible to achieve if not attempted cross-disciplinary. Surgical and anesthesia providers, together with public health researchers, economists, and health planners, need to work collaboratively and maximize the impact each discipline brings to the field of global surgery. ACKNOWLEDGMENTS The authors acknowledge the contribution of the whole Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) research consortium. Jakub Gajewski, PhDInstitute of Global SurgeryRoyal College of Surgeons in IrelandDublin, Ireland[email protected]Chiara Pittalis, MSRuairi Brugha, MDDepartment of Epidemiology and Public Health MedicineRoyal College of Surgeons in IrelandDublin, Ireland