WFSA describes its vision for implementation of WHA 68.15

The World Federation of Societies of Anaesthesiologists (WFSA) is composed of 135 member societies in more than 150 countries and represents hundreds of thousands of anesthesiologists around the world.

The WFSA’s vision is of “universal access to safe anesthesia,” and its mission is “to unite anaesthesiologists around the world to improve patient care and access to safe anaesthesia and perioperative medicine.”¹ Anesthesiologists are leaders in teamwork and patient safety and are experts in anesthesia and perioperative care, resuscitation, intensive care medicine, and pain management.

WHA 68.15, safe anesthesia, and safe surgery

The year 2015 marked a turning point for the 5 billion out of 7 billion people in the world without access to safe, affordable, and timely surgery and anesthesia care.² With the release of the following publications and reports—the third edition of Disease Control Priorities: Essential Surgery;³ The Lancet Commission on Global Surgery (LCoGS) “Global surgery 2030: Evidence and solutions for achieving health, welfare, and economic development”;² and the unanimous passage of World Health Assembly (WHA) Resolution 68.15, Strengthening Essential and Emergency Surgery and Anaesthesia as a component of Universal Health Coverage⁴—a platform was established to ensure that the surgical patient is included in any commitment and action to ensure universal health coverage (UHC), as outlined in the United Nations’ sustainable development goal (SDG) 3.⁵

The WFSA has official liaison with the World Health Organization (WHO) and was part of the campaign to promote the passage of WHA Resolution 68.15, which is intended to ensure that safe anesthesia is an indivisible and indispensable element of safe surgery, and that both are a human right.

In addition to supporting the resolution, the WFSA has been active in ensuring that key indicators, such as perioperative mortality rate and surgical workforce density, are included in the WHO list of 100 Core Health Indicators,⁶ and that the WHA commits to regular progress reporting against the resolution. Ongoing reporting is an essential requirement if we are to convert WHA 68.15 into action and measurable change.

Our framework for action

As part of its response, the WFSA defined its goals, described the size of the crisis in anesthesia, and outlined a plan for achieving its mission and measuring its progress.

The plan is based on the WFSA International Standards for a Safe Practice of Anesthesia.⁷ The latest revision of these standards will be published in 2018 and will be a shared WFSA-WHO set of guidelines establishing the minimum standards required for the provision of safe anesthesia in the areas of workforce, equipment and infrastructure, and medicine. With the establishment of a clear description of safe anesthesia practice, the WFSA can define which efforts are required to ensure safe, affordable, and timely anesthesia care. The standards also can be used to inform the development of national guidelines, which are useful in achieving more local buy-in, targets, legislation, and national improvement plans.

The WFSA Global Anesthesia Workforce Survey highlights the breadth of this health care crisis and helps measure how it progresses in the future.⁸ Conducted in 2015–2016, the survey documented the shortage of anesthesia providers against the LCoGS recommendation of 20 specialist surgeons, anesthesiologists, and obstetricians (SAOs) per 100,000 population, with an interim target for the number of anesthesiologists set at five per 100,000 population. The survey showed the stark differences in physician and nonphysician anesthesia provider numbers between different regions of the world and between resource-rich and resource-poor countries. The study also found that to meet the target, at least an additional 136,000 anesthesiologists are needed—mostly in low-income countries.

To measure differences in anesthesia provider numbers, the aim is to repeat the survey every four years. Notably, the survey also is augmented by a web-based map, which is a real-time tool for tracking the anesthesia workforce and is updated as new information is received (see Figure 1). The survey also is enhanced by ongoing support of advocacy efforts.

Figure 1. WFSA Global Anesthesia Workforce map

Source: World Federation of Societies of Anaesthesiologists. The WFSA Global Anesthesia Workforce Map. Available at: www.wfsahq.org/workforce-map. Accessed March 22, 2018.

In 2017, the WFSA member societies unanimously approved a position statement on anaesthesiology and UHC,⁹ describing how the federation and anesthesia providers will respond. The statement describes anaesthesiology as a medical specialty, one that is potentially high-risk and that must, wherever and whenever possible, be provided, led, or overseen by physicians. The statement explains that in many countries, nonphysician providers (nurses, clinical officers, and technicians) are and will be part of any solution and acknowledges that a range of trained providers are necessary to achieve UHC by 2030. Teamwork is vital to meeting this goal, as is the development of a task-sharing approach across the anesthesia-surgical team.

Four programs for accessibility

The WFSA has four program areas that are intended to ensure access to proper anesthesia care for all global populations, including: advocacy, education and training, safety and quality, and innovation and research.

The WFSA’s advocacy-related priorities include informing both the public and policymakers about the role of anesthesia and positioning it as a priority for all stakeholders, including the United Nations’ WHO/WHA, government bodies, nongovernmental organizations, industry, and funders, as well as for the surgical team itself. As part of its mission to inform and support anesthesia care health policy, the WFSA organized the inaugural SAFE-T (Safe Anaesthesia For Everybody–Today) Summit, which took place in London, U.K., in April 2018.

Education and training priorities include the expansion of the WFSA’s fellowship program—a sub-specialty mentoring program that provides clinical and leadership training for up to 50 young anesthesiologists every year. The WFSA also intends to expand short-term Safer Anaesthesia From Education (also known as SAFE) training aimed at all anesthesia providers, including those who work in obstetrics, pediatrics, and operating room settings, as well as training for those who work in pain management. In addition, the WFSA supports the attendance of young anesthesiologists at scientific conferences, including the World Congress of Anaesthesiologists, through the WFSA scholarship program.

The WFSA will continue to produce a range of online educational materials, including the web-based Anaesthesia Tutorial of the Week,¹⁰ the continuing medical education journal Update in Anaesthesia,¹¹ and the global health section in Anesthesia and Analgesia via our partnership with the International Anesthesia Research Society. The federation plans to engage in ongoing improvement of in-person and online education resources available through the WFSA, member societies, and other partners.

The safety and quality goals include all WFSA program areas, specifically the ongoing revision and dissemination of the international standards, as well as the support of professional well-being programs for anesthesiologists.¹² The WFSA soon will expand its role and that of its member organizations in the development of national surgical, obstetric, and anesthesia plans.¹³ The WFSA has developed an anesthesia capacity assessment tool (based on the standards) to help with the expansion process.¹⁴

The innovation and research goals include a global innovation awards program and research fellowships. Alongside these programs, our publications aim to encourage more research in low- and middle-income countries (LMICs) where the lack of evidence and data hinders the drive for policy change and action.

WHA 68.15: The main challenge to implementation

The WFSA maintains that the primary hurdle to the implementation of WHA 68.15 is the workforce deficit—a deficit that is heightened when one considers the concentration of anesthesiologists in urban centers and, as is often the case, in private practice. Other resources, such as equipment and medicines, are also important, but workforce needs must be met first, both as a driver for change and as the essential resource to ensure that equipment and medicines are used appropriately and safely.

Although the WFSA has a well-developed strategy for strengthening the skills, knowledge, competencies, and leadership of anesthesia providers who are already qualified and providing anesthesia, the Federation recognizes that much more needs to be done to qualify and retain new anesthesia providers. In response to WHA 68.15, the WFSA is now developing a framework for anesthesia training that will help national societies determine the different levels of competency required for specific operations at different levels of hospitals. In some countries, the guidelines might go on to provide a foundation for training programs to develop an expanded cadre of nonspecialist nurse and physician anesthesia providers who can be trained, mentored, and overseen by anesthesiologists (see Figure 2).

Figure 2. The WFSA fellowship programs

Source: World Federation of Societies of Anaesthesiologists. The WFSA Fellowship Programmes. Available at: www.wfsahq.org/wfsa-fellowship-programmes. Accessed March 22, 2018.

The data suggest that less than 1 percent of global health funding is spent on any aspect of anesthesia-surgical care, despite surgical conditions accounting for 30 percent of the global burden of disease.¹⁵ These disparities must change, and the WFSA will continue to work with partners such as the WHO and the G4 Alliance (also known as the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care) to ensure that health care leaders and funders are aware of these inequities.

Governments seem to have a tendency to undervalue anesthesia, with providers in many LMICs unable to qualify in and go on to develop careers in the specialty. Indeed, in some low-income countries, anesthesia trainees do not receive a salary. Strengthened partnership with surgeons will be helpful in this regard, as will a broader acknowledgment of the role of anesthesia care in health system strengthening, mother and child health, pain management, palliative care, noncommunicable diseases, and trauma and critical care.

The WFSA’s solutions

Advocacy and education are paramount in the WFSA’s implementation of Resolution 68.15. The WFSA will continue to scale up activity, provided that funding and resources are available. The WFSA recognizes that large numbers of new providers are required and is working with national societies, educational organizations, and other stakeholders to scale up training of specialists and nonspecialist providers. In so doing, the WFSA is aware of both the urgency of the need and the economics involved, but is also determined to help every patient achieve access to safe and timely anesthesia.

The WFSA’s network is unique. Physician-led but patient-focused, this organization provides extraordinary and investible resources to ensure the realization of the goal of universal access to safe anesthesia and surgery.

References

1. World Federation of Societies of Anaesthesiologists. Vision and mission. Available at: www.wfsahq.org/about-us/vision-and-mission. Accessed March 20, 2018.
2. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
3. Mock CN, Donkor P, Gawande A, et al. Essential surgery: Key messages from Disease Control Priorities, 3rd edition. Lancet. 2015;385(9983):2209-2219.
4. World Health Assembly Resolution 68.15: Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage. Sixty-Eighth World Health Assembly. Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_R15-en.pdf. Accessed November 30, 2017.
5. United Nations. Sustainable Development Goals. Available at: www.un.org/sustainabledevelopment/sustainable-development-goals/. Accessed March 4, 2018.
6. World Health  Organization. Global Reference List of 100 Core Health Indicators, 2015. Available at: www.who.int/healthinfo/indicators/2015/en/. Accessed March 4, 2017.
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9. World Federation of Societies of Anaesthesiologists. WFSA position statement on universal health coverage. Available at: www.wfsahq.org/latest-news/latestnews/682-wfsa-releases-position-statement-on-anaesthesiology-and-universal-health-coverage-uhc. Accessed March 19, 2018.
10. World Federation of Societies of Anaesthesiologists. Anaesthesia Tutorial of the Week. Available at: www.wfsahq.org/resources/anaesthesia-tutorial-of-the-week. Accessed March 19, 2018.
11. World Federation of Societies of Anaesthesiologists. Update in anaesthesia. August 2017. Available at: www.wfsahq.org/resources/update-in-anaesthesia. Accessed March 19, 2018.
12. Occupational Well-Being in Anesthesiologists. Sociedade Brasileira de Anestesiologia. 2014. Available at: www.wfsahq.org/images/Occupational_Well-Being_in_Anesthesiologists-2.pdf. Accessed March 19, 2018.
13. Surgical care systems strengthening: Developing national surgical, obstetric and anaesthesia plans. World Health Organization 2017. Available at: http://apps.who.int/iris/handle/10665/255566. Accessed March 19, 2018.
14. World Federation of Societies of Anaesthesiologists. Anaesthesia Capacity Assessment Tool. Available at: www.wfsahq.org/our-work/advocacy/national-anaesthesia-plans. Accessed March 20, 2018.
15. Dieleman JL, Yamey G, Johnson EK, Graves CM, Haakenstad A, Meara JG. Tracking global expenditures on surgery: Gaps in knowledge hinder progress. Lancet Glob Health. 2015 Apr 27;3 Supplement 2:S2-4.