Cross-sectional analysis tracking workforce density in surgery, anesthesia, and obstetrics as an indicator of progress toward improved global surgical access

Abstract

Introdution: Safe surgical care, including anesthesia, obstetrics, and trauma, is an essential component of a functional health system, yet is lacking in much of the world. One indicator of surgical access is the number of specialist surgeons, anesthesiologists, and obstetricians (SAO) per 100,000 population, but global progress reaching threshold SAO density (SAOD) is unknown. This study measured SAOD change/trajectory and highlighted components of workforce expansion. Methods: SAOD in 2019 was captured utilizing publicly available medical licensing data for a convenience sample of 21 countries. Projected 2030 SAOD were estimated by extrapolating annual changes since 2015. Ugandan medical students were surveyed regarding postgraduate plans and SAO training availability. Workforce contribution by nonphysician surgical and anesthetic providers was measured in Sierra Leone. Results: Three low-income countries (LICs), 4 lower middle-income countries (L-MICs), 7 upper middle-income countries (UMICs), and 7 high-income countries (HICs) were included. Overall SAOD increased since 2015. The average 2019 SAOD was 1.16±0.81 (LICs), 3.19±1.92 (L-MICs), 20.98±12.55 (UMICs), and 44.04±12.41 (HICs). The projected 2030 SAOD in LICs and L-MICs remains below 20. In Uganda, 144 specialist SAO training positions and practice preferences predict an inadequate future workforce. In Sierra Leone, nonphysician providers contributed a 6-fold increase in the surgical workforce, though remains inadequate. Conclusions: Despite incremental positive changes since 2015, the current SAOD trajectory is inadequate to realize 2030 access goals. Increased training and retention of specialists and nonphysician providers are necessary to address this critical deficit.

Association between Surgery, Anesthesia, and Obstetric Workforce and Emergent Surgical and Obstetric Mortality among United States Hospital Referral Regions

“…In 2019, the average SAO density was 1.16 ± 0.81 for low-income countries, 3.19 ± 1.92 for lower-middle-income countries, 20.98 ± 12.55 for upper-middle-income countries, and 44.04 ± 12.41 for HICs. 16 Our results based on US data suggest that there do exist some HRRs with workforce densities similar to middle income countries, however these far exceed any workforce densities in low-income countries. This reflects the need for subnational data in Low- and middle-income countrys where there are also regions of care that likely have SAO densities far below the reported national average and where there are few providers.…”

A critical threshold for global pediatric surgical workforce density

“…Correlating surgical workforce density with population-level mortality rates allows for establishing a critical threshold of workforce density associated with significant improvements in survival. In fact, the LCoGS identified a critical threshold of 20 surgeons, anesthesiologists, and obstetricians per 100,000 people is associated with significant increases in maternal survival, which has subsequently served as a benchmark for tracking progress toward global surgical access and a target for countries when developing national health strategies [12,13]. Although studies have described the significant variability in pediatric surgeons around the world and the critical role they play in pediatric care, there are no previous studies of the specific PSWD threshold associated with improvements in childhood survival.…”

“…Unfortunately, all LMICs (and one UMIC) sampled were below the critical threshold PSWD of 0.37, representing 332 million children with inadequate access to surgical care. This PSWD deficit is especially critical in LMICs, where a greater proportion of the population is less than 15 years old and there are higher birth rates, with a greater prevalence of complex, congenital conditions [13,14]. Thus, many children will continue to die from treatable conditions if this deficit is not addressed.…”

Providing paediatric surgery in low-resource countries

“… 1 23 The shortage of paediatric surgeons is concerning, and to aggravate, the existing specialised surgeons are mostly concentrated in major cities. 24 To contribute to filling this gap, KidsOR in partnership with local institutions such as the College of Surgeons of East, Central and Southern Africa and the West African College of Surgeons provide education grants to countries with scarce number of paediatric surgeons, and the intended results of this work are found in table 2 . Alongside local partners and stakeholders, priority countries, regions and hospitals are defined and consequently a specific number of scholarships are publicised each year, with candidates shortlisted by the surgical colleges.…”

“…No country in Africa has reached the LCoGS’s recommendation of 20 specialist surgeons, anaesthesiologists and obstetricians per 100 000 population 1 23. The shortage of paediatric surgeons is concerning, and to aggravate, the existing specialised surgeons are mostly concentrated in major cities 24. To contribute to filling this gap, KidsOR in partnership with local institutions such as the College of Surgeons of East, Central and Southern Africa and the West African College of Surgeons provide education grants to countries with scarce number of paediatric surgeons, and the intended results of this work are found in table 2.…”