29 Oct 2020

Anesthesiology Training in Developing Nations

According to the World Federation of Societies of Anesthesiologists (WFSA), there is a critical shortage of trained anesthesia providers in low- and middle-income countries (LMICs).1 This issue contributes to a global crisis where millions of people do not have access to safe surgical and anesthesia care when needed.1 In LMICs, anesthesia providers may have differing levels of training, models of care are variable, and there is often a lack of coordination between training programs.2 It is critical to improve the number and quality of anesthesiology training programs globally.

The WFSA Global Anesthesia Workforce Survey found that 77 LMICs had an anesthesiologist density of <5/100,000 population compared to an average of 20/100,000 in high-income countries.When comparing high-income countries (such as the United States, Canada, Australia, and United Kingdom) to LMICs, how anesthesia care is delivered is centered on how medical professionals are trained and educated.3 In high-income countries, educational standards for anesthesiologists are well-established by a combination of government entities and professional societies.3 Students in high-income countries typically require approximately 11-15 years to complete anesthesiology education, which demands the completion of several rigorous examinations and practical training sessions.3 However, in LMICs, a lack of training programs, insufficient numbers of graduates from medical school who choose anesthesia, a scarcity of proper training materials, and a lack of academic educational partnerships contribute to the overall shortage of trained anesthesiologists to care for the millions of patients in LMICs.3

The migration of physicians from LMICs to developed countries is often referred to as the “brain drain.”4 One example comes from Addis Ababa University (AAU) Department of Anesthesiology.4 Between 1991 and 2003, 31 residents enrolled in the AAU Anesthesiology residency.4 Of the 24 residents that graduated, 10 (41.6%) are currently practicing in other countries.4

A number of efforts on the international stage have been implemented to assist LMICs in training and retaining more anesthesia providers.3 In 2006, a program concluding in a Master’s degree in Anesthesia was established in Rwanda as a joint venture between the National University of Rwanda (NUR), the Canadian Anesthesiologists’ Society of International Education Fund (CASIEF), and the American Society of Anesthesiologists Overseas Teaching Program (ASAOTP).5 A Master’s in Anesthesia is similar to a fellowship in Canada and has become common in many African countries.4 Before the implementation of the Master’s program in Rwanda, there was only one Rwandan anesthesiologist in the country.5 All other anesthesiologists were expatriates working in the country on contract.5 The four-year Master’s in Anesthesiology has helped to train more anesthesia providers in Rwanda, but there is still a need to send residents or anesthesiologists out of country to receive subspecialty training.5

This was not the first time CASIEF was involved in the development of an anesthesia training program abroad.5,6In 1985, it launched a one-year DA training program in Nepal.6 By 1987, the Society of Anesthesiologists of Nepal was formed, and the country soon became self-sufficient in training their own anesthesiologists.5,6 By 2005, 43 anesthesiologists were trained in the DA program.6 It is hoped that, over time, a similar outcome will be reached in Rwanda.6

Similarly, Belgium has been collaborating for 20 years with Abomey-Calavi University in Benin to train anesthesiologists for Sub-Saharan African countries.7 With 123 graduates and 46 residents still in training, this program has succeeded in bolstering the anesthesiology workforce in Sub-Saharan African and improving the quality of anesthesia and patient outcomes.7

The establishment of local training programs, strong guidance from developed nations, and the formation of a national professional society have all shown to be positively correlated with professional self-esteem and retention of trained anesthesia providers.5,6,7 Continuing international support remains of critical importance, especially in the form of anesthesia rotations to high-income countries.7 The development of structured anesthesiology programs should be encouraged by governments of LMICs, as quality anesthesia care is needed for surgical development.


  1. Morriss, W., Ottaway, A., Milenovic, M.,  et al. (2019). A Global Anesthesia Training Framework. Anesthesia & Analgesia128(2), 383-387. doi:10.1213/ane.0000000000003928
  2. Lipnick, M., Bulamba, F., Ttendo, S., & Gelb, A. (2017). The Need for a Global Perspective on Task-Sharing in Anesthesia. Anesthesia & Analgesia125(3), 1049-1052. doi:10.1213/ane.0000000000001988
  3. Roth, R., Frost, E., Gevirtz, C., & Atcheson, C. (2015). The Role of Anesthesiology in Global Health. Springer International Publishing. ISBN: 978-3-319-09422-9
  4. Patel, K., Dooley, M., Abate, A., & Moll, V. (2017). Distributed Learning: Revitalizing Anesthesiology Training in Resource-Limited Ethiopia. Frontiers in Public Health5. doi:10.3389/fpubh.2017.00059
  5. Enright, A. (2007). Anesthesia training in Rwanda. Canadian Journal of Anesthesia54(11), 935-939. doi:10.1007/bf03026799
  6. Shrestha, B., & Rana, N. (2006). Training and development of anesthesia in Nepal — 1985 to 2005. Canadian Journal of Anesthesia/Journal Canadien D’anesthésie53(4), 339-343. doi:10.1007/bf03022496
  7. Zoumenou, E., Chobli, M., le Polain de Waroux, B., & Baele, P. (2018). Twenty Years of Collaboration Between Belgium and Benin in Training Anesthesiologists for Africa. Anesthesia & Analgesia126(4), 1321-1328. doi:10.1213/ane.0000000000002772