From the Department of Anaesthesiology, Faculty of Health Sciences, Medical College, Aga Khan University, Karachi, Pakistan.
Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand.
Anesth Analg. 2018 Apr;126(4):1312-1320. doi: 10.1213/ANE.0000000000002728.
The safety of anesthesia characteristic of high-income countries today is not matched in low-resource settings with poor infrastructure, shortages of anesthesia providers, essential drugs, equipment, and supplies. Health care is delivered through complex systems. Achieving sustainable widespread improvement globally will require an understanding of how to influence such systems. Health outcomes depend not only on a country's income, but also on how resources are allocated, and both vary substantially, between and within countries. Safety is particularly important in anesthesia because anesthesia is intrinsically hazardous and not intrinsically therapeutic. Nevertheless, other elements of the quality of health care, notably access, must also be considered. More generally, there are certain prerequisites within society for health, captured in the Jakarta declaration. It is necessary to have adequate infrastructure (notably for transport and primary health care) and hospitals capable of safely carrying out the "Bellwether Procedures" (cesarean delivery, laparotomy, and the treatment of compound fractures). Surgery, supported by safe anesthesia, is critical to the health of populations, but avoidable harm from health care (including very high mortality rates from anesthesia in many parts of the world) is a major global problem. Thus, surgical and anesthesia services must not only be provided, they must be safe. The global anesthesia workforce crisis is a major barrier to achieving this. Many anesthetics today are administered by nonphysicians with limited training and little access to supervision or support, often working in very challenging circumstances. Many organizations, notably the World Health Organization and the World Federation of Societies of Anaesthesiologists, are working to improve access to and safety of anesthesia and surgery around the world. Challenges include collaboration with local stakeholders, coordination of effort between agencies, and the need to influence national health policy makers to achieve sustainable improvement. It is conceivable that safe anesthesia and perioperative care could be provided for essential surgical services today by clinicians with moderate levels of training using relatively simple (but appropriately designed and maintained) equipment and a limited number of inexpensive generic medications. However, there is a minimum standard for these resources, below which reasonable safety cannot be assured. This minimum (at least) should be available to all. Not only more resources, but also more equitable distribution of existing resources is required. Thus, the starting point for global access to safe anesthesia is acceptance that access to health care in general should be a basic human right everywhere.
当今，高收入国家的麻醉安全性在基础设施较差、麻醉提供者短缺、基本药物、设备和用品不足的资源匮乏环境中无法实现。医疗保健是通过复杂的系统提供的。要实现全球可持续广泛改善，就需要了解如何影响这些系统。健康结果不仅取决于一个国家的收入，还取决于资源的分配方式，而这些在国家之间和国家内部都有很大差异。麻醉安全性尤为重要，因为麻醉本质上具有危险性，而不是治疗性的。然而，医疗保健质量的其他要素，特别是可及性，也必须得到考虑。更一般地说，在社会中存在某些健康的先决条件，这些条件被概括在《雅加达宣言》中。必须要有足够的基础设施（特别是交通和初级卫生保健）和能够安全进行“标杆手术”（剖宫产、剖腹术和复合骨折治疗）的医院。在安全麻醉的支持下，外科手术对人口健康至关重要，但医疗保健造成的可避免伤害（包括世界许多地区麻醉的高死亡率）是一个重大的全球问题。因此，外科和麻醉服务不仅必须提供，而且必须是安全的。全球麻醉劳动力危机是实现这一目标的主要障碍。如今，许多麻醉剂是由接受过有限培训、几乎无法获得监督或支持的非医师管理的，他们通常在非常具有挑战性的环境中工作。许多组织，特别是世界卫生组织和世界麻醉医师联合会，正在努力改善全球范围内的麻醉和手术可及性和安全性。面临的挑战包括与当地利益攸关方合作、协调各机构之间的工作以及需要影响国家卫生政策制定者以实现可持续改善。可以想象，今天使用训练有素程度适中的临床医生，使用相对简单（但设计和维护得当）的设备和数量有限的廉价通用药物，就可以为基本外科服务提供安全的麻醉和围手术期护理。然而，这些资源有一个最低标准，低于这个标准就无法保证合理的安全性。这一最低标准（至少）应面向所有人。不仅需要更多的资源，还需要更公平地分配现有的资源。因此，全球获得安全麻醉的起点是接受这样一个事实，即医疗保健的可及性应该是各地所有人的基本人权。
