• Linden S Baxter, Vaonandianina A Ravelojaona, Hasiniaina N Rakotoarison, Alison Herbert, Emily Bruno, Kristin L Close, Vanessa Andean, Hery H Andriamanjato, Mark G Shrime, and Michelle C White.
• From the *Mercy Ships, Port of Toamasina, Madagascar; †College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; ‡Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; §Department of Anesthesia, The Austin Hospital, Melbourne, Australia; ‖Ministère de la Santé Publique, Madagascar; ¶Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts; and #Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.
• Anesth. Analg. 2017 Jun 1; 124 (6): 2001-2007.

BackgroundThe global lack of anesthesia capacity is well described, but country-specific data are needed to provide country-specific solutions. We aimed to assess anesthesia capacity in Madagascar as part of the development of a Ministry of Health national surgical plan.MethodsAs part of a nationwide surgical safety quality improvement project, we surveyed 19 of 22 regional hospitals, representing surgical facilities caring for 75% of the total population. The assessment was divided into 3 areas: anesthesia workforce density, infrastructure and equipment, and medications. Data were obtained by semistructured interviews with Ministry of Health officials, hospital directors, technical directors, statisticians, pharmacists, and anesthesia providers and through on-site observations. Interview questions were adapted from the World Health Organization Situational Analysis Tool and the World Federation of Societies of Anaesthesiologists International Standards for Safe Practice of Anaesthesia. Additional data on workforce density were collected from the 3 remaining regions so that workforce density data are representative of all 22 regions.ResultsAnesthesia physician workforce density is 0.26 per 100,000 population and 0.19 per 100,000 outside of the capital region. Less than 50% of hospitals surveyed reported having a reliable electricity and oxygen supply. The majority of anesthesia providers work without pulse oximetry (52%) or a functioning vaporizer (52%). All the hospitals surveyed had very basic pediatric supplies, and none had a pediatric pulse oximetry probe. Ketamine is universally available but more than 50% of hospitals lack access to opioids. None of the 19 regional hospitals surveyed was able to completely meet the World Federation of Societies of Anaesthesiologists' standards for monitoring.ConclusionsImproving anesthesia care is complex. Capacity assessment is a first step that would enable progress to be tracked against specific targets. In Madagascar, scale-up of the anesthesia workforce, investment in infrastructure and equipment, and improvement in medication supply-chain management are needed to attain minimal international standards. Data from this study were presented to the Ministry of Health for inclusion in the development of a national surgical plan, together with recommendations for the needed improvements in the delivery of anesthesia.

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