The untold story of anaesthesia care challenges in Tanzania

Dar es Salaam. For decades, Mpoki Ulisubisya, one of the first Tanzanian doctors to be trained as an anaesthesiologist, has witnessed the highs and lows of anaethesia care in the country.

Recently in Dar es Salaam, as he stood up to address a conference room full of health experts and senior government officials on anesthesia, it was all silence. Participants waited with bated breath for his remarks. You could hear a pin drop.

With a sense of humour, coupled with oratory experience, he was emphatic as he raised the curtain with his speech: “A story needs to be told…”

As he detailed the realities behind worrying statistics on maternal and newborn deaths in Tanzania, he further explained how this is connected with anaesthesia care, while comparing the situation in Africa and the rest of the world.

Dr Ulisubisya was speaking on the day Tanzania witnessed the inauguration of the country’s first Anesthesia and Critical Care Simulation Laboratory at Muhimbili University of Health and Allied Sciences (Muhas).

As the president of the Society of Anaesthesiologists of Tanzania (Sata) and diplomat, he had joined the Muhas community and high ranking government officials to unveil the new skills lab, supported by a US-based technology company, Gradian Health Systems to improve anaesthesia care in the country’s neediest regions.

As an expert with hands-on skills in anaethesia care and a leader, he was better positioned to elucidate what the newly inaugurated skills lab means to Tanzania’s health system.

In the operating room

Mid his speech, he recalled his gloomy moments in an operating room at a rural hospital in his country, where medics hadn’t seen a vital pain-relieving medication known as pethidine, for years.

In that hospital where he had gone to provide services, treatment options—even in critical procedures as major surgery—were entirely dictated by stock out/availability of basic medical supplies —not by standards.

A well-travelled doctor, Ulisubisya now recalled that eventful day when—as an expert in anaesthesiology—he was flown to a health facility, located in Southern Tanzania—a trip that would turn out to offer him lessons on the anaesthesia care situation in Tanzania.

“I once had the privilege of flying on an Amref plane to Nachingwea,” he began. “[I was] in the company of my friend [a gynaecologist/obstetrician]… [when we arrived there], we reviewed patients and we decided that those qualify for surgery,” recalls Dr Ulisubisya.

“Having worked at the national hospital, I had expected that at least the basic minimum was available, so [during the operation], I shouted that I needed a strong analgesic (pain-relieving drug) pethidine because during [such a procedure] tissues were to be cut and there would so much pain.”

“...so, I told the surgeon that let’s wait for the drug (pethidine] to be provided. Thirty minutes went by; there was no pethidine, 45 minutes! And, I realised we had limited time because in next few hours, we were to fly back.” It would never come!

Any alternative?

“I told the surgeon [mentions his name] that, please go ahead and [operate]…using Ketamine, and then, once the surgery is over, we should be able to give the patient the analgesic [that was required].

“…four hours down the line, then somebody came over and told me that you know what, to say the truth, it’s about six years since we last glanced at the drug that you asked for. So, what do you do?” I asked, says Dr Ulisubusya. The response to him was, “…we simply give the patients diazepam.”

Left amazed, Dr Ulisubisya says: “I didn’t learn in my training in anaethesia that diazepam could [suit that kind of service in theatre] so, that’s how [challenging it has become]…when it comes to learning appropriate skills...”

To him, the best way to ensure quality healthcare is to consider three pillars— the right infrastructure, health commodities and human resource for health.

“…what I am trying to say here is that no system is strong without the plans that are implemented to make it deliver for the whole system. That’s why we say that the human resource must be trained appropriately and adequately.

He reflected on the gap which would be addressed by the new Simulation Lad training at Muhas, in which a certified team of instructors from the university are training physicians across the country as part of a $3 million project to boost anaethesia care.

Currently in Tanzania, there is one anaesthesiologist per million people—meaning that most surgeries are performed by non-physicians with a year or less of training.

This happens at a time when rural parts of the country, where health facilities are ill-equipped, healthcare providers end up managing patients with less effective, riskier methods of care.

Dr Ulisubisya says the situation is largely to blame for high levels of maternal and newborn deaths, based on research evidence and the on-site assessment he has done when he was a key leader at the Health Ministry. Due to high population and geographical challenges, coupled with lack of essential health services, the Lake Zone has been reported to have high levels of maternal mortality, compared to any other part of Tanzania.

“I also had a privilege of doing a survey in the Lake Zone. We were looking forward to establishing critical care facilities, so my duty was to do it in Kagera Region, so I went to Bukoba...” says Dr Ulisubisya.

“[Upon arrival] I enquired from the then district medical officer if there was a critical care hospital [for assessment]…He [the district medical officer] said no problem, “You better go to Ndolage, they have one.”

“So, he drove me all the way to Kamachumu [in Bukoba]. While in that place, I enquired to go to the ICU [intensive care unit] and I was taken to the room that was referred to as an ICU. What did I see there?...

Five patients…an oxygen concentrator… with three outlets, distributed among three patients and you see, after one patient has had sufficient amount of oxygen, then an outlet is moved to another patient…”

However, he believes that the shortages and the resulting mortality outcomes are not restricted to Tanzania alone, referring to recent studies that have assessed the situation in Africa and the globe.

He referred to a study titled ‘African Surgical Outcomes’, which he says despite having a patient-low-risk profile and low complication rates, patients in Africa were twice as likely to die following surgery when compared to the global average.

The study provides the most comprehensive data on surgical outcomes in Africa, comprising 25 countries, 247 hospitals, and data from over 11,000 patients.

Importantly, it says, 95 per cent of the deaths in occurred in the period after the surgical procedure, suggesting that many lives could be saved by effective surveillance amongst the patients who developed complications.

The death rate among women undergoing Caesarian-section to deliver a baby is about 50 times higher in Africa than in most wealthy nations, researchers say.

One in 200 women perished during or soon after a caesarean in a sampling of nearly 3,700 births across 22 African countries, says a study in The Lancet Global Health.

By comparison, maternal mortality is approximately one woman per 10,000 operations in Britain. Death rates related to C-sections are roughly the same across most developed countries.

Deaths related to C-section mostly stemmed from a ruptured uterus, in mothers who had pre-existing complications in their placenta, bleeding before birth or during surgery, and problems related to anaesthesia.

In his speech, Dr Ulisubisya reflected on the deaths likely to occur at the hands of those who are not adequately trained as physicians in the provision of anaesthetic services.

“…the number combines physicians that have not been trained and non-physicians that offer the services of anaethesia…which is not very different from previous systematic reviews that were done…but indicated that anaesthesia contributed to 2.8 per cent of all maternal deaths.”

What do numbers say in Tanzania?

“When you look at the numbers in our country,” says Dr Ulisubisya, “552 women out of 100,000, die out of these [C-section deliveries]…”

‘[However], because of various interventions, the number of women who are dying in the country, could be much lower, thanks to the dedicated men and women in the field…who have decided to carry the burden of this job…to ensure that quality services are delivered…”

“…when you use the 552, it means that 11,000 women die every year. When I was working in the Ministry of Health, I did some follow-up, we asked ourselves, how many women are dying literally from every health facility—every week, every month?.”

“I am going to tell you that the National Bureau of Statistics is going to be the final on the actual numbers but we were not losing any more than 100 women every month in the country. That divide by four is about 24 in a week, it’s not a day, not even an hour…”

“I am sure, with the interventions that the government has put in place, the upgrading of health centres that has just taken place, the numbers should be much lower, so in a sense, we [can] celebrate the great role that the Society of Obstetricians and Gynaecologists have been doing in the country, what the Society of Anaesthesia is doing…”