International Journal of Surgery Open 26 (2020) 64e72

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International Journal of Surgery Open

journal homepage: www.elsevier.com/locate/ijso

Research Paper

Challenges and associated factors of anesthesia practice in Ethiopia

Eyayalem Melese Goshu*, Leulayehu Akalu Gemeda
Department of Anesthesia, School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Anesthesia is mainly needed in surgical services, for diagnostic services in almost all fields
Received 28 July 2020 of specialty in medicine. When anesthesia services are inadequate, difficulties are experienced. There are
Received in revised form multifactorial reasons for the inadequacy of anesthesia services in sub-Saharan countries. The aim of this
13 August 2020
study is to assess the challenges and problems of anesthesia practice in Ethiopia.
Accepted 17 August 2020
Available online 27 August 2020
Methodology: An observational survey carried out in 60 hospitals of the Nine regional states and two city
administrative states of Ethiopia in 2018. A structured questionnaire sent to each hospital, the ques-
tionnaire consisted of eight sections to assess the availability of basic Anesthesia equipment, Drugs, and
Keywords:
Ethiopia
Professional Anesthetists. The head of anesthetists represented in each Hospital. The data were analyzed
Anesthesia using Statistical Package for Social Sciences (SPSS) version 20.0, the results are presented in appropriate
Practice statistical tools, and the findings discussed.
Challenges Results: This study shows that 81% of the anesthetists do have challenges and problems, which weigh
down the provision of Safe anesthesia service. Eighty-three percent (83%) of anesthetists working alone
without assistant. 83.2% of Anesthetists have main difficulties to perform pre-anesthetic evaluation.
Around 55% of hospitals/anesthetists/have no minimum standard of monitoring devices. The availability
of Anesthetic drugs in the Operation room is inadequate, for instance, 89.6%, 97.9%, and 45.8% Operation
rooms/Anesthetists/have no Isoflurane, Etomidate, and Propofol respectively. Due to lack of Analgesics,
only 22.9% of Anesthetists administer Analgesics Intraoperatively. 67% of Anesthetists have no emer-
gency drug kit and 81.2% of Anesthetists have no Cricothyrodtomy set to Manage difficult airway. The
overall Challenges stated by Anesthetists include Shortage of workforce, drugs & equipment, Lack of
skills & Knowledge in some specialized procedures, less payment in comparison with Work overload,
risks & stress, and Lack of insurance to the Anesthetists.
Conclusion: Since the Anesthesia service is least addressed, Major focus in terms of Anesthesia working
force, Anesthesia drugs, and equipment is required to bring up to date and improve the safety of
anesthesia for patients in Ethiopia.
© 2020 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Anesthesia is an essential component of the health care delivery
system at all levels of health service. It is one of the core service in
surgical activities, in preparatory services, for diagnostic services in
almost all fields of specialty in medicine. When anesthesia services
are inadequate, difficulties are experienced in the provision of the
above-varied services. In many developing countries especially in
Sub Saharan Africa, the reason for the inadequacy of anesthesia
services is multifactorial such as critical shortage of health care
* Corresponding author.
E-mail addresses: eyayalem.melese@aau.edu.et, eyayalem@yahoo.com
(E.M. Goshu), leulayehu_a@yahoo.com (L.A. Gemeda).
workers and very limited resources [1]. Many surgical interventions
worldwide are performed in developing countries [1].In the
developed world; anesthesia has progressed to a comprehensive
medical specialty in the past few decades with a well-established
presence in allied disciplines, including intensive care medicine,
emergency medicine, and pain therapy. However, in developing
countries, anesthesia is mostly focused on intraoperative patient
care for basic surgical procedures. Compared with the situation in
industrialized nations, perioperative morbidity and mortality in
developing countries remain unacceptably high [1,3,5, and 8]]. This
is particularly alarming because relatively simple and inexpensive
technology could readily decrease the burden of illness and injury
in these countries. To improve survival of acutely and critically ill
patients in developing countries, it is important to identify basic
problems that are bottlenecks to the provision of anesthesia

https://doi.org/10.1016/j.ijso.2020.08.008
2405-8572/© 2020 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 E.M. Goshu, L.A. Gemeda / International Journal of Surgery Open 26 (2020) 64e72
services in the health facilities of such countries, in which case
Ethiopia is not an exception, and the resulting demands in anes-
thesia and its allied disciplines. Unfortunately, except for anecdotal
reports and regional evaluations, there are few data on the status of
anesthesia, intensive care, emergency medicine, and pain therapy
in developing countries. Such information is essential to guide the
efforts of the governmental and private sectors to improve health
care delivery in the developing world.
In Ethiopia Anesthesia, services, unlike any other medical ser-
vices, are particularly subject to constraints in health resources due
to the competing priorities of the government [7]. The poor
attention given to the service by program managers, Moreover,
there are few anesthesia service providers compared to other
specialties, provision of the anesthesia services is limited to highly
specialized teaching hospitals, large towns, and certain private
hospitals. Generally, the Anesthesia services are providing In the
presence of scarcity of all basic anesthesia resources, not base the
implementation of the service on the anesthesia practice standard.
This study assessed the Availability of Human resources, Practice of
pre-anesthetic evaluation, availability of Anesthesia ancillary
equipment, Drugs (inhalational, Iv agents & emergency drugs), use
and availability of intraoperative Monitors, The practice of Intra-
operative pain management, uses of Regional Anesthesia, and the
Challenges of anesthesia practice. Therefore, this descriptive
exploratory study showed the problems faced by anesthesia pro-
fessionals in providing the anesthesia services in Ethiopia. The
findings of the study will be, the basis for improving the services, an
input to policymakers for better decision-making processes, also
hospitals owners and anesthesia professionals could use the
finding in their delivery of services.
2. Methods
It is an observational survey carried out in 60 hospitals of the
nine regional states and two city administrative states of Ethiopia in
2018. This study is registered at www.researchregistry.com with
Registration number UIN: research registry 5822.this study is re-
ported according to.
STROCSS criteria [17].
2.1. Study setting and period
Ethiopia is an ancient and independent country Located on the
Horn of Africa. The total surface area is about 1.1 million square ki-
lometers. Djibouti, Eritrea, the Republic of the Sudan, the Republic of
the Southern Sudan, Kenya, and Somalia border the country. It has
nearly 110 million population. Ethiopia takes an active role in African
affairs, for example, playing a pioneering role in the formation of the
Organization of African Unity (OAU). In fact, the capital city Addis
Ababa is seat for the AU since its establishment and continues to
serve as the seat for the African Union (AU) today. At present Ethiopia
is administratively structured into nine regional states and two city
administrations that are Tigray, Afar, Amhara, Oromia, Somali,
Benishangul-Gumuz, Southern Nations Nationalities and Peoples
(SNNP), Gambela, Harari. Addis Ababa and Diredawa Administration
Councils (Fig. 1). This survey conducted in 60 districts, referral &
specialized hospitals all over the countries. The selection of the
hospitals were based on the number of surgical cases they handle.
Hospitals, which are selected in the study, are providing the majority
of surgical service in this country. The study was conducted from
January 10, 2018, to March 10, 2018 GC.
2.2. Study design
Institutional based observational Study was employing.
65
2.3. Source population
This survey has been conducted in 60 districts, referral &
specialized hospitals all over the country.
2.4. Study population
Operation Room (Anesthesia set up) of 60 district, referral &
specialized hospitals all over the country.
2.5. Dependent variables
Availability of resources and utilization of anesthesia equi-
pment& facilities, Type and utilization of Drugs. Anesthetist's
preparation and attitude to deliver safe anesthesia.
2.6. Independent variables
Location, Level and ownership of hospitals, Experience of the
workers, Training levels (Educational status of anesthesia provider),
Age& Sex, Number of Anesthetists per hospital, Surgical patient
load of the hospital.
2.7. Operational definition
1. Nurse Anesthetist Level V: is a practitioner who, having been
admitted to TVET level V anesthesia program, duly recognized in
the country and has successfully completed the prescribed
course of level V studies and licensed by the regulatory au-
thority to practice anesthesia services.
2. Anesthesia Professional (BSc Anesthetists): is a practitioner
who, is joining to an anesthesia educational program, duly
recognized in the country and has successfully completed the
prescribed course of baccalaureate-level studies and licensed by
the regulatory authority to practice anesthesia services.
3. Anesthesia professional specialist (MSc Anesthetists): is a
practitioner who, having been admitted to MSc educational
program, duly recognized in the country and has successfully
completed the prescribed course and licensed by the regulatory
authority to provide anesthesia services
4. Anesthesiologist: is a medical doctor who has completed a
residency program in anesthesiology, with a specialty certificate
from a recognized medical institution, and licensed by the reg-
ulatory authority to practice anesthesiology
5. Safe Anesthesia Service: Providing/conducting/anesthesia with
availability of anesthesia Equipment, anesthetic agents and
anesthetists according to the WHO definition of minimum re-
quirements for safe anesthesia, with minimal complications.
6. Minimal requirements for safe anesthesia service: The
presence of the following airway equipment's monitoring,
machines, O2 source and drugs in different anesthetic pro-
cedures (Table 1).
2.8. Inclusion criteria
All Anesthetists who are working in governmental & private
hospitals.
2.9. Exclusion criteria
Hospitals that has no Professional Anesthetists, Nurses, or other
health professionals who have no formal training in Anesthesia.
66 E.M. Goshu, L.A. Gemeda / International Journal of Surgery Open 26 (2020) 64e72

Fig. 1. Administrative regions and zones of Ethiopia. Adapted from Wikimedia Commons, the free media repository.

Table 1
WHO Minimal requirements for safe anesthesia service.

1 2 3 4

Adult GA Pediatric GA Spinal Anesthesia Obstetrics Anesthesia

1. O2 Supply 1. O2 Supply 1. O2 Supply 1. All Of No. 1 (GA) &

2. Facemask 2. Pediatrics Facemask 2. Equip In adult GA 2. All of No 2 (Pedi. GA)
3. Laryngoscope 3. Pediatrics. Laryngoscope 3. LA Drugs 3. Access To Blood For Transfusion
4. Tracheal Tube 4. Pediatrics. ETT 4. Sterile Syringe 4. Oxytocin and Ergometrine injection
5. Suction Apparatus 5. Pediatrics. Oral Airway 5. Disinfection Clan 5. Hydralazine Or Lubricant
6. Pulse Oximeter 6. Pediatrics. Breathing 6. Glass 6. Magnesium sulfate injection
7. Tilting Tube 7. Circulation 7. Sterile Gloves
8. ECG 8. Pediatrics. IV Cannula 8. B/P Monitors
9. B/P 9. Pediatrics.BP Apparatus 9. IV Flash
10. Catheterization 10. Pediatrics Catheter
11. Blood 11. IV Fluids
12. IV Fluids
13. Anesthetic Drugs

3. Sample size determination Considering a refusal rate of 5% … were the final sample size for
the study.where
To determine the sample size for this particular exploratory n ¼ estimated sample size
descriptive study design, the following assumptions have taken. z ¼ Level of statistical significance that set up level 0.05, i.e. 1.96
Assumptions: A 95% confidence level, the margin of error (0.05) p ¼ proportion of anesthetists who had the minimum re-
and prevalence of satisfaction with HEP from a previous study. quirements safe provision of.
Anesthesia service to an adult was only 23% cited in research at
n ¼ ðZ f = 2Þ  Pð1  PÞ = d2 Uganda
q ¼ proportion of Anesthetists who had no minimum re-
ð1:96Þ2  Pð1  PÞ ¼ quirements safe provision of Anesthesia service were, 1e23% ¼ 77%
N¼ d ¼ degree of accuracy required i.e., allowable error ¼ 0.05.
ð0:05Þ2
Therefore, the sample size of this study was:
 E.M. Goshu, L.A. Gemeda / International Journal of Surgery Open 26 (2020) 64e72 67

in governmental, private & NGO hospitals representing by their

n ¼ ðZ f = 2Þ  Pð1  PÞ = d2 head Anesthetists.

ð1:96Þ2  0:23 ð1  0:23Þ 4. Result

n¼
ð0:05Þ2
Questionnaires distributed to 60 Hospitals (Head of Anesthesia
department) and received completed forms. Fifty-five (55%) Hos-
n ¼ 272 pitals (Head of Anesthesia department) responds to the question-
aries’ which means (91.6%) was response rate. The head of the
Considering a refusal rate of 10% … were the final sample size
Anesthesia service department (anesthetists) represented just
for the study.
Approximately 318 anesthetists in all 55 hospitals. The Responses
from each head of the anesthetists working in Government and
n ¼ 272 þ (10% of 272) ¼ 272 þ 27
private-owned hospitals have analyzed. The number of hospitals
included in the study (Fig. 3).
n ¼ 299 anesthetists
Considering that minimum of five anesthetists found in each
4.1. Result & discussion
hospital, 299 anesthetists were distributing in 60 Zonal, district and
Referral Hospitals.
4.1.1. Human resources
Number of Anesthetists working in 55 hospitals included in the
3.1. Data collection tool and processes
study; out of this Diploma, holders were 35, BSc Holders - 263, MSc
holders- 20. It is clear that anesthesia service has many challenges.
Data were collecting using a structured questionnaire for the
The study result showed that 83% anesthetists in OR worked alone
survey of the hospitals developed from various literatures. Senior
in each Operation table and in each surgery without assistance.
Anesthetists collected the data through visiting and auditing of
each hospital for the suggested questions in the questionnaire. A
self-administered questionnaire sent to the anesthetist, and then 4.1.2. Consultation
the questionnaire collected through the enclosed postal envelope. The number of MSC Anesthetists and physician Anesthesiolo-
All data from the surveys kept confidentially. gists are low in number, which critically affects the consultation &
anesthesia service. At the same time, lack of appropriate consul-
tation increases risks and stress to the Anesthetists and patients.
3.2. Sampling technique
This survey shows that 60% of anesthetists consult each other be-
tween the same levels of education. They use senior staffs who has
From the 60 total hospitals owned and run by both the private
greater year of service as a consultant (Table 2).
and government hospitals, using simple random sampling and
computer-generated methods. Eighteen hospitals from private and
42 from the government selected randomly. All anesthetists 4.2. Practice of preanesthetic evaluation
working in those selected hospitals were interviewed about the
constraints they face while providing anesthesia services (Fig. 2). Preanesthetic evaluation is the cornerstone of anesthesia ser-
vice. Due to several reasons, it is not practicing appropriately. The
study shows: 62% of Hospitals/anesthetists/have no up to standard
3.3. Data quality control
preanesthetic format, 27.1% of hospitals did not perform pre-
anesthesia evaluation regularly/. According to the research result,
Collected data had checked for completeness, accuracy, and
83.3% of the anesthetists have main problems/influences/to
clarity. The data had checked by Epi-info for completeness. Data
perform preanesthetic evaluation. The problems include: In-
clean up and crosschecking had done before analysis on SPSS. Su-
vestigations not being done (70%), No separated room to do a pre-
pervision has done during data collection by the principal investi-
anesthetic evaluation (85%), No enough time due to Work overload/
gator and senior Anesthetists.
scarcity of adequate Anesthetists/(55%), the patent is not prepared
for surgery by the surgeon (78%), The surgeon makes the anes-
3.4. Data analysis and interpretation
thetists to hurry up to do surgery without (45%). Due to failure of
doing preanesthesia evaluation, Anesthetists faced to challenges
The Collected data entered into statistical software SPSS 20.0
intraoperatively (Fig. 4).
and analyzed using proportions, median and mean number of re-
sponses, the inclusion criteria are All Anesthetists who are working
4.3. Air way equipment

The majority of airway-related deaths and severe neurologic

morbidity result not from a failure to intubate the trachea but
rather from a failure to ventilate and oxygenate. To deliver oxygen
to the patient, the availability of airway equipment is mandatory.
The anesthetists working in OR do have stress and challenges in
getting airway equipment (Table 3).

4.4. Availabilities of monitoring

Monitors are the basic requirement to attend patients who are

Fig. 2. Schematic presentation of sampling procedure Public, private and NGO under GA or RA. According to this study, only 45% of hospitals/
hospitals. anesthetists/have the minimum monitoring requirements for the
68 E.M. Goshu, L.A. Gemeda / International Journal of Surgery Open 26 (2020) 64e72

Fig. 3. The number of hospitals included in the study.

Table 2 &there is leakage). 64.6% of the anesthetist's/hospitals/have no

The consultant during anesthesia complications. anesthesia machine checklist or they have no practice to check the
Anesthetists/consultants/ % machine other than the leak test.
Senior staffs among BSC anesthetists 60
MSC Anesthetist 28.7 4.6. Anesthesthetic drugs
Anesthesiologists 9.2
No consultant 2.1 Thinking anesthesia service without anesthetic drugs is
impossible. They are important to induce, maintain anesthesia,

Fig. 4. Intraoperative Challenges of Anesthetist faced because of not doing Pre Anesthetic evaluation.

safe provision of anesthesia to an adult. The items most frequently and recover from anesthesia, however, most anesthetists are
unavailable monitors in the operation theater were (Fig. 5). working in the environment with the scarcity of anesthetics drugs
(Table 4).

4.5. Anesthesia machine

One of the important devices in anesthesia service is the
Anesthesia machine. It helps to address the inhalational agent and
gas (oxygen) to the patient, nevertheless, the anesthesia machines
in OR are very old, nonfunctional, and lack regular maintenance.
This study shows that 15% of the anesthesia machine is nonfunc-
tional (i.e. the APL valves stuck, the machine is not recalibrated
4.7. Pain management
One of the responsibility of Anesthetists in OR is to abolished
pain. Intraoperative pain management in Ethiopia needs
improvement. The survey shows that pain management is poor due
to several factors, such as lack of analgesics, & Fail to administer
analgesics routinely.
 E.M. Goshu, L.A. Gemeda / International Journal of Surgery Open 26 (2020) 64e72 69

Table 3 Table 5
The availability of ancillary anesthesia airway equipment in Operation Room. The availability of analgesic drugs.

Equipment yes No Sometimes Analgesics yes No Sometimes

Pediatrics ETT cuffed 41(85.4%) 5 (10.4%) 2 (4.2%) Paracetamol Suppository 29 (60.4) 19 (39.6.4%) 2 (4.2%)
Pediatrics ETT uncuffed 39 (81.2%) 7 (14.6%) 2 (4.2%) NSAID 7 (14.6%) 41 (85.4%) 2 (4.2%)
Adult ETT 47 (97.9%) 1 (2.1%) 0 Tramadol Injection 38 (79.2%) 10 (20.9%)
Armoured(Spiral)ETT 13 (27.1%) 32 (66.7%) 3 (6.2%) Pethidine Injection 11 (22.9%) 37 (77.1%) 3 (6.2%)
Magil Forceps 37 (77.1%) 11 (22.9%) 0 Morphine Injection 9 (18.8%) 39 (81.2%)
Fiberoptic laryngoscopes 7 (14.6%) 40 (83.3%) 1 (2.1%) Fentanyl Injection 6 (12.5%) 42 (87.5%)
LMA 29(60.4%) 15 (31.2%) 4 (8.3%)
Bougie gum 23 (47.9%) 23 (47.9%) 2 (4.2%)
Face mask 45 (93.8%) 3 (6.3%) 0
Laryngoscope/miller/ 19 (39.6%) 29 (60.4%) 0 analgesics drug availability.16 (33.3%) of anesthetists have verities
Laryngoscope/Macinitosh/ 39 (81.2%) 9 (18.8%) 0
of analgesics, but they use for selected patients. 1 (2.1%) of Anes-
Suction catheter 39 (81.2%) 9 (18.8%) 0
Suction machine 31 (64.6%) 17 (35.4%) 0 thetists are not allowed to prescribe opioids & Narcotics. 26 (54.2%)
AMBU bag 44 (91.7%) 4 (8.3%) 0 of the anesthetists says traditionally they consider as if Inhalational
Cricothyrotomy set 9 (18.8%) 39 (81.2%) 0 drug is enough to treat pain.

Fig. 5. Availability of the minimum standard Intraoperative monitoring.

Table 4 4.8. Emergency drugs availability

The availability of anesthetic drugs (Inhalational agents; Intravenous agents; Local
Anesthetic agents).
Anesthetist take the leading part in the management of preop-
Anesthetics Drug YES NO erative emergency Conditions. They need adequate availability of
Inhalational agents emergency drugs, but the situation in OR cannot allow them to
Halothane 46 (95.8%) 2 (4.2%) manage emergencies due to several factors.the majority is due to
Isoflurane 5 (10.4%) 42 (89.6%) the scarcity of emergency drugs (Table 6). Sixty-seven percent
Sevoflurane 1 (2.3%) 47 (97.9%) (67%) of anesthetists have no emergency drug kit.
Nitrous oxide 1 (2.3%) 47 (97.9%)
Intra Venous agents
Thiopentone 47 (97.9%) 1 (2.1%) 4.9. Regional anesthesia (RA) practice
Ketamine 48 (100%) 0
Etomidate 1 (2.1%) 47 (97.9%)
Propofol 26 (54.2%) 22 (45, 8). Ninety-seven percent (97%) of the anesthetists regularly uses
Suxamethonium 47 (97.9%) 1 (2.1%) Spinal Anesthesia, Only 10% of the Anesthetists uses epidural
Pancuronium 44 (91.7%) 4 (8.3%) Anesthesia,27% of the Anesthetists practice on Axillary blocks,
vecuronium 35 (72.9%) 13 (27.1%)
18.8% of the Anesthetists implemented other peripheral blocks,
Neostigmine 44 (91.7%) 4 (8.3%)
Cis atracurium 15 (31.2%) 25 (68,8%) This indicates that regional anesthesia other than Spinal anesthesia
Local anesthetic agents is least addressing/practicing/.
Lidocaine 45 (93.8%) 3 (6.2%)
Bupivacaine 46 (95.8%) 2 (4.2%)
5. Problems & challenges of the anesthetists

The study shows that 81% of the anesthetists do have challenges

The study shows that only 22.9% of the anesthetists administer
analgesics intraoperatively for all patients routinely under General
Anesthesia to maintain balanced anesthesia. The study address why
the majority are not administering analgesia during GA. The rea-
sons raised by Anesthetist were:- two (4.2%) of anesthetists say no
and problems that hinder the provision of Safe anesthesia service,
The Challenges stated by Anesthetists include Work overload (97%)
Shortage of Anesthetist (68%), Shortage of drugs & equipment (84%)
Lack of recognition by the managerial bodies of Hospitals & even
other health professional (72%), Medico-legal issues (59.7%). Lack of
70 E.M. Goshu, L.A. Gemeda / International Journal of Surgery Open 26 (2020) 64e72

Table 6 challenge to keep the patient airway open during surgery, this was
Emergency drug availability. evidenced by 60.4% of Anesthetists have no Millar laryngoscope,
Analgesics yes No Sometimes Cricothyrothomy set is not available in 81.2% hospitals. 52.1% of
Ephedrine 3(6.2%) 45 (93.8%) 0
Anesthetists (hospitals) have no Bougie gum and 83.3% of Hospitals
Adrenaline 48 (100%) 0 0 have no Fiberoptic laryngoscopes there is major problem to get
Adenosine 4 (8.3%) 43 (89.6%) 1 (2.1%) airway equipment. According to this study, 55% of hospitals/anes-
amiodarone 2 (4.2%) 45 (93.8%) 1 (2.1%) thetists/have no minimum monitoring devices for the safe provi-
Atenolol 10 (20.8%) 37 (77.1%) 1 (2.1%)
sion of anesthesia to an adult. The items most frequently
atropine 48 (100%)
Calcium chloride 21 (43.8%) 24 (50%) 3 (6.2%) unavailable monitors were (figure). Providing Anesthesia without
Calcium gluconate 29 (60.4%) 18 (37.5%) 1 (2.1%) monitoring is catastrophic. Most of the anesthesia machines in OR
Dexamethasone 40 (83.3%) 3 (6.2%) 5 (10.4%) are very old, nonfunctional, and lack regular maintenance. This
Dextrose 46 (95.8%) 1 (2.1%) 1 (2.1%)
study shows that 15% of the anesthesia machine is nonfunctional
Diazepam 44 (91.7%) 4 (8.3%)
Digoxin 19 (39.6%) 25 (52.1%) 4 (8.3%)
(i.e. the APL valves stuck, the machine is not recalibrated &there is
Aminophylline 20 (41.7%) 25 (52.1%) 3 (6.2%) leakage). 64.6% of the anesthetist's/hospitals/have no anesthesia
Hydralazine 33 (68.8%) 15 (31.2%) 0 machine checklist or they have no practice to check the machine
Flumazenil 3 (6.2%) 45 (93.8%) 0 other than the leak tests. Thinking anesthesia service without
Antiemetics 39 (81.2%) 9 (18.8%) 0
anesthetic drugs is impossible. They are important to induce,
maintain anesthesia and recover from anesthesia. However, most
anesthetists are working in the environment with the scarcity of
skills & Knowledge in some specialized procedures (43%), Lack of anesthetics drug (Tables 4e6). One of the responsibilities of Anes-
professional commitment in some professionals (38%), less pay- thetists in OR is to abolished pain. Intraoperative pain management
ment in comparison with the risks &stress (97%) Lack of insurance in Ethiopia needs improvement. This survey shows that pain
to the Anesthetists, (98%) Malpractice of professional, and management is poor due to several factors, such as lack of anal-
disagreement among the professional (48%). gesics, & Fail to administer analgesics routinely. The study shows
that only 22.9% of the anesthetists administer analgesics intra-
6. Discussion operatively for all patients routinely under General Anesthesia to
maintain balanced anesthesia. The study address why the majority
This study showed that extreme shortage in four major areas, are not administering analgesia during GA. The reasons raised by
human resource, infrastructure, Anesthesia supplies (Drugs and Anesthetist are: 2 (4.2%) of anesthetists says no analgesics drug
equipment), and Malpractices or inadequacy. Mainly the in- availability.26 (54.2%) of the anesthetists says traditionally they
adequacy includes three major areas, like preanesthesia evaluation consider as if Inhalational drug is enough to treat pain.16 (33.3%) of
(patient preparation), post-operative management, and Regional anesthetists have verities of analgesics, but they use for selected
Anesthesia practice. patients. 1 (2.1%) of Anesthetists are not allowed to prescribe opi-
These categories are very important to have better functioning oids & Narcotics.
of surgical and Anesthesia service in the health system. Although Anesthetist take the leading part in the management of preop-
this study is one of the nationally representative study of the erative emergency Conditions. They need adequate availability of
government, Private, and NGO Hospitals, The result does not differ emergency drugs, but the situation in OR cannot allow them to
from previous similar studies conducted in the sub-Saharan manage emergencies due to several factors.the majority is due to
countries [8,12,14]. There are measurable inadequacies and short- scarcity of emergency drugs (table).67% of anesthetists have no
ages in the number and distribution of anesthesia care and anes- emergency drug kit. Based on the study, the Anesthetists responded
thesia workforce. The average Anesthesia workforce density is even shortage of important drug is due to Inappropriate (unable to)
more terrible with 1.4 per 100,000 people compared with the request, Anesthetists are depended on the routinely used drugs, but
recommended, 12.43 per 100, 000 in the WHO Region of the not trying to use safe drugs, Drugs are not available in market, Heads
American (Peter kempt hone et al., 2017). More than 98% of the & concerned bodies are not volunteer to respond for drug request.
Anesthesia workforce in Ethiopia is a non-physician with a variable Ninety-seven percent (97%) of the anesthetists regularly uses
level of training. The majority of regional, Zonal, and Primary Spinal Anesthesia. Only 10% of the Anesthetists uses epidural
Hospital does have no Anesthetist or have only one Anesthetist. Anesthesia. Twenty-seven percent (27%) of the Anesthetists prac-
As it is depicted on the result, Surgical Patients preparation is tice on Axillary blocks, and 18.8% of the Anesthetists implemented
not appropriate from the surgeon side (78%), this is evidenced by, other peripheral blocks. This indicates that regional anesthesia
important and basic Laboratory and diagnostic investigations were other than Spinal anesthesia is least addressing/practicing/as the
not done (70%), moreover 45% of Anesthetists responds that the Anesthetists responded. The reasons for inadequate practicing of
surgeons hurry the Anesthetists to do the surgery without profes- RA are; Shortage of Drugs, equipment & work force Work overload
sional notification. Sixty-two (62%) of Hospitals have no standard of anesthetists, and the surgeons did not give them adequate time
preanesthetic evaluation format, mostly they took some minute to to do procedures.
do short preview of patient Chart and the patient in the waiting The study shows that 81% of the anesthetists do have challenges
room or the gate of the Operation room. Due to failure of doing and problems that hinder the provision of Safe anesthesia service.
preanesthetic evaluation, Anesthetists faced to different cata- The Challenges stated by Anesthetists were; Work overload,
strophic challenges, such as 60.4% of them were challenging with a Shortage of Anesthetists, Shortage of drugs & equipment, Lack of
difficult airway, 8% and 12.5% of Anesthetists were facing for recognition by the managerial bodies of Hospitals & even other
cardiac-related arrest and aspiration respectively. health professional. It also includes Medico-legal issues, Lack of
The majority of airway-related deaths and severe neurologic skills & Knowledge in some specialized procedures, Lack of pro-
morbidity result not from a failure to intubate the trachea but fessional commitment in some professionals, less payment in
rather from a failure to ventilate and oxygenate. The anesthetists comparison with the risks &stress, Lack of insurance to the Anes-
working in OR do have stress and challenges in getting airway thetists, Malpractice of professional, Disagreement among the
equipment. The study shows Anesthetists ware working in a severe professional.
 E.M. Goshu, L.A. Gemeda / International Journal of Surgery Open 26 (2020) 64e72 71

The overall result of this survey is in line with the same study Author's contribution
done in Uganda [8], on which, the result showed that only 23% of
the Anesthetists have the facility to deliver Safe Anesthesia, 13% to Eyayalem Melese Goshu; Leulayehu Akalu Gemeda: as a team
deliver safe anesthesia to a child and 6% to deliver anesthesia for developed the proposal, trained the data collectors, analyzed the
caesarian section. The same research done in Malawi [5] supports data & prepared the manuscript.
the result of this survey, which has concluded every hospital pro-
vided general anesthesia but some did not always have a func- Conflict of interest statement
tioning Anesthesia machine (52.2%, 50%).surgical rate, operating
theater density and surgical workforce density per 100,000 popu- Nothing to declare.
lation was 289.48e747.38 procedures, 0.98 and 3.68 surgical pro-
viders respectively. Research registration number
The other research done in Ghana is also in line with this survey
regarding the human resource (number of Anesthetists) [16]. The researchregistry5822.
research result says that there were no enough physicians to su-
pervise care, especially in the post-anesthesia care units (PACUs) Acknowledgement
and the critical care unit (CCU). In contrary, the same research
result from Ghana [16] shows that much basic infrastructure, The authors would like to express our heartfelt gratitude to all
equipment, and medications were present in OR. Patient safety was Anesthetists involved in the data collection Addis Ababa University
hindered by hospital-wide oxygen supply failures and a shortage of for providing us, ethical clearance, internet and Library service.
vital signs monitors and working ventilators.
Generally, the Anesthesia service in Ethiopia has many chal- List of Abbreviations
lenges, which requires the attention of federal Ministry of Health
and the administrative bodies of each hospital. ASA American Society of Anesthesiologists
AIDS Acquired Immune Deficiency syndrome
Limitation BLS Basic Life Support
CAB Circulation, Airway and Breathing
The data was collecting from big cities and Zonal administrative CDs Communicable Diseases
towns, which could not address the status of Hospitals in rural ETT Endotracheal tube
areas and small towns. GA General Anesthesia
GoE Government of Ethiopia
Strength of the study HIV Human Immune deficiency virus
HSDP IV Health Sector Development Program 4
It tried to reach the all-regional states and two administrative IV Intravenous route
cities.it will be the baseline information for further investigation. MOE Ministry of Education
MOH Ministry of Health
Conclusion and recommendations NGO None Governmental Organizations
O2 the symbol of oxygen
Anesthesia practice in our country is least addressing, Due to RA Regional Anesthesia
several factors anesthesia practice is compromising; such as TBC Tuberculosis
Shortage of anesthetics drugs, emergency drugs, Monitors & UIN Unique Identifying Number
anesthesia equipment, Shortage of manpower, lack of recognition WHO World Health Organization
from the respective departments &offices, Professional
malpractices. Appendix A. Supplementary data

Consent for publications Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ijso.2020.08.008.
Not applicable.
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