Anaesthesia in Ethiopia: providers' perspectives on the current state of the service

Abstract

The improvement of surgical and anaesthetic safety in low-resource settings is hampered by a lack of reliable information on the current provision of these services. Ethiopia is one of the world's poorest countries and, despite large amounts of both foreign and domestic investment, still reports some of the worst health outcomes. However, information on anaesthesia and surgical provision is sparse. This work reproduces a questionnaire study, first used in Uganda in 2006, to survey practising anaesthetists regarding the current state of anaesthesia services across Ethiopia. The results indicate that a large proportion of centres remain unable to provide safe general, spinal, paediatric and obstetric anaesthesia, at all levels of hospital and across almost all of the country's regions. In addition to a lack of equipment and pharmaceuticals, anaesthetists report problems with professional recognition and a lack of access to continuing professional development as key barriers to service development.

Keywords

Anaesthesia surgery Ethiopia

Introduction

It is increasingly recognized that the surgical burden of disease in low-income countries is growing and that the provision of safe surgical and anaesthetic services are instrumental to improving global health outcomes. Recent reviews have attempted to quantify both the surgical burden and anaesthetic mortality in the developing world but such work is hampered by a lack of primary data.^1–3 Ethiopia is one of the worlds' poorest countries, with a per capita gross domestic product (GDP) of US$1100 and a population of 82.8 million. Studies attempting to quantify surgical disease in Ethiopia have been published but, so far, only one study has attempted to provide a combined assessment of surgical and anaesthetic capacity.^4,5

In 2006, Hodges et al. used questionnaire sampling at a national conference of anaesthesia providers in Uganda in order to investigate anaesthesia provision, referenced against a set of minimum safe criteria and the 1992 World Federation of Societies of Anaesthesiologists (WFSA) guidelines for safe anaesthesia.^6,7 One of the stated aims of this study was to provide a tool for other countries to assess the state of their anaesthetic provision. With their permission, the author has used the same questionnaire technique to survey the state of anaesthesia provision in Ethiopia in 2012. It is hoped that this, along with a growing corpus of work from Ethiopia, will aid the identification of critical gaps in funding, equipment, infrastructure and supply chains and help inform effective targeting of limited resources.

Methods

The minimum standards for safe general, spinal, paediatric and obstetric anaesthesia were as used by Hodges et al. (Table 1), with the exception of the need for labetalol or hydralazine for obstetric anaesthesia. These standards for safe anaesthesia correspond broadly with those described as ‘Level 1’ by the WFSA in their revised standards in 2010 with the exception of the World Health Organization (WHO) Surgical Safety Checklist which is ‘highly recommended’.⁸ The standards used for safe spinal, paediatric and obstetric anaesthesia represent a degree of overlap between Level 1 and Level 2 criteria.

Table 1.

Definitions of the minimal requirements of safe anaesthesia (adapted from Hodges et al. 2007).

A	B	C	D
Safe general anaesthesia	Safe paediatric anaesthesia	Safe spinal anaesthesia	Safe obstetric anaesthesia
As for A but including:	As for A but including:	As for A & C but including:
Oxygen supply	Paediatric laryngoscope	Local anaesthetic drugs	Blood for intravenous infusion
Correct-sized facemask	Paediatric facemasks	Sterile spinal needles ≤22G	Oxytocin or ergometrine
Suction equipment	Paediatric tracheal tubes	Sterile syringes	Magnesium sulphate
Correct-sized tracheal tubes	Paediatric oropharyngeal airway	Disinfectant to clean skin
Tilting table	Paediatric IV cannula	Sterile gloves
Pulse oximeter	Paediatric bag / bellows	Blood pressure monitor
Working laryngoscope

The questionnaire developed by Hodges et al. was obtained with the permission of the authors. This examined: the type of hospital in which the respondents worked; their basic training and access to continuing professional development (CPD) and textbooks; an estimate of their monthly workload with reference to specific cases (laparotomy, children aged <5 years and Caesarean section); and their current ability to provide anaesthesia. Anaesthetists were also asked to make an assessment of some general facilities in their operating theatres, their access to specific drugs, and the availability of staff to maintain anaesthetic equipment. In addition, respondents were asked to suggest three ways in which the standard of anaesthesia in their hospital could be improved. When assessing the capacity of hospitals with more than one respondent, the best response given by an anaesthetist in that hospital was used. Numbers of indexed cases were averaged over the responses given where those from different practitioners within the same hospital varied.

The questionnaire was adapted to make it suitable for Ethiopian anaesthetists with regard to the classification of hospitals. No other changes were made to the body of questionnaire in order to obviate the need for further piloting and validation. Two additional questions were added at the end of the questionnaire relating to use of the WHO Surgical Safety Checklist (WHO SSC) plus participants' views on the appropriateness of the checklist in their hospital and the available support of an anaesthesiologist. These questions were not subject to piloting or validation due to time and resource constraints. A presentation on the WHO SSC and its use was made to the conference by the author before collection of the questionnaires. During this presentation, the nature of the survey and the intent to publish its findings was also explained.

Questionnaires were distributed to 150 delegates attending the 2012 Annual Conference of the Ethiopian Anaesthetists Association (EAA) at the Ghion Hotel, Addis Ababa, on the 22 June 2012. The EAA is the body representing non-physician anaesthetists in Ethiopia, with all attendees being non-physician anaesthetists of at least Diploma or BSc level of qualification. Questionnaires were distributed at the start of the day by the author and colleagues from Yekatit 12 Hospital and were collected at the end of the day. Data was transcribed by the author into Microsoft Excel © (Microsoft Corporation, Washington, USA) for ease of transport and analysis, with free text comments being transcribed verbatim. Where no answer was entered or, in the case of some free text comments, was illegible, this was entered into the data file as ‘N/R’.

Results

84 responses were collected, giving a response rate of 56% and representing around 20% of the estimated 400 non-physician anaesthetists in Ethiopia. All returned questionnaires contained sufficient information to be analysed although some sections had answers with no response marked.

A total of 41 hospitals were surveyed, although a burns unit with separate resources and financing from its main hospital was treated as a separate unit when considering anaesthesia provision and facilities. Nine of the 11 regions of Ethiopia were represented, with responses from anaesthetists working at every level of government institution from district to federal hospitals. One respondent was from a health centre, not normally equipped for surgery, which also hosted a Médecins Sans Frontières (MSF) Hospital and this was classed as a non-governmental hospital for the purposes of analysis.

Training and access to continuing professional development

73 of the 84 responders held a BSc, with four having gone on to complete an MSc. One respondent was still currently a student. Almost all candidates reported between 3–4 years' worth of training (Table 2), although it is difficult to assess the length of time since qualifications in Ethiopia operate on the Ge'ez calendar and it was not possible to confidently ascribe a year of completion to all candidates where the calendar used to answer was not specified. In addition, many candidates reported completing a two-year diploma and then upgrading over 1 or 2 years to a BSc at a later date and it was unclear which date they had chosen to report as ‘completion’. Only one respondent had completed their basic training outside of Ethiopia.

Table 2.

Training of anaesthetists and their access to continuing professional development.

Duration of training (years)	Number of anaesthetists
5	1
4	37
3	28
2	9
1	1
Not recorded	8
Training institution
Addis Ababa University	45
Jimma University	17
Gondar University	14
Other	3
Not recorded	5
Access to anaesthesia textbook	40
Refresher course / upgrade between 2007 and 2012 (GC)	34

Overall, 48% of respondents had access to an anaesthesia textbook, with 40% having attended a recent refresher course or qualification upgrade. Several reported having access to electronic versions of textbooks in the free text comments.

General anaesthesia for adults

Of the hospitals surveyed, 61% of government hospitals and 100% of non-governmental hospitals were able to provide safe general anaesthesia to an adult. When considering the government institutions alone, 74% of federal, university and referral hospitals could provide this service compared to only 33% of general and district hospitals (Table 3).

Table 3.

Estimated caseload, operating room provision and ability to give safe anaesthesia by hospital category. Two hospitals classed as both Federal and University are treated as Federal by this summary.

Federal hospitals	University hospitals	RHB¹ referral hospitals	RHB general hospitals	RHB district hospitals	Zonal hospitals	RHB health centre/MSF² hospitals	Private hospitals
No. of respondents	25	18	22	6	6	1	1	5
No. of beds	427	363	169	152	60	120	10	33
No. of operating rooms	8	5	3	2	2	2	1	2
Caesareans per month	83	182	103	32	46	90	12	34
Laparotomies per month	137	277	90	36	29	35	8	11
Children ≤5 per month	91	67	27	8	5	20	4	5
No. of hospitals surveyed	5	5	13	6	6	1	1	5
No. able to give safe general anaesthesia	4	3	10	2	2	1	1	5
No. able to give safe spinal	3	2	8	2	1	1	1	4
No. able to give safe paediatric anaesthesia	3	2	3	1	0	1	1	3
No. able to give safe obstetric anaesthesia	2	2	3	0	1	1	1	2

¹RHB; Regional Health Bureau controlled.

²MSF = Médecins Sans Frontières.

The minimum safe requirements for the delivery of anaesthesia to an adult were reported by 62% of anaesthetists (Table 4). However, 73 (87%) had access to pulse oximetry and appropriate tracheal tubes, and 80 (95%) had access to oxygen and working laryngoscopes. The most commonly lacking item was correctly-sized facemasks, with only 69 (82%) having access to them. Re-use of tracheal tubes was ubiquitous, with 78 (93%) of the responders recording this as normal practice.

Table 4.

Provision of safe anaesthesia against standards defined in Table 1.

No. of anaesthetists
Total respondents	84
No. able to give safe general anaesthesia	52 (62%)
No. able to give safe spinal	42 (50%)
No. able to give safe paediatric general anaesthesia	31 (37%)
No. able to give safe obstetric anaesthesia	9 (11%) ‘Always’
14 (27%) ‘Sometimes’

General anaesthesia for children under 5 years

Over a third (37%) of anaesthetists reported having the minimum capacity to provide safe anaesthesia to a child of 5 years or less (Table 4). Some hospitals reported no paediatric cases being performed and, in the free text comments, several anaesthetists documented that their institutions did not offer a surgical service for these patients. Hospitals that reported paediatric operations but in which no anaesthetist responded with safe criteria for anaesthesia in a child aged less than 5 years performed an estimated 4572 of these operations per year (Table 3).

Provision of spinal anaesthesia

Half (50%) of all those surveyed reported the equipment to perform safe spinal anaesthesia (Table 4). 74 (88%) of the respondents had access to local anaesthetic agents for spinal blockade, with 67 (80%) having access to sterile spinal needles. Re-use of spinal needles was the norm, with 67 (80%) of the respondents reporting this practice. The most commonly documented method of sterilization involved soaking in a bleach solution, rinsing and then autoclaving used spinal needles. Access to adult intravenous (IV) cannulas, IV fluid, blood pressure monitoring equipment, sterile gloves and cleaning solution was almost universal. The most common reason for being unable to provide safe spinal anaesthesia was the inability to fulfil the criteria for providing safe general anaesthesia.

Obstetric anaesthesia

Only 11% of the anaesthetists reported routinely safe conditions for delivering caesarean section by spinal and general anaesthesia (Table 4). Those hospitals reporting caesarean section cases but in which no anaesthetist responded with safe criteria for obstetrics performed an estimated 16,464 of these operations per year (Table 3).

Access to magnesium sulphate was limited with 73% of all anaesthetists reporting this as only sometimes or never available. Equally notable was the lack of access to blood for infusion with 60% reporting this as never or only sometimes available. When those anaesthetists who were unable to deliver safe obstetric anaesthesia solely due to a lack of reliable access to blood or magnesium sulphate were included, the figure of those able to ‘sometimes’ deliver safe obstetric anaesthesia rose to 27% (Table 4).

General hospital and theatre facilities

Access to electricity was variable, with 55 anaesthetists (65%) recording mains electricity to be always available and a further 23 documenting intermittent supply. Similarly, 55 always had generator facilities, with 21 sometimes having access to generator backup. Running water was also intermittent, with 53 (63%) having a constant source, and 25 only sometimes. Near-patient investigations were not readily available, with only 45% having constant access to haemoglobin testing and 42% always having access to blood glucose monitoring. See Table 5 for more details.

Table 5.

General hospital facilities available to respondents.

n=84	Always	Sometimes	Never	Don't know	N/R
Main electricity	55 (65%)	23 (27%)	1 (1%)	0 (0%)	5 (6%)
Generator	55 (65%)	21 (25%)	3 (4%)	1 (1%)	4 (5%)
Running water	53 (63%)	25 (30%)	0 (0%)	2 (2%)	4 (5%)
Sterile gloves	74 (88%)	4 (5%)	3 (4%)	0 (0%)	3 (4%)
Non-sterile gloves	75 (89%)	0 (0%)	2 (2%)	1 (1%)	6 (7%)
Haemoglobin measurement	38 (45%)	12 (14%)	29 (35%)	0 (0%)	5 (6%)
Glucose measurement	35 (42%)	28 (33%)	18 (21%)	0 (0%)	3 (4%)

N/R, not recorded.

Drug availability

Ketamine was the staple anaesthetic agent with 100% of respondents always having access to it. Access to other basic anaesthetic drugs was also high, with all reporting constant supplies of: thiopentone (98%); suxamethonium (86%); non-depolarizing muscle relaxants (94%); neostigmine (94%); inhalational anaesthetic agents (92%); atropine (99%); and adrenaline (99%). Access to analgesia other than ketamine was rarer, with only 63% always having access to an opiate of some sort. Reversal for opiate narcosis was scarce with only 5% having routine access to naloxone. Benzodiazepine access was better, with 82% always having it available. Despite the otherwise high capacity for spinal anaesthesia reported above, only 27% of all responders had access to any vasopressor other than adrenaline on a reliable basis. See Table 6 for more details.

Table 6.

Availability of anaesthetic drugs. Values given are number (%) of anaesthetists.

n= 84	Always available	Sometimes available	Never available	Don't know	N/R
Ketamine	84 (100%)	0 (0%)	0 (0%)	0	0
Thiopentone	82 (98%)	0 (0%)	1 (1%)	0	1
Propofol	27 (32%)	31 (37%)	24 (29%)	0	2
Suxamethonium	72 (86%)	6 (7%)	2 (2%)	0	4
NDPMR (1)	79 (94%)	2 (2%)	1 (1%)	0	2
Neostigmine	79 (94%)	2 (2%)	2 (2%)	0	1
Halothane/isoflurane	77 (92%)	4 (5%)	1 (1%)	0	2
Opiate	53 (63%)	24 (29%)	5 (6%)	0	2
Naloxone	4 (5%)	12 (14%)	61 (73%)	1	6
Atropine	83 (99%)	0 (0%)	0 (0%)	0	1
Adrenaline	83 (99%)	1 (1%)	0 (0%)	0	0
Vasopressor	23 (27%)	18 (21%)	38 (45%)	1	4
Benzodiazepine	69 (82%)	14 (17%)	1 (1%)	0	0
Oxytocin/ergometrine	77 (92%)	1 (1%)	5 (6%)	0	1
Magnesium	17 (20%)	31 (37%)	30 (36%)	4	2
Blood	31 (37%)	44 (52%)	6 (7%)	0	3
Intravenous infusion	82 (98%)	2 (2%)	0 (0%)	0	0
Available	Unavailable	N/R
Local anaesthesia	74 (88%)	8 (10%)	2 (2%)

Equipment maintenance

Only 32 (38%) of the anaesthetists worked in hospitals with staff trained in the maintenance of anaesthetic equipment and only 20 (24%) could get oxygen concentrators repaired locally. Suction repair was more reliable, with 57 (68%) being able to get these fixed at their place of work. In the free text comments, several anaesthetists noted that their department used only oxygen cylinders for supply and were not reliant on oxygen concentrators. In addition, several noted that their electric suction devices had manually-operated backup functionality which they used if the electronic component could not be repaired.

The WHO SSC

There was general support for the WHO SSC, with 69 (82%) of the anaesthetists feeling that it would be of use in their hospital. Indeed, 29 (35%) reported that they were already using it at their place of work and 25 (71%) of these were using it for every case. Only six (5%) of anaesthetists surveyed felt that the WHO SSC would not be suitable for their hospital.

Anaesthesiology support

30 (36%) of the respondents reported that they had the support of a physician anaesthetist (anaesthesiologist) at work. However, these respondents were limited to six hospitals, four of which were within Addis Ababa, and all of which were university or federal hospitals. No respondents from any district or general hospitals had access to anaesthesiology support and no hospitals outside Addis Ababa and the Oromiya region reported access to physician anaesthetist support.

Comments

Increasing the availability of equipment, monitoring and anaesthetic drugs were the most frequently cited suggestions for improving anaesthetic service (Table 7). However, a number of suggestions also centred on the status of anaesthesia professionals, their relationships with both surgeons and hospital managers, and a need for further education and training. The development of regional anaesthesia, improved recovery facilities and an increase in the workforce were less common themes. Examples of specific comments for the main categories are given in Table 8.

Table 7.

Categories for anaesthetists' suggestions for improving anaesthesia in their hospitals.

Category	No. of anaesthetists
Better availability of anaesthetic equipment	50
Adequate monitoring	43
Better availability of anaesthetic drugs	39
Improved professional status/communication	24
Postgraduate education	21
Development of regional anaesthesia	11
Access to recovery facilities	11
Increased workforce	10
Access to intensive care facilities	6
Better salary	6
Guidelines/checklists	6
Books	5

Table 8.

Examples of anaesthetists' comments when asked to suggest ways to improve the standard of anaesthesia currently offered in their department.

Category	Comments
Better availability of anaesthetic equipment	‘Improving the availability of anaesthesia equipment’ ‘Most important improvement in anaesthesia in our hospital the types of inhalational anaesthesia should be improved’ ‘Anaesthesia machine which have leakage of halothane to be renewed’
Adequate monitoring	‘Monitors, such as pulse oximetry, ECG machine, nerve stimulator as mandatory for safe anaesthesia practice’ ‘There are a lot of things to be improved. We don't have ECG monitor even we don't have a simple pulse oximeter’ ‘We have a lack of monitoring instruments especially for paediatrics.’
Better availability of anaesthetic drugs	‘Currently there is no blood transfusion service due to lack of blood banks and no blood bank in the region at this moment.’ ‘Anaesthetic drugs currently in use are few in quantity and old types which should be changed at least which can be afforded by our country’ ‘Shortage of some emergency drugs like ephedrine, phenylephrine, and antiemetics.’
Improved professional status / communication	‘Recognition of anaesthesia department.’ ‘Improvement of communication between surgeons and anaesthesia department (development of team spirit).’ ‘Awareness of pharmacists and managers about anaesthesia and related materials urgently required, drugs required and items required.’
Postgraduate education	‘Trainings on the latest techniques.’ ‘Professional development (educational) opportunity for better knowledge and experience for safe anaesthesia’ ‘We have not been getting the opportunities for participating in different training such as neonatal resuscitation, blood transfusion, etc.’
Development of regional anaesthesia	‘Regional anaesthesia - epidural, nerve blocks, caudal for paediatric, depends on their surgical problem because most of the time we give GA due to lack of skill and resources’
Increased workforce	‘Increase the number of anaesthetists and anaesthesiologists’
Access to recovery / intensive care facilities	‘Regarding post operation management, either stable or unstable patients, it is too difficult to manage or monitor patients due to lack of optimal unit - recovery room, ICU beds… staff (nurses, non-anaesthesia physicians) etc.’
Better salary	‘Nobody knows our role so we have been paid discouraging duties, risk allowance, salary’
Guidelines / checklists / books	‘Guideline, reference materials, books, booklet and any such materials has to be available’ ‘Proper preoperative checklist for all cases’

Discussion

The recognition of safe surgery as an important tool to improve health outcomes in low-resource settings is comparatively recent. Although there are now global efforts to improve the quality and safety of both surgery and anaesthesia, interventions need to be based on an understanding of the state of the existing provision and this has been difficult to establish. The results presented here, albeit from a small and self-selecting group of respondents, provide some important insights into the opinions of working anaesthetic practitioners and the barriers they face to the delivery of safe anaesthesia.

Estimates on the number of hospitals in Ethiopia vary greatly, making it hard to assess the coverage of this study. The Federal Ministry of Health website states that there are currently 89 public hospitals,⁹ while the Ethiopian National Health Accounts (2010) state that there were 149 public hospitals at the end of 2007/2008, with ongoing construction in 2009 of a further 29 hospitals.¹⁰ In its 2012 country factsheet, the Institute of Migration estimates there to be 188 hospitals in the country, with 116 of these being government-run.¹¹ The survey of Ethiopian surgical and anaesthetic capacity by Chao et al. also quotes government figures of 116 hospitals.⁵ Therefore, the 35 public institutions surveyed represent between approximately 20% and 40% of the Ethiopian public hospitals based on the above estimates. The hospitals surveyed were not stratified by region to prevent identification of individual anaesthetist respondents.

A large proportion of respondents were not able to deliver safe general (39%), spinal (50%), paediatric (63%) and obstetric (89%) anaesthesia. However, many anaesthetists lacked only a single parameter from the defined minimum criteria for each of these modalities. This paints a picture of piecemeal access to equipment, with departments needing targeted investment in specific pieces of equipment in order to attain minimum safety standards. This study has not addressed the age or state of repair of any of the equipment listed and the widespread feeling among the respondents, reflected in the free text comments, that equipment, monitoring and pharmacy are the key limitations to their practice must not be ignored.

A worryingly small proportion of clinicians reported the ability to offer safe obstetric anaesthesia. For 2010, the WHO reported inter-agency figures for maternal mortality in Ethiopia of 350/100,000 and a 2008 survey of the country's ability to provide emergency obstetric and newborn care showed a huge gap in service provision.^12,13 Improving the anaesthetic capacity to safely manage caesarean section anaesthesia is fundamental to improving this figure. While only 11% of respondents could ‘always’ provide safe obstetric anaesthesia, this rose to 27% of respondents who could ‘sometimes’ deliver it when supplies of blood and magnesium sulphate were available. As pharmaceutical supply chains in Ethiopia appear to be robust, evidenced by the universal access to ketamine and other basic anaesthetic drugs, the reasons for a lack of access to key obstetric medications need to be addressed at a local and national level. While Chao et al. report that ‘infrastructure limitations of electricity, water, oxygen, and blood banking do not prove to be significant barriers to surgical care’,⁵ the figures reported here show a supply gap in blood services with 60% of anaesthetists finding blood to be never, or only sometimes, available. Understanding the discrepancy between the apparent availability of resources and the perceived accessibility by practitioners is an issue of key importance for agencies working to improve anaesthetic safety.

There was a demonstrable lack of continuing professional development for the respondents. Basic training was universal by virtue of the chosen sample population but access to reference books and refresher training was limited. The free text comments reflect a profession which feels marginalized in the workplace and excluded from existing training programmes. Enthusiasm for quality improvement processes was modest, with a small number of free text comments mentioning guidelines, checklists and reference books as ways to improve their departments. However, there was general enthusiasm for adopting the WHO SSC. Given that only 35% of all respondents were using the WHO SSC in their hospitals, it may be reasonably assumed that were this included as a component of minimum criteria for all the investigated modalities of anaesthesia, the number of anaesthetists meeting the minimum safe criteria would be dramatically lower.

The author has deliberately matched this survey to that published by Hodges et al.⁶ Since 2007, the WFSA has updated its guidelines on safe standards based on the 2010 International Standards for the Safe Practice of Anaesthesia.⁸ The distinction drawn between the three levels of hospital in the 2010 guidelines provide the opportunity for individual departments to critique themselves specifically against the standards they should meet for their surgical demand. While all of the hospitals surveyed here might expect to meet Level 1 criteria, the federal and university hospitals may reasonably aspire to those of a Level 2 or Level 3 hospital. Such audit can then be used as the foundation for further work in quality improvement.¹⁴

Problems with workforce recruitment and retention in low-resource settings are well documented, particularly within anaesthesia.¹⁵ This study has not examined workforce constraints, other than in the area of anaesthesiology support or where this has been mentioned in free text boxes. It was felt that introducing detailed questions regarding workforce might be viewed with suspicion by respondents fearing for their positions and would reduce the response rate. Ethiopia has a very limited number of physician anaesthetists, with estimates placing this at roughly 17, and this is consistent with the lack of physician anaesthetist support reported.

More information on the state of surgery and anaesthesia in Ethiopia, as elsewhere, is still required. A more complete picture will inform improvements in the existing service and allow evidence-based, targeted interventions.

Ethical considerations

This study represents an audit rather than research and no local research ethics committee was consulted. No patient data was collected and responses were voluntary with no financial or other inducements offered. It was explained to respondents that the results were intended to be published by the author in advance of their submission of completed questionnaires. Care was taken that, where possible, no individual respondents or hospitals could be identified from the data presented in order to avoid repercussions for those completing questionnaires.

Footnotes

Acknowledgements

The author is indebted to the authors of the Hodges et al. 2007⁶ paper for use of their questionnaire and their support in publishing this follow-up study. He was also kindly assisted in the distribution and collection of questionnaires by anaesthetic colleagues from Yekatit 12 Hospital.

Declaration of conflicting interests

This work was completed by the author while working as a volunteer anaesthetist at Yekatit 12 Hospital, Addis Ababa, as part of a Voluntary Service Overseas (VSO) placement.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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