Children's surgery and the emergency, critical, and operative care resolution: Immediate actions to eliminate disparities in surgery, anesthesia, and perioperative care for all children.

Around 1.7 billion children lack access to surgical care worldwide. To reinvigorate the efforts to address these disparities and support work to address global challenges in surgery, anesthesia, emergency, and critical care, the World Health Assembly passed World Health Organization Resolution World Health Assembly 76.2: Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies (ECO) in 2023. This resolution highlights the integral role of surgery, anesthesia, and perioperative care in health systems. However, understanding how best to operationalize this resolution is challenging. We review the ECO resolution and highlight points that the pediatric surgical and anesthesia community can leverage to advocate for its recommendations for operative care.

The role of collaboration in educating the global pediatric anesthesia workforce.

An estimated 1.7 billion children and adolescents do not have access to safe and affordable surgical care, and the vast majority of these are located in low-middle-income countries (LMICs). Pediatric anesthesia, a specialized field that requires a diverse set of knowledge and skills, has seen various advancements over the years and has become well-established in upper-middle and high-income countries. However, in LMICs, due to a multitude of factors including severe workforce shortages, this has not been the case. Collaborations play a vital role in increasing the capacity of pediatric anesthesiology educators and training the pediatric anesthesia workforce. These efforts directly increase access for children who require surgical intervention. Collaboration models can be operationalized through bidirectional knowledge sharing, training, resource allocation, research and innovation, quality improvement, networking, and advocacy. This article aims to highlight a few of these collaborative efforts. Specifically, the role that the World Federation of Societies of Anaesthesiologists, the Safer Anesthesia from Education program, the Asian Society of Pediatric Anaesthesiologists, Pediatric Anesthesia Training in Africa, the Paediatric Anaesthesia Network New Zealand, the Safe Pediatric Anesthesia Network and two WhatsApp™ groups (global ped anesthesia and the Pediatric Difficult Intubation Collaborative) have played in improving anesthesiology care for children.

GAPS phase II: development and pilot results of the global assessment in pediatric surgery, an evidence-based pediatric surgical capacity assessment tool for low-resource settings.

PURPOSE: Pediatric surgical care in low- and middle-income countries is often hindered by systemic gaps in healthcare resources, infrastructure, training, and organization. This study aims to develop and validate the Global Assessment of Pediatric Surgery (GAPS) to appraise pediatric surgical capacity and discriminate between levels of care across diverse healthcare settings. METHODS: The GAPS Version 1 was constructed through a synthesis of existing assessment tools and expert panel consultation. The resultant GAPS Version 2 underwent international pilot testing. Construct validation categorized institutions into providing basic or advanced surgical care. GAPS was further refined to Version 3 to include only questions with a > 75% response rate and those that significantly discriminated between basic or advanced surgical settings. RESULTS: GAPS Version 1 included 139 items, which, after expert panel feedback, was expanded to 168 items in Version 2. Pilot testing, in 65 institutions, yielded a high response rate. Of the 168 questions in GAPS Version 2, 64 significantly discriminated between basic and advanced surgical care. The refined GAPS Version 3 tool comprises 64 questions on: human resources (9), material resources (39), outcomes (3), accessibility (3), and education (10). CONCLUSION: The GAPS Version 3 tool presents a validated instrument for evaluating pediatric surgical capabilities in low-resource settings.

Addressing knowledge gaps in Surgical Safety Checklist use: statistical process control analysis of a surgical quality improvement programme in Ethiopia.

BACKGROUND: The WHO Surgical Safety Checklist reduces morbidity and mortality after surgery, but uptake remains challenging. In particular, low-income countries have been found to have lower rates of checklist use compared with high-income countries. The aim of this study was to determine the impact of educational workshops on Surgical Safety Checklist use implemented as part of a quality improvement initiative in five hospitals in Ethiopia that had variable experience with the Surgical Safety Checklist. METHODS: From April 2019 to September 2020, each hospital implemented a 6-month surgical quality improvement programme, which included a Surgical Safety Checklist workshop. Statistical process control methodology was used to understand the variation in Surgical Safety Checklist compliance before and after workshops and a time-series analysis was performed using population-averaged generalized estimating equation Poisson regression. Checklist compliance was defined as correctly completing a sign in, timeout, and sign out. Incidence rate ratios of correct checklist use pre- and post-intervention were calculated and the change in mean weekly compliance was predicted. RESULTS: Checklist compliance data were obtained from 2767 operations (1940 (70 per cent) pre-intervention and 827 (30 per cent) post-intervention). Mean weekly checklist compliance improved from 27.3 to 41.2 per cent (mean difference 13.9 per cent, P = 0.001; incidence rate ratio 1.51, P = 0.001). Hospitals with higher checklist compliance at baseline had the greatest overall improvements in compliance, more than 50 per cent over pre-intervention, while low-performing hospitals showed no improvement. CONCLUSION: Surgical Safety Checklist workshops improved checklist compliance in hospitals with some experience with its use. Workshops had little effect in hospitals unfamiliar with the Surgical Safety Checklist, emphasizing the importance of multifactorial interventions and culture-change approaches. In receptive facilities, short workshops can accelerate behaviour change.

Delivery of Safe Pediatric Anesthesia Care in the First 8000 days: Realities, Challenges, and Solutions in Low- and Middle-Income Countries.

BACKGROUND: Worldwide, perioperative mortality has declined over the past 50 years, but the reduction is skewed toward high-income countries (HICs). Currently, pediatric perioperative mortality is much higher in low- and middle-income countries (LMICs) compared to HICs, despite studied cohorts being predominantly low-risk. These disparities must be studied and addressed. METHODS: A narrative review of the literature was undertaken to identify contributing factors and potential knowledge gaps. Interventions aimed at alleviating the outcomes disparities are discussed, and recommendations are made for future directions. RESULTS AND CONCLUSIONS: There is a lack of adequately trained pediatric anesthesia providers in LMICs, and the number must be bolstered by making such training available. Essential anesthesia medications and equipment, in pediatric-appropriate sizes, are often not available; neither are essential infrastructure items. Perioperative staff are underprepared for emergent situations that may arise and simulation training may help to ameliorate this. The global anesthesia community has implemented several solutions to address these issues. The World Federation of Societies of Anaesthesiologists (WFSA) and Global Initiative for Children's Surgery have published standards that outline essential items for the provision of safe perioperative pediatric care. Several short educational courses have been developed and introduced in LMICs that either specifically address pediatric patients, or contain a pediatric component. The WFSA also maintains a collection of discrete tutorials for educational purposes. Finally, in Africa, large-scale, prospective data collection is underway to examine pediatric perioperative outcomes. More work needs to be done, though, to improve perioperative outcomes for pediatric patients in LMICs.

The Capnography Project.

Capnography is an essential tool used in the monitoring of patients during anesthesia and in critical care which, while required in most high-income countries, is unavailable in many low- and middle-income countries. Launched in 2020, the Smile Train-Lifebox Capnography Project aimed to find a "capnography solution" for resource-poor settings. The project was specifically interested in a capnography device that would meet the needs of the Smile Train partner hospitals to help monitor children requiring airway or cleft surgery. Project advisory and technical groups were formed and included representation from anesthesia practitioners from a balanced representation from all level of income countries, technical experts in capnography, and representatives from the Global Capnography Project (GCAP), the University of California at San Francisco Center for Health Equity in Surgery & Anesthesia (CHESA), and the World Federation of Societies of Anaesthesiologists (WFSA). Built upon the WFSA minimum capnometer specifications, a human centered design approach was used to develop a Target Product Profile. Seven manufacturers submitted 13 devices for consideration and 3 devices were selected for the testing phase. Each of these devices was evaluated for build quality, and clinical and usability performance. Based on the findings from the overall testing process, a combined capnography and pulse oximetry device by Zug Medical Systems was chosen. To accompany the new Smile Train-Lifebox capnograph, an international team of experienced anesthesiologists and educators came together to develop the necessary education materials. These materials were piloted in Ethiopia, subsequently modified, and endorsed by the education team. The device is now ready for distribution, with the accompanying education package, to the Smile Train network and beyond. In addition, a study is being planned to measure the impact of capnography introduction into operating rooms in resource-constrained settings.

Defining Surgical Workforce Density Targets to Meet Child and Neonatal Mortality Rate Targets in the Age of the Sustainable Development Goals: A Global Cross-Sectional Study.

OBJECTIVES: To reduce preventable deaths of newborns and children, the United Nations set a target rate per 1000 live births of 12 for neonatal mortality (NMR) and 25 for under-5 mortality (U5MR). The purpose of this paper is to define the minimum surgical workforce needed to meet these targets and evaluate the relative impact of increasing surgeon, anesthesia, and obstetrician (SAO) density on reducing child mortality. METHODS: We conducted a cross-sectional study of 192 countries to define the association between surgical workforce density and U5MR as well as NMR using unadjusted and adjusted B-spline regression, adjusting for common non-surgical causes of childhood mortality. We used these models to estimate the minimum surgical workforce to meet the sustainable development goals (SDGs) for U5MR and NMR and marginal effects plots to determine over which range of SAO densities the largest impact is seen as countries scale-up SAO workforce. RESULTS: We found that increased SAO density is associated with decreased U5MR and NMR (P < 0.05), adjusting for common non-surgical causes of child mortality. A minimum SAO density of 10 providers per 100,000 population (95% CI: 7-13) is associated with an U5MR of < 25 per 1000 live births. A minimum SAO density of 12 (95% CI: 9-20) is associated with an NMR of < 12 per 1000 live births. The maximum decrease in U5MR, on the basis of our adjusted B-spline model, occurs from 0 to 20 SAO per 100,000 population. The maximum decrease in NMR based on our adjusted B-spline model occurs up from 0 to 18 SAO, with additional decrease seen up to 80 SAO. CONCLUSIONS: Scale-up of the surgical workforce to 12 SAO per 100,000 population may help health systems meet the SDG goals for childhood mortality rates. Increases in up to 80 SAO/100,000 continue to offer mortality benefit for neonates and would help to achieve the SDGs for neonatal mortality reduction.

Evaluation of Open Access Websites for Anesthesia Education.

BACKGROUND: While the prevalence of free, open access medical education resources for health professionals has expanded over the past 10 years, many educational resources for health care professionals are not publicly available or require fees for access. This lack of open access creates global inequities in the availability and sharing of information and may have the most significant impact on health care providers with the greatest need. The extent of open access online educational websites aimed for clinicians and trainees in anesthesiology worldwide is unknown. In this study, we aimed to identify and evaluate the quality of websites designed to provide open access educational resources for anesthesia trainees and clinicians. METHODS: A PubMed search of articles published between 2009 and 2020, and a Startpage search engine web search was conducted in May 2021 to identify websites using the following inclusion criteria: (1) contain educational content relevant for anesthesia providers or trainees, (2) offer content free of charge, and (3) are written in the English language. Websites were each scored by 2 independent reviewers using a website quality evaluation tool with previous validity evidence that was modified for anesthesia (the Anesthesia Medical Education Website Quality Evaluation Tool). RESULTS: Seventy-five articles and 175 websites were identified; 37 websites met inclusion criteria. The most common types of educational content contained in the websites included videos (66%, 25/37), text-based resources (51%, 19/37), podcasts (35%, 13/37), and interactive learning resources (32%, 12/37). Few websites described an editorial review process (24%, 9/37) or included opportunities for active engagement or interaction by learners (30%,11/37). Scores by tertile differed significantly across multiple domains, including disclosure of author/webmaster/website institution; description of an editorial review process; relevancy to residents, fellows, and faculty; comprehensiveness; accuracy; disclosure of content creation or revision; ease of access to information; interactivity; clear and professional presentation of information; and links to external information. CONCLUSIONS: We found 37 open access websites for anesthesia education available on the Internet. Many of these websites may serve as a valuable resource for anesthesia clinicians looking for self-directed learning resources and for educators seeking to curate resources into thoughtfully integrated learning experiences. Ongoing efforts are needed to expand the number and improve the existing open access websites, especially with interactivity, to support the education and training of anesthesia providers in even the most resource-limited areas of the world. Our findings may provide recommendations for those educators and organizations seeking to fill this needed gap to create new high-quality educational websites.

Challenges with pediatric anesthesia and intraoperative ventilation of the child in the resource-constrained setting.

The systemic challenges in providing safe anesthesia, including safe ventilation, to children in resource-constrained settings are many. For anesthesia providers caring for children, the lack of appropriate equipment, inadequate anesthesia workforce and deficiencies in postoperative care are especially difficult. The clinical decisions made by anesthesia providers around when and how to ventilate a child for surgery are influenced by all of these factors and can result in patient management which may vary significantly from that in a high-resource setting. This educational review considers the intraoperative ventilation of a small child in a resource-constrained setting and discusses specific challenges and context-sensitive solutions.

Delivering Essential Surgical Care for Lower-limb Musculoskeletal disorders in the Low-Resource Setting.

BACKGROUND: Mismatched surgeon-anesthesiologist ratios often exist in low-resource settings making safe emergency essential surgical care challenging. This study is an audit of emergency essential procedures performed for lower-limb (LL) musculoskeletal disorders (MSD) when an anesthesiologist was unavailable. It aims to identify strategies for safe anesthesia. METHODS: A 5-year retrospective audit of emergency essential LL orthopedic procedures performed at remote mission hospital in Central India was performed. Out of necessity, a regional anesthesia (RA) protocol was developed in collaboration with anesthesiologists familiar with the setting. The incidence of intraoperative surgical and perioperative anesthesia complications when RA was administered by a surgeon was evaluated. RESULTS: During this period, 766 emergency essential LL MSDs procedures were performed. An anesthesiologist was available for only 6/766. RA was administered by a surgeon for 283/766. This included spinal anesthesia (SA) for 267/283 patients, peripheral nerve blocks for 16/283. Local infiltration and/or sedation was administered to 477/766. There were 17 intraoperative surgical complications. Anesthesia-related complications included 37/267 patients who required multiple attempts to localize subarachnoid space and SA failure in 9/267 patients all of whom had successful re-administration. Additional sedation and infiltration of local anesthetic was required in 5/267 patients. CONCLUSION: Remote pre-anesthesia consultation for high-risk patients, local surgeon-anesthesiologist networking, protocol-guided management, and dedicated short duration of training in anesthesia may be considered as an alternative for delivering RA for emergency essential surgery for LL MSDs due to unavailability of anesthesiologists.

Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala.

BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

Is Intensive Care Unit Admission Necessary After Removal of Mandibular Distraction Devices in Infants With Robin Sequence?

OBJECTIVE: Intensive care unit (ICU) care is routinely required after the operation to initiate mandibular distraction osteogenesis (MDO) in infants with Robin sequence (RS). Many patients are also managed in the ICU after subsequent device removal. It is uncertain if ICU care, which is expensive and limited, is necessary after this second operation. The objective of this study was to evaluate the incidence of respiratory events following device removal. We hypothesized that respiratory events would be infrequent and non-ICU inpatient monitoring would be adequate. DESIGN: This is a retrospective study of patients with RS from 2013 to 2018. PATIENTS: Patients were included if they had MDO and distractor removal during the first year of life. Patients were excluded if they had a tracheostomy or remained intubated after distractor removal. MAIN OUTCOME MEASURE: Postoperative respiratory events. RESULTS: Twenty-five (60% male) patients were included. Mean age and weight at distractor removal were 142 ± 79 days of life and 5.5 ± 1.1 kg. Mean apnea-hypopnea index after completion of distraction was 1.1 ± 1.5 events/hour. Two (8%) patients experienced postoperative respiratory events that required intervention. In 1 (4% of sample) of these, the event was deemed to have benefited from ICU-level care. Two variables were significantly associated with these events: congenital heart disease (P = .020) and concomitant procedure performed during the same operation (P = .020). CONCLUSIONS: Intensive care unit-level care is rarely needed after distractor removal in infants with RS. Intensive care unit admission should be considered in patients with congenital cardiac disease and when having multiple operations during the same anesthetic.

Impact of COVID-19 response on global surgical volumes: an ongoing observational study.

OBJECTIVE: To determine whether location-linked anaesthesiology calculator mobile application (app) data can serve as a qualitative proxy for global surgical case volumes and therefore monitor the impact of the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We collected data provided by users of the mobile app "Anesthesiologist" during 1 October 2018-30 June 2020. We analysed these using RStudio and generated 7-day moving-average app use plots. We calculated country-level reductions in app use as a percentage of baseline. We obtained data on COVID-19 case counts from the European Centre for Disease Prevention and Control. We plotted changing app use and COVID-19 case counts for several countries and regions. FINDINGS: A total of 100 099 app users within 214 countries and territories provided data. We observed that app use was reduced during holidays, weekends and at night, correlating with expected fluctuations in surgical volume. We observed that the onset of the pandemic prompted substantial reductions in app use. We noted strong cross-correlation between COVID-19 case count and reductions in app use in low- and middle-income countries, but not in high-income countries. Of the 112 countries and territories with non-zero app use during baseline and during the pandemic, we calculated a median reduction in app use to 73.6% of baseline. CONCLUSION: App data provide a proxy for surgical case volumes, and can therefore be used as a real-time monitor of the impact of COVID-19 on surgical capacity. We have created a dashboard for ongoing visualization of these data, allowing policy-makers to direct resources to areas of greatest need.

Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Bradycardia and asystole during temporomandibular joint reconstruction.

Anesthesia providers are familiar with the oculocardiac reflex, one type of trigeminocardiac reflex. While less common, arrhythmias associated with manipulation of other trigeminal nerve branches can occur. We report the presentation and management of bradycardia and asystole from stimulation of the mandibular branch of the trigeminal nerve during temporomandibular joint reconstruction.

Adaptations in pediatric anesthesia care and airway management in the resource-poor setting.

The need for safe and quality pediatric anesthesia care in low- and middle-income countries (LMICs) is huge. An estimated 1.7 billion children do not have access to surgical care, and the majority are in LMICs. In addition, most LMICs do not have the requisite surgical workforce including anesthesia providers. Surgery is usually performed at three levels of facilities: district, provincial, and national referral hospitals. Unfortunately, the manpower, equipment, and other resources available to provide surgical care for children vary greatly at the different level facilities. The majority of district level hospitals are staffed solely by non-physician anesthesia providers with variable training and little support to manage complicated pediatric patients. Airway and respiratory complications are known to account for a large portion of pediatric perioperative complications. Management of the difficult pediatric airway pathology is a challenge for anesthesia providers regardless of setting. However, in the low-resource setting poor infrastructure, lack of transportation systems, and crippled referral systems lead to late presentation. There is often a lack of pediatric-sized anesthesia equipment and resources, making management of the local pathology even more challenging. Efforts are being made to offer these providers additional training in pediatric anesthesia skills that incorporate low-fidelity simulation. Out of necessity, anesthesia providers in this setting learn to be resourceful in order to manage complex pathologies with fewer, less ideal resources while still providing a safe anesthetic.

Unifying Children's Surgery and Anesthesia Stakeholders Across Institutions and Clinical Disciplines: Challenges and Solutions from Uganda.

BACKGROUND: There is a significant unmet need for children's surgical care in low- and middle-income countries (LMICs). Multidisciplinary collaboration is required to advance the surgical and anesthesia care of children's surgical conditions such as congenital conditions, cancer and injuries. Nonetheless, there are limited examples of this process from LMICs. We describe the development and 3-year outcomes following a 2015 stakeholders' meeting in Uganda to catalyze multidisciplinary and multi-institutional collaboration. METHODS: The stakeholders' meeting was a daylong conference held in Kampala with local, regional and international collaborators in attendance. Multiple clinical specialties including surgical subspecialists, pediatric anesthesia, perioperative nursing, pediatric oncology and neonatology were represented. Key thematic areas including infrastructure, training and workforce retention, service delivery, and research and advocacy were addressed, and short-term objectives were agreed upon. We reported the 3-year outcomes following the meeting by thematic area. RESULTS: The Pediatric Surgical Foundation was developed following the meeting to formalize coordination between institutions. Through international collaborations, operating room capacity has increased. A pediatric general surgery fellowship has expanded at Mulago and Mbarara hospitals supplemented by an international fellowship in multiple disciplines. Coordinated outreach camps have continued to assist with training and service delivery in rural regional hospitals. CONCLUSION: Collaborations between disciplines, both within LMICs and with international partners, are required to advance children's surgery. The unification of stakeholders across clinical disciplines and institutional partnerships can facilitate increased children's surgical capacity. Such a process may prove useful in other LMICs with a wide range of children's surgery stakeholders.

Education: The Heart of the Matter.

There are inadequate numbers of anesthesia providers in many parts of the world. Good quality educational programs are needed to increase provider numbers, train leaders and teachers, and increase knowledge and skills. In some countries, considerable external support may be required to develop self-sustaining programs. There are some key themes related to educational programs in low- and middle-income countries:(1) Programs must be appropriate for the local environment-there is no "one-size-fits-all" program. In some countries, nonuniversity programs may be appropriate for training providers.(2) It is essential to train local teachers-a number of short courses provide teacher training. Overseas attachments may also play an important role in developing leadership and teaching capacity.(3) Interactive teaching techniques, such as small-group discussions and simulation, have been incorporated into many educational programs. Computer learning and videoconferencing offer additional educational possibilities.(4) Subspecialty education in areas such as obstetric anesthesia, pediatric anesthesia, and pain management are needed to develop leadership and increase capacity in subspecialty areas of practice. Examples include short subspecialty courses and clinical fellowships.(5) Collaboration and coordination are vital. Anesthesiologists need to work with ministries of health and other organizations to develop plans that are matched to need. External organizations can play an important role.(6) Excellent education is required at all levels. Training guidelines could help to standardize and improve training. Resources should be available for research, as well as monitoring and evaluation of educational programs.