Introduction
Drugs scheduled as a Schedule I drug in the Single Convention are subject to all measures of control under the Convention; only Schedule IV drugs are more tightly regulated within this Convention [28]. Measures include, amongst others, obligatory annual estimates, full documentation of quantities produced, manufactured, used, imported and/or exported, and special licenses for distribution. |
Schedule IV substances in the Convention on Psychotropic Substances are subject to control measures such as special licenses for manufacture, trade and distribution, full documentation similar to the Single Convention provision, import and export is only allowed when tightly regulated, and countries are allowed to prohibit the import of any psychotropic substance [29]. |
Methods
Study design
Study participants and recruitment
Data collection
Data management and analysis
Quality assurance
Ethical considerations
Results
Availability of anaesthetic commodities in Rwandan hospitals
Key informant interviews
Participant number | Country / region | Profession | Sex |
---|---|---|---|
P1 | Europe | Anaesthesiologist | Female |
P2 | Democratic Republic of Congo | Anaesthesiologist | Male |
P3 | Ethiopia | Anaesthesiologist | Male |
P4 | The Gambia | Anaesthesiologist | Male |
P5 | Namibia | Anaesthesiologist; critical care | Male |
P6 | Nigeria | Anaesthesiologist | Male |
P7 | Somaliland | Nurse-anaesthetist | Male |
P8 | South Africa | Anaesthesiologist | Female |
P9 | Zambia | Anaesthesiologist; critical care | Male |
P10 | Zimbabwe | Anaesthesiologist | Female |
Barriers to anaesthesia care
Quote number | Quote (participant number) |
---|---|
1 | “In Somaliland still, they don’t have any single local physician anaesthesia provider.” (P7) |
2 | “The DRC is a large country with more than one hundred million inhabitants, but the number of anaesthetists is still low, less than 100 and all concentrated in the big cities: Kinshasa the majority, Lubumbashi (5 and doctors in training), East of the country (six), Central Kongo (two), and the rest of the provinces do not have anaesthetists and therefore the anaesthesia is done by anaesthesia technicians (anaesthesia nurses) or even nurses and general practitioners.” (P2) |
3 | “Very, very few of the of the hospitals in Zambia have physician anaesthesiologists. Most of them have people that are below that level of training, and so they may not be able to provide very complex anaesthetics.” (P10) |
4 | “More than 85% of our anaesthetists in South Africa that qualifies annually, leaves for the private sector. And the private sector sees less than 40% of the patient burden. So the number is really very skewed in our country. And now, with all the economic things that is happening, a lot of us are leaving the country as well.” (P8) |
5 | “In general, anaesthesia care is growing. But it is highly challenged by availability of equipment and drugs. Like modern equipment, anaesthesia machines, monitoring equipment, like in the ICU too, […] and drugs like sevoflurane, the wide variety of modern drugs are lacking, it’s not available. Access is highly limited.” (P3) |
6 | “I would say the biggest barrier is maybe ignorance about the importance of anaesthesia. What anaesthesia’s role is in the hospitals, and how big of an impact a good anaesthetic service would have on our health system. I think that ignorance translates into poor funding into the field. It translates into poor recruitment. It translates into poor sponsorships for healthcare workers who do want to study anaesthesia.” (P9) |
Ketamine for anaesthesia care
Quote number | Quote (participant number) |
---|---|
1 | “Propofol is the preferred one. The issue is, it’s costly, and its availability is limited. […] So I would say, until recently, the majority of the cases are being induced by ketamine. But you know, request for propofol is highly increasing. We are getting, at least at my institution, We are getting more propofol these days.” (P3) |
2 | “Ketamine is very important in DRC because it is available, cheaper, and easy to use even without an anaesthesia machine. Everyone – specialists, general practitioners, nurses – can use it.” (P2) |
3 | “Some […] of the providers don’t have the skill or knowledge of how to perform a spinal anaesthetic, and the majority of surgeries that are done in rural settings tend to be for obstetric emergencies in which a spinal anaesthetic may be, would be warranted. But because they don’t have that skill, they would prefer to use a drug like ketamine that would […] keep the patient breathing on their own, and would allow for surgery to be done.” (P9) |
4 | “Because out of the operation theatre, the [health] facility, in case if the patient lost breathing effort, the facility is not appropriate. So we will feel safe only when we are using ketamine, because, as compared to other sedative agents, its adverse effects, loss of breathing and so on, is very much minimal with ketamine compared to others. Because of all this, I think I would say ketamine is very important, you know.” (P3) |
5 | “Ketamine is about the cheapest. The one we have here […] so that bottle is sold, in our local currency, that’s about 500 Naira which is less than 1 USD. So, yeah, so it’s always available. Propofol goes for 2,500 per ampoule. And that is about 4 times or 5 times the price of ketamine. Now, fentanyl goes for about 5,000 Naira. Which is about 10 times the price of ketamine. […] Then for regional anaesthesia, we’re using bupivacaine, bupivacaine goes for 4,000. Which is about 8 times the price of ketamine per ampoule. So ketamine is somehow cheap and is available for us to use.” (P6) |
6 | “Ketamine, eight months ago I would have said that number is very close to 100%. Because of how important it was. But with what’s happening right now, the supply, I would say maybe under 10% of hospitals have it. We are one of the largest hospitals in the country, and we don’t have ketamine. And usually we’re the last to get hit. So I think that if we don’t have ketamine I can’t imagine many others will.” (P9) |
Misuse of ketamine
Quote number | Quote (participant number) |
---|---|
1 | “With the Schedule 5 [of ketamine] in South Africa, ketamine is also still locked. And ketamine is also still signed for. And I think education and the enforcement of patient-by-patient administration and access to ketamine is the best way for patient care and for protecting the provider, from […] exposing themselves to the risk of ketamine misuse.” (P8) |
2 | “So when ketamine is being abused in other places, then it’s likely that it will come here later. So I mean restricting those drugs not to be accessible for individuals, other than hospitals, has to be, I think, considered. But now it is not a major of a concept.” (P3) |
3 | “In smaller hospitals, however, I have found that it’s not as tightly controlled. So the ketamine ampoule will be given, and it will be placed on your product trolley for the day.” (P8) |
4 | “I think in our local hospitals, there should be protocols on who to use ketamine. So if there are protocols and there are controls within the hospitals, such that whoever uses ketamine signs in and signs out. […] Whatever prescription has been, that he has written, should be stated clearly so that such can be traced. And also people handling ketamine. So we can now start using it as a [controlled] drug within the anaesthesia room. Such that it is not left in the open. So that it is only accessed when we need to use it.” (P6) |
5 | “I think it’s going to affect a lot of us who practice in rural communities. Because one, it’s going to affect the availability. And how we access. And it’s also going to make it very, very expensive. Because there will be a lot of controls, bottlenecks, trying to import ketamine, and make it available.” (P6) |
6 | “It will just affect it as it is affecting the opioid supplies in our country. And having an opioid medication for analgesia is the hardest challenge that one can have. And we know the exact reason why. Because of the categorization of the medication.” (P4) |
7 | “We can’t be seen as part of the international group, if our resources and operational profile is completely different. I mean, I don’t think it can be standardized that a drug that can potentially be life-saving, and a drug that is definitely part of our armoury for effective analgesia in a resource-limiting setting, that we are then under the same strict scheduling as a developed country that might have access to multiple other options.” (P8) |
International scheduling of ketamine as a controlled substance
Recommendations to improve access to anaesthesia care
Quote number | Quote (participant number) |
---|---|
1 | “Unless the countries, governments, themselves do not take action, we will not succeed. So what has been done with those national anaesthesia, surgical and obstetric plans is important, that we must have the countries’ governments to take responsibility. And that goes for training, […] and all kind of medications we are using, and so on.” (P1) |
2 | “Incentivise the department of anaesthesia. Give more opportunity to those that are ready to go into it, because the competition is between specialities. So obviously everyone wants to go to an area where they have a better chance in their academic progress. So if you incentivise the department of anaesthesia, we will have so many clinicians or nurse anaesthetists who are giving safe anaesthetic care within the country.” (P4) |
3 | “There should be a policy, a deliberate policy by government. […] COVID-19 came with a lot of problems. it opened our eyes to our emptiness. So after COVID-19, a lot of things have been done, provided. For example, anaesthetic machines, monitors, multi-parameter monitors, and even pulse oximeters, and the rest of them. […] So what I will say is, we shouldn’t wait for such things to happen.” (P6) |
4 | “Training more people, having more staff in the department. So we have limited number of theatres, we’re trying to expand the number of theatres that we have, but one of the stumbling blocks is limited number of [staff in the] anaesthesia department. So we’re trying to push for more staff.” (P5) |
5 | “Decentralisation of care is definitely, I feel, a buzzword, and is something that we need to do nationally and in sub-Saharan Africa really look at. That we don’t spend all our money that is already limited, in bringing amounts and amounts of patients, 700, 900, 1000 km, them staying in hospital for three, four, five nights, versus two specialists travelling down, sleeping over and delivering the same quality of care at the patient. So I do think decentralisation is definitely the way to go in sub-Saharan Africa for us to make… to actually make our healthcare service accessible to our patients” (P8). |