Training for transformation – human resources for health in West Africa

On 3 July 2025, the Future of Hospitals and Health Systems Initiative, in partnership with the French NGO La Chaîne de l’Espoir, hosted a webinar on: “Training human resources for health in low-resource settings: The transferable example from regional anaesthesia in West Africa.”

Nathalie De Sousa Santos, Health Consultant at La Chaîne de l’Espoir, chaired the discussion and shares the key takeaways for global healthcare leaders.

Use of regional anaesthesia worldwide

Regional anaesthesia (RA) is a technique that involves injecting a local anaesthetic near peripheral nerves to block feeling in a specific area of the body. It’s often used instead or to complement general anaesthesia, particularly for limb surgeries. Less invasive and better tolerated, RA usually allows for quicker recovery. Today, doctors commonly use ultrasound to find the right nerve, a method known as ultrasound-guided regional anaesthesia (UGRA). This has largely replaced the older standard practice of nerve stimulation.

While widely practiced in hospitals in high-income countries, its use is often limited to specific types of surgeries (notably in orthopaedics and gynaecology-obstetrics). It could be used more broadly, but limited training and a preference for familiar routines hold back wider adoption.

In low- and middle-income countries, RA remains largely unknown. Most doctors aren’t trained in the technique, and many hospitals can’t afford the ultrasound machines and special needles needed to perform it. Yet UGRA offers numerous benefits in all contexts, particularly in economically vulnerable countries that are also exposed to climate challenges.

Expert insights on building capacity in West Africa

At the webinar, six panellists shared insights into the current status of regional anaesthesia practice in West Africa. They explained its value for both physicians and patients, and shared key strategies to expand training – through a “training the trainers” model. They also emphasized critical points for ensuring high-quality training that is socially and psychologically acceptable for both learners and educators.

Prof. Afak Nsiri, an anaesthetist from Morocco and President-Elect of the African Society of Regional Anaesthesia and Pain Therapy (AFSRA), highlighted the growing need for safe, effective, resource-efficient anaesthesia in Africa. She stressed that UGRA is a safe, cost-effective technique which reduces the need for general anaesthesia and critical resources. It also improves outcomes: less pain, earlier mobility, and shorter hospital stays. However, she pointed out several barriers to its dissemination: limited access to training, equipment shortages (ultrasound machines and needles), and a lack of standardized local guidelines. That is why AFSRA promotes education, research, and excellence.

Dr Thomas Kefas Malau, consultant anaesthetist at Jos University Teaching Hospital (JUTH) in Nigeria, shared that until 2019, general anaesthesia was the main technique for surgeries at his hospital. However, in September 2019, things changed. A team from La Chaîne de l’Espoir, led by Dr Xavier Raingeval and in partnership with the ICRC, conducted a week-long training session in Jos on UGRA. The training was attended by 26 physicians. After completing the training, all participants actively encouraged hospital administrators, surgeons, and patients to adopt UGRA. Because of this advocacy, the hospital bought two mobile ultrasound machines and other necessary supplies.

Today, after several training sessions, the hospital staff can perform single-shot UGRA using a combination of nerve stimulation and ultrasound. They now perform trunk blocks, and upper and lower limb blocks. They are even considering establishing a regional anaesthesia centre for ongoing UGRA training.

Prof. Zouménou, anaesthetist in Benin and President of the Beninese Society of Anaesthetists (SMARB), pointed out a major issue: West Africa faces a serious shortage of anaesthetists, with an average of 2 per 100,000 inhabitants, mostly in urban centres. In contrast, there are ten times more nurse anaesthetists. In Benin and neighbouring countries, 80% of anaesthesia procedures are performed by non-physician providers. Prof. Zouménou strongly supports training paramedics in UGRA because of its many benefits. He recommends establishing a formal diploma-based training programme for these providers.

A scalable model for essential UGRA

Dr Xavier Raingeval, anaesthetist in Paris, has been training health teams across Africa in UGRA for 10 years with La Chaîne de l’Espoir. He highlights UGRA’s many benefits: safety, lower costs, reduced pain, improved patient comfort, fewer complications, reduced environmental impact compared to general anaesthesia (GA), and shorter hospital stays.

His approach is based on a structured method that trains future trainers. Training is measured through pre-and-post evaluations, and support continues afterwards through a dedicated smartphone app. A partnership with the ICRC helps spread the training, especially in English-speaking parts of Africa. The long-term goal is to establish an “essential UGRA” model, similar to the “essential surgery” concept promoted by the World Health Organization (WHO) and widely adopted in many countries. Essential surgery is a core component of primary healthcare. It includes lifesaving, cost-effective procedures that can prevent death and serious disability. However, in many low- and middle-income countries (LMICs), access to these procedures is still very limited. Integrating essential surgery into health systems is a key strategy for strengthening equity and improving global health.

Following this model, Dr Raingeval calls for the recognition of “essential UGRA”, to be taught to nurse anaesthetists and anaesthesia technicians in countries with few anaesthetists. But he recognizes some resistance, both from doctors and professional societies, and also from the nurses and technicians themselves, who may feel unsure or anxious about learning new, advanced skills.

Understanding and overcoming resistance

Sébastien Chamayou, advanced practice nurse and PhD candidate in education sciences, explored this issue further. He points out that healthcare staff shortages create serious system-wide challenges and solving them requires changing how care is organized. One well-documented solution is “skill-mix”, or the reallocation of tasks, which means shifting certain tasks to other professionals, giving more responsibility and independence to nurses and other non-doctor roles. Although studies show this model improves working conditions, reduces pressure on medical staff, and increases both the amount and quality of care, many professionals still resist putting it into practice.

To address this, psychoanalyst Magali Taïeb-Cohen highlighted the role of emotions and relationships in education. A key idea from psychoanalysis is “transference”: learners often idealize their instructors, who become a kind of mirror or guide. Meanwhile, teachers experience “countertransference”, their own emotional response to learners. Managing these emotional dynamics is crucial for real learning to happen.

That’s why participation in UGRA training must be voluntary. Learners need structured validation from supervisors and peers to feel confident and accepted. Magali Taïeb-Cohen also emphasized that knowledge should flow both ways: the trainer and the learner both have insights to offer. Finally, to support wide dissemination, she recommends developing a charter, a moral contract that clarifies the rights and responsibilities of everyone involved.

Towards the hospital of tomorrow

This webinar was aligned with the goals of the Future of Hospitals and Health Systems Initiative, which promotes the sharing of knowledge, tools, and skills to build the “hospital of tomorrow.” This hospital must be sustainable, climate-resilient, and committed to improved training and retention of health workers, better quality of care, good governance, and financial sustainability.

Expanding UGRA training supports all of these goals. It strengthens the health workforce in countries with few physicians, promotes safer and greener anaesthetic techniques, and improves patient outcomes.

The Future of Hospitals and Health Systems Initiative encourages knowledge exchange and fosters a collaborative environment to support a transformational agenda, especially in low-resource settings where innovation is needed most.  The shared commitment of the Initiative’s partner organizations promotes actions that improves the standard, quality, and level of healthcare service delivery. The impact of these actions on the wellbeing of communities will improve health for all.

References

1. Cochrane Database of Systematic Reviews. Peripheral Nerve Blocks for Hip Fractures in Adults.
2.  Graff V. et al. Perioperative costs of local or regional anaesthesia versus general anaesthesia in the outpatient setting: a systematic review of recent literature, BJA, Volume 73, Issue 3, May–June 2023, Pages 316-339. DOI: 1016/j.bjane.2021.09.012
3. Dohlman LE, Kwikiriza A, Ehie O. Benefits and Barriers to Increasing Regional Anaesthesia in Resource-Limited Settings. Local Reg Anesth. 2020 Oct 22;13:147-158. doi: 10.2147/LRA.S236550. PMID: 33122941; PMCID: PMC7588832.
4. Zouménou E. Pratique de l’anesthésie et analgésie locorégionales en Afrique subsaharienne. Rev Afr Anesthésiol Med Urg. 2017 ; 22 (1) : 1-2.
5. Beye M. Anesthésie locorégionale périphérique en Afrique : quelles perspectives ? RAMUR Tome 16, n°3-2011 https://www.docsity.com/fr/docs/anesthesie-locoregionale-peripherique-en-afrique-quelles-perspectives/4989526/
6. Ho M, Livingston P, Bould MD, Nyandwi JD, Nizeyimana F, Uwineza JB, Urquart R. Barriers and facilitators to implementing a regional anaesthesia service in a low-income country: a qualitative study. Pan Afr Med J. 2019 Apr 1;32:152. doi: 10.11604/pamj.2019.32.152.17246. PMID: 31303923; PMCID: PMC6607318.
7. Biccard, Bruce MAbadagan, Hippolyte et al. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study. The Lancet, Volume 391, Issue 10130, 1589 – 1598. DOI: 1016/S0140-6736(18)30001-1
8. The Efficacy of Transverse Abdominal Plane Block with Bupivacaine Combined with Dexamethasone for the Management of Post-Caesarean Pain Guibla, S. I. S. Traoré, K. B. Ki, S. C. Ilboudo, B. I. Bado, C. A. Ouattara, B. E. Komboigo, J. N. Savadogo, D. A. Sawadogo, D. A. Somé, Z. C. Méda, I. A. Traoré. EAS J Anesthesiol Crit Care; 2024, 6(2): 12-19.  DOI: 10.36349/easjacc.2024.v06i02.001
9. Shabani M, Beye SA, Traore A, Raingeval X, Coulibaly D, Crespo S. Combined Supra-Inguinal Fascia Iliaca, Sciatic Nerve, and Posterior Femoral Cutaneous Nerve Blocks in Austere Settings for Hemodynamically Unstable Patients with Vascular Injuries from Weapon Wounds: A Case Series. Local Reg Anesth. 2024;17:19-27 https://doi.org/10.2147/LRA.S452367
10. Chobli M. Pratique de l’anesthésie par les infirmier(e)s en Afrique francophone subsaharienne. 1999, Annales Francaises D Anesthesie Et De Reanimation. https://doi.org/10.1016/S0750-7658(99)80150-6
11. J‌ean-Pierre Winter, Transmettre (ou pas), Albin Michel, 2012.