To the Editor,

We read with interest the symposium report by Orser et al. on increasing anesthesia access in rural areas,1 and agree that this is an important initiative. We wish to highlight several existing initiatives in the global context that could be advantageous to this work.

National Surgery Obstetric and Anesthesia Planning (NSOAP), as outlined by the Lancet Commission on Global Surgery, needs an integrated approach, needs to engage all appropriate stakeholders, must not be siloed by provider type, and requires ministry of health and ministry of finance buy-in and participatory leadership—“NSOAPs provide a vision, along with costed and time-bound targets, of how actors within the SOA system will work together to systematically improve the SOA health system. Coordination of actors improves efficiency and impact”.2 National Surgery Obstetric and Anesthesia Planning provides a useful template for how to approach complex systemic anesthetic and surgical access issues and provides suggested metrics for monitoring this progress.3 In many countries, healthcare is a complex interaction among federal and provincial/state governments. An approach to managing such an interaction has been described.4

Successful programs exist that recognize health inequity as a shared challenge across regions. The Health, Action, Equity and Leadership (HEAL) Initiative recruits healthcare practitioners from both well- and under-resourced settings for a two-year commitment.5 Fellows provide rotating clinical service at both domestic (e.g., Navajo Nation, a Native American reservation) and international underserved sites (e.g., Chiapas, Mexico, or Mbale, Uganda). It includes a robust fellow curriculum in health equity and emphasizes that health equity is an important goal in every setting. Many graduates continue service in these communities and continue to advocate for health equity. It would be an excellent model to adopt in Canada.

A major investment in research to determine the major drivers of provider maldistribution is necessary to understand the problem and to establish tenable solutions. Increasing workforce numbers is unlikely to be effective without also addressing recruitment and retention to rural areas. There are data on barriers and strategies to increase recruitment and retention in both high- and low-resource countries.6,7,8 As the barriers and incentives differ across providers, a multifaceted policy response is necessary. Financial incentives should be bundled with other strategies, such as interventions for annual leave and improved housing and working conditions.

Inadequate access to care in rural areas affects most countries, and well- and under-resourced countries share many common challenges and solutions. Inadequate access to healthcare is equally important in both settings, and can be pursued simultaneously and synergistically.