Authors: Lu-Boettcher Y et al.
Anesthesia Patient Safety Foundation Newsletter, volume 41, number 1, February 2026.
Summary
This article reviews the current state of perioperative patient safety in low- and middle-income countries and highlights recent advances, persistent gaps, and practical next steps to reduce the disproportionate burden of surgical morbidity and mortality in these settings. The authors emphasize that although a relatively small fraction of global surgical volume occurs in LMICs, these countries account for a majority of perioperative death and disability, reflecting systemic limitations in workforce, infrastructure, equipment, medications, and standardized safety processes.
A central theme is anesthesia workforce shortage as a foundational safety threat. Global estimates indicate that only a small portion of anesthesia professionals practice in LMICs, and many countries lack the infrastructure to train, credential, and track anesthesia personnel reliably. The article highlights how limited specialist availability, particularly outside major cities, contributes to delays in accessing care, reduced confidence in services, and unsafe perioperative conditions. Data from large African hospital cohorts demonstrate high complication rates and higher-than-expected mortality, even among relatively low-risk patients, underscoring the reality that “routine” surgery can remain high risk in low-resource settings.
The authors describe National Surgical, Obstetric, and Anesthesia Plans as a key policy mechanism for improving access and outcomes. NSOAPs aim to build workforce capacity, expand service delivery, and track perioperative outcomes as part of national quality strategy. Tanzania is presented as an example where workforce metrics improved after NSOAP implementation, while also noting that governance structure, awareness, and reliable baseline tracking remain major barriers to implementation and evaluation.
Another major domain is access to safety monitoring and essential medicines. Many LMIC facilities lack basic equipment considered standard for safe anesthesia care, including reliable oxygen delivery, pulse oximetry, capnography, and rescue medications. These deficits are particularly pronounced as surgical services expand into district and community hospitals where trained anesthesia professionals may be scarce. The article highlights international efforts to close equipment gaps and accelerate checklist adoption, noting that safety checklists can reduce major complications and mortality when reliably implemented. However, uneven adoption and persistent supply chain and funding limitations remain obstacles.
The authors also discuss global anesthesia safety assessment tools, focusing on the International Standards for a Safe Practice of Anaesthesia. These standards provide a structured framework for assessing compliance with recommended training, staffing, monitoring, medications, and systems of care. Reports from different LMIC health systems show variable compliance: some elements such as pre-anesthetic evaluation and basic monitoring may be strong, while postanesthesia care, ongoing education, advanced monitoring, and medication availability often lag. The authors emphasize that improvement needs are highly region- and institution-specific and require local leadership support and resources.
Finally, the article highlights barriers to quality improvement and outcomes tracking. Many LMIC settings lack infrastructure for consistent documentation, risk-adjusted data collection, and protected research time. Surveys of perioperative stakeholders identify heavy clinical workloads, limited mentorship and training, cost barriers, and documentation gaps as key obstacles to measuring outcomes and sustaining improvement. The authors argue that expanding access to surgery must be matched with investment in the people, equipment, medications, and processes required for safe care, and that outcomes tracking is essential to guide policy and measure progress over time.
Key Points
Perioperative mortality and disability disproportionately occur in LMICs despite lower overall surgical volume
Workforce shortages and limited training, credentialing, and tracking of anesthesia professionals are major safety threats
NSOAPs provide a national framework to improve workforce, access, and perioperative outcome tracking, but implementation barriers remain
Lack of basic monitors, oxygen reliability, and essential medications continues to compromise anesthesia safety, especially in district hospitals
International standards such as ISSPA can guide structured assessment and targeted safety improvements
Checklist adoption and safety culture interventions can meaningfully reduce complications, but uptake remains inconsistent
Outcomes data collection is limited by documentation gaps, heavy workloads, lack of research time, and insufficient infrastructure
Thank you to the Anesthesia Patient Safety Foundation for allowing us to summarize and share this APSF Newsletter article focused on global perioperative safety.