Challenges to Anesthesia in Low- and Middle-Income Countries

December 9, 2019

Providing anesthesia services in low and middle-income countries (LMICs) comes with a host of challenges. According to the World Bank, low and lower-middle income countries are those with a gross national income (GNI) per capita of less than $3,995 [1]. There are 78 countries that fall into these categories, with the majority located in Central Africa and Central and Southeast Asia. Many anesthesia-related challenges in LMICs stem from a lack of resources, which can lead to a shortage of personnel, an inability to meet minimum standards for safe practice, and poor infrastructure in and around hospital facilities.

Without adequately trained staff, it is difficult to administer anesthesia properly and safely. According to a study by Turkot et al., many LMICs only have 1 to 3 anesthesiologists per million residents [2]. In Kenya, which has a population of almost 50 million, there are only 300 registered anesthetists in the country, with most clustered in urban centers [3]. In these cases, anesthesia is often administered by adjacent personnel, such as nurses or assistants, who are usually trained informally. A study by Kruk et al., which focused on three countries in central Africa, found that 77.5% of anesthesia personnel at the hospitals studied were nurses. In 39.4% of the cases studied, those nurses were the sole party responsible for administering anesthesia [4].

Research has shown that increasing the number of trained anesthesiologists in LMICs can lead to decreased death rates. Some of the strongest evidence for this comes from an international study on maternal mortality rates (MMR) by Holmer. The study found that every 10 additional anesthesiologists per 100,000 people led to a 13% decrease in MMR. From this data, the researchers concluded that a ratio of 20 to 40 anesthesiologists per 100,000 people would significantly improve health outcomes in LMICs [5].

In addition to staffing concerns, the anesthesia services at many hospitals in LMICs do not meet minimum requirements for safe practice [6]. The International Standards for a Safe Practice of Anesthesia segments its standards according to facility type, with lower standards and fewer procedures required at small or rural hospitals than at their urban counterparts [7]. However, due to a lack of funding, many hospitals in LMICs still fail to meet these requirements. A study of anesthesia services in 22 LMICs by Vo et al. found that only 53.4% of facilities had access to a functioning anesthesia machine and between 21% and 45% of hospitals lacked access to basic airway management technology [8]. As the report notes, even hospitals that do have access to these tools sometimes lack uninterrupted access to crucial infrastructure, such as running water, electricity, and supplemental oxygen.

When operations are performed in environments that do not meet minimum requirements for safe practice, complications such as infection can arise. A study by Médecins Sans Frontières (MSF) found that 7.3% of women in sub-Saharan African LMICs who underwent cesarean sections ended up with surgical site infections (SSIs). These infections, often a result of poor practices and inadequate sanitary techniques, are a major cause of post-surgical mortality [9]. Implementing an intraoperative checklist at low-resource hospitals can be a simple step to avoiding SSIs and other infections, according to a study de Dios and Bainbridge [10]. Likewise, Pelland and RB George point to the rise of standardized care procedures in high-income countries (HICs) and the resulting impacts on patient outcomes as a potential tool to implement in LMICs [11].

In short, staffing shortages, limited resources, poor infrastructure, and a high rate of post-surgical infection are major challenges to providing anesthesia in LMICs. At the same time, establishing systems for the intraoperative period and standardizing care procedures have the potential to mitigate these challenges.


[1] “World Bank Country and Lending Groups.” World Bank Data Help Desk, The World Bank, 2019,

[2] Turkot, Oleg, et al. “A Review of Anesthesia Simulation in Low-Income Countries.” Current Anesthesiology Reports, vol. 9, no. 1, 2019, pp. 1–9., doi:10.1007/s40140-019-00305-4.

[3] “Kenya Decries Shortage of Anesthetists.” Capital News, Capital Group Limited, 15 Sept. 2009,

[4] Kruk, Margaret E., et al. “Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey.” PLoS Medicine, vol. 7, no. 3, 9 Mar. 2010, doi:10.1371/journal.pmed.1000242.

[5] Holmer, Hampus, et al. “Towards Closing the Gap of the Global Surgeon, Anaesthesiologist, and Obstetrician Workforce: Thresholds and Projections towards 2030.” The Lancet, vol. 385, 26 Apr. 2015, doi:10.1016/s0140-6736(15)60835-2.

[6] Epiu, Isabella, et al. “Challenges of Anesthesia in Low- and Middle-Income Countries.” Anesthesia & Analgesia, vol. 124, no. 1, Jan. 2017, pp. 290–299., doi:10.1213/ane.0000000000001690.

[7] Merry, Alan F, et al. “International Standards for a Safe Practice of Anesthesia 2010.” Canadian Journal of Anesthesia/Journal Canadien D’anesthésie, vol. 57, no. 11, 21 Sept. 2010, pp. 1027–1034., doi:10.1007/s12630-010-9381-6.

[8] Mccunn, Maureen, et al. “Anesthesia Capacity in 22 Low and Middle Income Countries.” Journal of Anesthesia & Clinical Research, vol. 03, no. 04, 25 Apr. 2012, doi:10.4172/2155-6148.1000207.

[9] Chu, Kathryn, et al. “Cesarean Section Surgical Site Infections in Sub-Saharan Africa: A Multi-Country Study from Medecins Sans Frontieres.” World Journal of Surgery, vol. 39, no. 2, 31 Oct. 2014, pp. 350–355., doi:10.1007/s00268-014-2840-4.

[10] Vergel de Dios, Jennifer, and Daniel Bainbridge. “Systematizing Safety in the Low-Resource Operating Theater.” Current Anesthesiology Reports, vol. 7, no. 1, 23 Jan. 2017, pp. 37–41., doi:10.1007/s40140-017-0195-8.

[11] Pelland, A, and RB George. “Safe Obstetric Anaesthesia in Low- and Middle-Income Countries.” BJA Education, vol. 17, no. 6, 14 Feb. 2017, pp. 194–197., doi:10.1093/bjaed/mkw073.