Episode #307 Perioperative Safety In Low And Middle-Income Countries

Opening Clip: [Boettcher] Going forward, we would like to see steady, measurable progress in peri-operative safety across low and middle income countries, especially through expanding the anesthesia workforce and improving the quality of care during the perioperative period. We strongly believe in aligning with standards set by the World Health Organization and the World Federation of Society of Anesthesiologists, making sure every patient has access to safety and monitoring equipment, essential medicines, and trained anesthesia providers.

Hello and welcome back to the Anesthesia Patient Safety Podcast. I’m your host, Alli Bechtel. In November 2025, we had a special episode where we welcomed Dr. Kelly McQueen to the show to talk about considerations for providing safe anesthesia care in low and middle income countries. If you haven’t listened to it already, we hope that you will check it out. It’s episode #281, called safer anesthesia everywhere. In that episode, Dr. McQueen takes us through considerations for the workforce crisis with too few trained providers and concerns about credentialing and limited continuing education as well as the World Health Organization Surgical Safety Checklist and the power of perioperative mortality reviews that can help to boost quality improvement. We are returning to this topic today with one of the new APSF articles. We will discuss improving perioperative patient safety in low and middle-income countries by addressing systemic barriers including critical resource shortages, inadequate infrastructure, and absent standardized safety protocols. This is an area where we need to use evidence-based tools and global partnerships to improve surgical morbidity and mortality in these areas of the world.

Before we dive further into the episode today, we’d like to recognize Nihon Kohden a major corporate supporter of APSF. Nihon Kohden has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Nihon Kohden – we wouldn’t be able to do all that we do without you!”

Our featured article is “Perioperative Safety and Quality in Low- and Middle-Income Countries” by Eva Lu-Boettcher and Kelly Ann McQueen. This article is an APSF Article Between Issues published online March 13, 2026. To follow along with us, head over to APSF.org and click on the Newsletter Heading. The second one down is APSF Articles Between Issues. Then, you can scroll down until you get to our featured article, and I will include a link in the show notes as well.

To help kick off the show today, we have exclusive content from one of the authors. Here she is now.

[Boettcher] “ Hi, I’m Eva Boettcher, a pediatric anesthesiologist at the University of Wisconsin in the United States. I am the Associate Vice Chair for Quality and Safety within the Department of Anesthesiology.”

[Bechtel] I asked Eva why she wrote this article. Let’s take a listen to what she had to say.

[Boettcher] “We wrote this article to highlight both the challenges and the real opportunities to improve perioperative safety and patient outcomes in low and middle income countries. While preventable peri-operative deaths remain a serious concern, we wanted to emphasize the meaningful progress being made through workforce development, better access to equipment, and global collaborations supported by organizations like the World Health Organization and the Lancet Commission of Global Surgery. My hope is to highlight the continued coordinated efforts that strengthen anesthesia and surgical systems and ultimately improve outcomes for patients worldwide.”

[Bechtel] Thank you so much to Eva for helping to introduce this topic. And now it’s time to get into the article.

We are talking about this because there are significant threats to perioperative patient safety in different regions around the world. Six percent of surgical procedures take place in low- and middle-income countries, but over 50% of the perioperative death and disability from surgery occurs in these areas. Many of these are preventable including about 95% of the annual deaths in patients under 20 years at community and district hospitals in these nations.

First, let’s talk about the threats to anesthesia patient safety in low and middle income countries starting with workforce shortages. There are about 550,000 anesthesia professionals around the world with about 15% providing anesthesia care in low and middle income countries. This is a significant shortage due to a lack of infrastructure to support a certified, trained, and licensed anesthesia workforce. There is also a limited surgical workforce and this combination means that about 5 billion people do not have access to safe and affordable surgery and anesthesia care when needed according to the Lancet Commission for Global Surgery in 2015. Even when patients are able to receive care, there may be delays in accessing care from financial or geographic limitations, limited specialized workforce, limited awareness of available services, and low confidence in those services.

Another limitation is the lack of representative anesthesia societies in the majority of the low and middle income countries. Without representative anesthesia societies, there is a lack of data and support for practicing anesthesia professionals. In countries that have anesthesia societies including Mozambique, Ethiopia, and Rwanda, there are reported 0.3-0.6 anesthesia professionals available per 10,000 people. We can compare this to Australia where there are about 38 anesthesia professionals per 10,000 people. The numbers reveal significant shortages of specialists. Let’s look at the 11,422 surgical patients in 247 hospitals across Africa. At these hospitals, the average was 0.7 specialist surgeons, obstetricians, and anesthesia professionals per 100,000 patients. The most frequent procedure was caesarean deliveries at 33%. Postoperative complications occurred in 18.2% of patients and the mortality rate was 2.1%. Even though the surgical risk was low, the postoperative mortality in Africa was double the national average. Looking at just caesarean deliveries, the complication and mortality rates were 26.8% and 8.4% respectively. We hope that you will check out this publication and I will include the citation in the show notes.

Work is being done to make improvements in anesthesia training, credentialing, national tracking of anesthesia personnel, and access to safer surgery. An important step is the development of national policy frameworks including the development of National, Surgical, Obstetric, and Anesthesia Plans, or N-SOAP, combined with support from international organizations such as the World Health Organization (WHO), the International Federation of Nurse Anesthetists (IFNA), and the World Federation of Societies of Anesthesiologists (WFSA). Tanzania, Ethiopia, Nigeria, Rwanda, Senegal, and Zambia have developed and started to use these plans to increase the anesthesia and surgical workforce and track perioperative outcomes.

Let’s take a look at some of the results. In Tanzania, 19.3% of all deaths come from disease that could be treated by surgery and 85% of caesarean deliveries and 71% of non-obstetric procedures are provided by nonphysician clinicians in the roles of clinical officers and assistant medical officers. The Tanzanian N-SOAP have set the goal of increasing the specialist surgical, obstetric, and anesthesia professionals from 0.46 per 100,000 people in 2017 to 2.27 by 2025. By 2024 they had almost reached their goal and were at 1.96 per 100,000.

There are some challenges for implementing N-SOAPS in every country with lack of awareness and lack of a regional governance structure. Plus, the first step for the NSOAPS is to establish workforce baselines. Going forward, it will be important to track progress and tackle regional challenges. The Lancet Commission for Global Surgery has recommended a ratio of at least 20 specialists per 100,000 people for a specialist surgical workforce by 2030. Increasing the specialist surgical workforce would improve access to surgery, help to create a culture of patient safety, and improve patient outcomes.

Next up, let’s take a closer look at access to monitoring and essential medications. When you walked into your operating room today, did you have access to all the routine ASA monitors? Was your medication drawer stocked? In low- and middle-income countries, there may be limited access to monitors, oxygen, and rescue medications. The WFSA and WHO recommend pulse oximetry, oxygen, rescue medications, and capnography for every anaesthetic. In many district level hospitals that provide surgical services, these required monitors and medications are missing which is a big threat to anesthesia patient safety.  Do you know what else may be missing? Trained anesthesia professionals may also be missing which is a big threat to anesthesia patient safety.

Work is being done in this area. The WHO supports Lifebox, a non-profit organization established by Atul Gawande in collaboration with the Association of Anaesthetists of Great Britain and Ireland, the WFSA, and the Harvard School of Public Health. The mission for Lifebox is to provide affordable patient safety equipment like pulse oximetry and capnography and support patient safety tools like the WHO surgical safety checklist. Additional resources are needed especially in regional hospitals and Ministries of Health will need to address equipment and medication shortages. The WHO has an implementation manual for the Surgical Safety Checklist. Important factors for successful implementation include the following:

• Early engagement of staff
• Active leadership and identification of local champions
• Extensive discussion, education and training
• Multidisciplinary involvement
• Coaching
• Ongoing feedback
• Local adaptation

I will include a link to the implementation manual in the show notes as well. The authors tell us that providing safe anesthesia care across countries and regions requires access to safety monitors and essential medications and adoption of a culture of safety that incorporates checklists.

The WFSA and WHO developed the International Standards for a Safe Practice of Anesthesia in 1992 to provide guidance for anaesthesiology departments, institutions, health care professionals, and policy makers to establish and evaluate compliance with international quality anesthesia care standards. There is an updated version from 2018 that includes recommendations for standardized professional training, facilities, equipment, medications, monitoring, and anesthesia management. This is a useful tool to help anesthesia departments and hospitals align with global anesthesia care standards. The highly recommended standards which should be considered mandatory for the provision of safe anesthesia care. These are also the minimum standards and the goal should be to practice anesthesia care to an even higher standard. The highly recommended standards  include the following:

The continuous presence of a trained and vigilant anesthesia provider

Continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter

Intermittent monitoring of blood pressure

Confirmation of correct placement of an endotracheal tube by auscultation and carbon dioxide detection

Use of the WHO Safe Surgery Checklist

A system for transfer of care at the end of the anesthetic.

There are some studies that have evaluated alignment with the International Standards for a Safe Practice of Anesthesia. There is a 2024 report from the largest health care system in Morocco, a lower-middle income country, that determined percentages of anesthetic cases that met the standards. Here are the results. There was high compliance for pre-anesthetic visits, checklist completion, and record keeping. Post-anesthesia care units, nurse training, premedication use, and intraoperative neuromuscular monitoring had lower compliance. Let’s look at another report from a major hospital system in Cambodia from 2020. High compliance was found with one-to-one patient care, preoperative evaluation, and basic monitoring. On the flip side, there was low compliance with availability of carbon dioxide detectors, temperature and neuromuscular monitoring, defibrillators, fluid equipment, capnography, and continuing education. What is clear is that there are challenges related to the different regions and institutions and leadership resources. Going forward, more research is needed in this area to continue to evaluate challenges to align with the standards and successful incorporation of the standards.

Speaking of research, there has been increased perioperative research studies from low and middle income countries including Brazil, China, and India recently. Many of these studies evaluate short-term surgical results and patterns of diseases managed through surgery. We are still lacking large-scale studies from African regions. Another challenge is that without the infrastructure and means to collect risk-adjusted surgical outcomes data, it is hard to evaluate the specific challenges encountered in low-resource environments. Let’s turn to the 2024 article, “Barriers and Facilitators to Collecting Surgical Outcome Data in Low- and Middle-Income Countries: An International Survey” by Diehl and colleagues. The investigators conducted a survey of surgeons, anesthesia professionals, anesthesia and surgical trainees, and administrators. Here are the results:

• There were 229 participants from 36 separate countries
• 58% reported that their institution had experience with collecting surgical outcomes data and the majority thought that this had a positive impact on patient care.
• The top 3 barriers included burden of clinical responsibility, research costs, and accuracy of medical documentation.
• The most frequent proposed solutions included electronic data collection platform, dedicated research personnel, and access to research training.

We hope that you will check out this article to learn more about this topic.

Going forward, there is a strong push to improve access to surgical care in low and middle income countries and this push must be accompanied by all the necessary resources that we talked about on the show today –humans, available and functional equipment, medications, system processes, and robust data collection if we are to see a commitment to patient safety and improved surgical outcomes.

[Bechtel] Before we wrap up for today, we are going to hear from Eva again. I also asked her What do you hope to see going forward? Here is her response.

[Boettcher] “Going forward, we would like to see steady, measurable progress in peri-operative safety across low and middle income countries, especially through expanding the anesthesia workforce and improving the quality of care during the perioperative period. We strongly believe in aligning with standards set by the World Health Organization and the World Federation of Society of Anesthesiologists, making sure every patient has access to safety and monitoring equipment, essential medicines, and trained anesthesia providers. Of note, low and middle income countries often lack infrastructure and means to collect risk adjusted surgical outcomes data. To improve surgical outcomes tracking in low and middle income countries, a multidisciplinary understanding of the current practices and challenges to collect data is needed. Ultimately, we hope to see stronger data collection and better tracking of peri-operative outcomes so there is real accountability and continuous improvement in patient safety.”

Thank you so much to Eva for helping to contribute to the show today.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Thank you for joining us for another episode of the Anesthesia Patient Safety Podcast. At the APSF, we believe that patient safety is everyone’s responsibility, and every conversation helps move our specialty forward. If you enjoyed this episode, please subscribe, leave a review, and share the podcast with your colleagues, trainees, and anesthesia professionals committed to safer patient care.

Until next time, stay vigilant and stay informed so that no one shall be harmed by anesthesia care.

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