The global anesthesia crisis [13] limits access to emergency and essential surgical intervention, and contributes to poor patient outcomes. The survey data among practitioners in LMICs shows that a lack of education, limited training, and dwindling interest in the specialty have contributed to a lack of or absence of trained anesthesia providers [13]. Unpredictable access to essential medications and limited safety equipment has resulted in unsafe conditions for the provision of anesthesia and surgical intervention [13].

The contribution of anesthesia to unmet surgical need is difficult to quantify and measure [3]. Evidence from developed countries confirms that acceptable surgical outcomes—including mortality rates—depend on safe anesthesia practice, and safe anesthesia practice can only occur when trained anesthesia providers, safety equipment, essential medicines for anesthesia, and systems for pain control and resuscitation are available [14]. With this in mind, surgical burden, inclusive of both met and unmet surgical need, is predicated on lack of anesthesia care. In LMICs the scarcity of anesthesia resources may limit the provision of surgical intervention, but unfortunately, more often the intervention proceeds without appropriate anesthesia care. The resulting high anesthesia-related mortality rates are doubly tragic in the context of patient suffering [15–18]. Therefore, in order to impact the BoSD, a healthcare system must build capacity in all areas: physical infrastructure, surgeons, anesthesiologists, nurses, and technicians.

Anesthesia in resource-rich countries is very safe [14, 19]. Adequate numbers of physicians, supervision of nonphysician personnel, the continuous use of required safety monitoring, as well as an ample supply of medications, equipment, and blood products contribute to the safety and successful outcomes in developed countries. Outcomes related to anesthesia and surgery have steadily improved in these countries since the 1970s (Table 3.1).

Too little is known about anesthesia resources and practices in LMICs but the mortality rates reported in a few countries tell the shocking truth [15–18, 20]. Deaths attributable to anesthesia in most LMICs result from limited training and education, including continuing education, as well as limited or absent resources, especially safety monitoring. Published reports reveal mortality attributed to anesthesia as high as 1 in 133 anesthetics [15], with other reports of avoidable anesthesia-related death rates as high as 1 in 144 [16] and 1 in 504 anesthetics [17]. Of even greater concern is that many of the preventable anesthesia deaths occurred in otherwise young, healthy patients, many of whom were women undergoing cesarean delivery [20].

The WHO Model List of Essential Medicines [21] guides procurement of medications for governments internationally and includes a wide variety of pharmaceuticals for treatment or therapeutic uses—including anesthesia and pain management. The first Model List of Essential Medications was published in 1977, and since 2007, the list has been updated every two years. The anesthetic and analgesic medications from the 18th edition released in 2013 are listed in Table 3.2. The WHO’s process of selection utilizes a relatively small number of experts and who meet over a short period of time; in 2011, 20 experts met for 5 working days. Their goals are to “satisfy the health care needs of the majority of the population” while ensuring cost-effectiveness and promoting quality [22]. The list lacks many medications routinely used in HIC, many of the medicines not included are hotly debated annually, and the medicines within each category are included because they fulfill a specific function, are least expensive, or most consistently available.

Consistent with many guidelines provided by the WHO, country-level adherence to the essential medicine guidelines is influenced by resources as well as weighted prioritization within the healthcare system and Ministry of Health. Despite this planning and strategizing, in many LMICs the availability of medicines is inconsistent, especially in the first referral hospitals in LMICs. For example, oxygen, considered requisite to safe anesthesia, was only added to the WHO Essential Medicine list in 2013, and is available consistently in only 45.2 % of district hospitals and is unavailable in 35.0 % of these primary referral hospitals [23]. In addition, rescue medicines for hypotension and dysrhythmias are not consistently available. Finally, the paucity of narcotic pain medicines for treating acute and chronic pain in many of the poorest countries is of great concern. Regulatory issues, misinformation, and too few heath care practitioners providing access to these important medications contribute to this disparity¹ [24].

The ability to cross-match and transfuse blood to patients with symptomatic anemia or hemorrhage was a great medical advance that has positively impacted surgical and anesthetic outcomes globally over the past 40 years [25]. The ability to collect, match, and test blood for infectious disease is considered a prerequisite for surgical, obstetric, and trauma programs [26] but even as surgical care advances in LMICs, solutions for the provision of a safe and predictable blood supply are not obvious. The limitations of blood banking in LMICs primarily relate to basic issues of electricity and refrigeration, as well as the unavailability of pathology services [27]. Inexpensive and rapid blood typing and infectious disease screening are available [28], but the widespread use of this technology is often underutilized due to the greater issues of predictable, constant electricity necessary for refrigeration. Uninterrupted electricity is only available in 59 % of primary referral hospitals in Africa and Asia [23]. Utilizing “walking” or “living” blood banking—the practice of either formally or informally tracking blood types among community members with organized collection of whole blood and transfusion on demand—remains a viable practice in low-resource settings [26, 29]. However, even this practical solution is limited by the spread of misinformation, especially within the countries ravaged by the HIV pandemic, about the relationship of the donating and receiving blood products [30, 31].

The challenges of developing sufficient surgical capacity—the personnel, infrastructure, and systems—to meet surgical need in LMICs are many. Most advanced medical care including surgical procedures, diagnostic testing, and specialty care is centralized in LMICs [9]. At the first referral hospital where many patients in LMICs access health care there is limited infrastructure and few human resources. These primary care hospitals, often referred to as “district hospitals,” indicate regional hospitals, but transportation is limited, and even regional hospitals in the poorest countries have limited capacity to provide emergency and essential surgery [10, 11].

In the past decade many reports from LMICs have documented the extent of limited infrastructure, lack of anesthesia and surgical providers, and unpredictable availability of essential medications, monitors, and safety equipment; studies have also documented how these conditions impact access to surgery and anesthesia creating the unmet need for surgical intervention for a spectrum of disease [32–36].

The surgical and anesthesiology workforce is one area of well-documented disparity. It is estimated that a ratio of 7 surgeons per 100,000 people is needed to meet the surgical needs of a population. In the United States, there are 5.8 surgeons per 100,000 population (with more in urban and less in rural areas), but in many LMICs there is less than one surgeon per 100,000 people [37, 38]. The anesthesiology workforce is even more disparate (see Table 3.3) [39].

Many of the emergency and essential surgical interventions that address unmet surgical need in LMICs are cost-effective [40–43] as is the provision of safe anesthesia [44–47]. Ample documentation in the literature, as cited above, has brought attention to the issue, but such emphasis has not yet led to improved access or patient safety.

Too little is known about the longitudinal patient outcomes of surgical and anesthesia interventions in LMICs or about outcomes related to the absence of emergency surgery or late access to surgery. Improving data collection and reporting is a critical component of addressing surgical need.

An absence of surgical and anesthesia outcome data limits the investment of resources into surgical infrastructure and safe anesthesia in LMICs. Little is known about the incidence of mortality directly attributed to lack of surgical access especially in LMICs where death certificates are often not issued and most patients die at home where data collection is sparse [48]. In a majority of operating theaters in LMICs the only documentation of a serious operative complication or death is the paper logbook of the operating theater [49]. Little outside of the logbook is known about the perioperative mortality rate (POMR) of the hospital, region, or country. Follow-up of patients after surgery is limited to the time they are hospitalized, and once discharged to home few patients are followed [50].