Task-sharing anaesthesia in conflict zones: a cross-sectional study of safety gaps and systemic failures in Wad Medani, Sudan

Abstract

In Sudan, where physician anaesthesiologists are critically scarce (0.47/100,000 population), non-physician anaesthesia providers (NPAPs) deliver most perioperative care, a situation exacerbated by conflict-driven health system collapse. Despite global evidence supporting task sharing and task shifting, NPAP safety outcomes in fragile settings remain unquantified. This study aimed to quantify NPAP anaesthesia delivery, compare supervised and unsupervised safety outcomes, and identify systemic gaps in conflict-affected Sudan. We conducted a cross-sectional clinical audit of 1,559 surgical cases across four referral hospitals in Wad Medani, Sudan (2022–2023). Data on provider roles, supervision, and adverse events were collected by direct observation and record review using tools adapted from WHO/ASA. Data were analyzed using Stata 17.0; risk ratios (RR) with 95% confidence intervals (CI) were calculated, and statistical significance was set at p < 0.05. Ethics approval was obtained from the University of Gezira. NPAPs independently managed 46% of cases (718/1,559) in a task-shifting manner, while performing 82% of intubations and 91% of spinal anaesthetics under task sharing. Adverse events were 2.8× more frequent under unsupervised NPAP care (34% vs. 12% supervised; RR 2.8, 95% CI 1.9–4.1), dominated by cardiovascular (58%) and airway crises (41%). Systemic failures included 94% underreporting of adverse events and 0% NPAP access to continuing education. NPAPs sustain surgery in Sudan’s crisis but face lethal safety gaps. Urgent reforms require: (1) legislated scope-of-practice guidelines (e.g., Ethiopia’s model), (2) mobile supervision platforms (e.g., WhatsApp consults), and (3) NPAP integration into national surgical plans. These findings inform WHO strategies for conflict-affected states. • Low-income countries face severe anaesthesiologist shortages, relying on non-physician providers (NPAPs) for most essential procedures. • Unregulated NPAP practice in fragile and conflict-affected settings risks patient safety, but quantitative evidence on outcomes is scarce. • First quantitative audit in Sudan: NPAPs independently managed 46% of cases (718/1,559), with 2.8× higher adverse events in unsupervised care (34% vs. 12%). • Systemic gaps identified: 94% of adverse events unreported, 0% NPAP access to continuing education, highlighting a broken clinical safety loop. • Urges legislation of NPAP scope-of-practice (modelled on Ethiopia) and mobile supervision (e.g., WhatsApp consults, proven in other low-resource settings). • Informs WHO’s Surgical Care in Emergencies framework and humanitarian response strategies for fragile states.