Half the world population lacks access to life-saving surgery when needed, nine out of ten in lower income countries. The Global Surgery movement has emerged from this appalling figure, driven by the academia and countries engaged in drastically scaling up their surgical capacity. For the last five years, they have built up the evidence needed to implement safe and affordable surgical and anesthesia care. But on which side should the scale tilt – safety, or affordability – is a most pressing issue regarding the anesthesia workforce, regarded as a most critical challenge to surgical planning. Owing to the unsustainable time and cost of training thousands of physicians in countries with the lowest health expenditures, the recourse to task-shifting of medical prerogatives to non-physicians appears as a pragmatic means although, while the WHO endorses the paradigm, part of the medical literature suggests that it is unsafe. Much of this debate has been polarized by a dichotomy between anesthesiologists and “non-physician anesthesia providers”, a seemingly consistent category which actually encompasses very diverse professional cadres, from high school graduates trained on the job to doctorate holders. No study has compared these heterogeneous models of providers in regards to safety and efficiency, raising the question I have intended to answer: can the characterization of non-physician providers inform policy-makers with evidence-based pathways to scale up the anesthesia workforce in lower-income countries?

In the present study, I have aimed to provide an exploratory groundwork weighing scientific evidence with pragmatic implications. Through a literature review investigating surgical outcomes associated with different anesthesia professionals, I have substantiated that reliance on non-physicians is no mere “stop-gap” strategy for poor countries, and how insufficient training is more detrimental than a non-medical background. I have then hypothesized that improving the non-physician terminology is necessary to inform not if, but under what conditions, they can be considered safe and efficient. For this purpose, I used a cross-sectional design to assess the anesthesia workforce in lower-income countries, and an ecological analysis to search for associations between national-level surgical outcomes and anesthesia workforce variables. Finally, by compiling the literature, mapping their geographical distribution and analyzing their training patterns, I managed to stratify non-physician anesthesia providers into “types”. (...)