Global anesthesia care: a systematic review of capacity, workforce, and access

Safe anesthesia is essential for surgical, obstetric, and diagnostic care; however, substantial global disparities persist in capacity, workforce, and access. This systematic review aimed to map and synthesize the available evidence on structural gaps in anesthesia systems and to contextualize workforce inequities through complementary geospatial analysis. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA 2020). We systematically searched PubMed/MEDLINE, Scopus, and Web of Science from database inception to 19th February 2026, without restrictions on language or geographic region. Eligible sources included observational studies, institutional capacity assessments, health system analyses, and international comparative reports that provided data on anesthesia workforce, infrastructure, service capacity, access, or perioperative outcomes. A total of 1,946 records were identified, of which 51 studies from more than 25 countries met the inclusion criteria, predominantly representing low- and lower-middle-income settings. Commonly reported capacity gaps included unreliable electricity and oxygen supply, limited monitoring capabilities, insufficient post-anesthesia and intensive care resources, and low surgical volumes. Workforce shortages were marked, with anesthesiologist density ranging from 0.02 to 0.39 per 100,000 population in low-income countries, accompanied by a heavy reliance on non-physician providers and pronounced urban-rural disparities. Perioperative morbidity and mortality were consistently associated with resource-constrained settings. Geospatial analysis revealed substantial global variation in physician anesthesia provider (PAP) density. Anesthesia care remains profoundly unequal worldwide, with findings predominantly reflecting limitations in sub-Saharan Africa. Addressing these disparities will require coordinated and sustained investments in workforce development, infrastructure, monitoring systems, training, and equitable national health planning. This study was registered in PROSPERO with identification number CRD420261385265.