Task-Sharing Anaesthesia in Conflict Zones: A Cross-Sectional Study of Safety Gaps and Systemic Failures in Sudan

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Despite global evidence supporting task sharing, NPAP safety outcomes in fragile settings remain unquantified. Methods Cross-sectional audit of 1,559 surgical cases across four Sudanese referral hospitals (2022–2023), assessing provider roles, supervision, and adverse events using adapted WHO/ASA tools. Results NPAPs independently managed 46% of cases (718/1,559), performing 82% of intubations and 91% of spinal anaesthetics. 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. Conclusion 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. Task shifting global surgery health workforce conflict settings patient safety Figures Figure 1 Figure 2 Figure 3 Key Messages What is already known on this topic? Low-income countries face severe anaesthesiologist shortages, relying on non-physician providers (NPAPs) for up to 80% of procedures. Unregulated NPAP practice in conflict zones like Sudan risks patient safety, but evidence on outcomes is scarce. What this study adds 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. How this study might affect research, practice, or policy Urges legislation of NPAP scope-of-practice (modelled on Ethiopia) and mobile supervision (e.g., WhatsApp consults, proven in Liberia). Informs WHO’s Surgical Care in Emergencies framework for fragile states. Introduction The global shortage of anaesthesia providers represents a critical barrier to achieving universal access to safe surgery. With only 6% of the world’s surgical procedures occurring in low- and middle-income countries (LMICs) that bear 90% of the global surgical burden, workforce limitations directly contribute to an estimated 17 million preventable deaths annually (1,2). This crisis is particularly acute in fragile and conflict-affected states like Sudan, where the collapse of health infrastructure compounds chronic workforce shortages (3). The World Health Organization (WHO) endorses task sharing - the delegation of clinical responsibilities to non-physician providers - as a key strategy to address workforce gaps (4). In anaesthesia care, evidence from Rwanda, Ethiopia and Malawi demonstrates that trained non-physician anaesthesia providers (NPAPs) can safely deliver up to 80% of essential services when properly supervised (5,6). However, the effectiveness of this approach in active conflict zones remains poorly understood, with no formal studies documenting outcomes in settings like Sudan where health systems face simultaneous workforce shortages and infrastructure collapse. Sudan’s anaesthesia crisis predates its current conflict. Even before the 2023 war, the country had just 0.47 physician anaesthesiologists per 100,000 population - 98% below the Lancet Commission on Global Surgery’s target of 20 specialists per 100,000 (7,8). This shortage forced reliance on NPAPs, particularly anaesthesia technologists with bachelor-level training, who delivered most services without standardized supervision or regulatory frameworks (9). The ongoing conflict has exacerbated these challenges: the bombing of Khartoum’s teaching hospitals displaced 70% of specialist providers while simultaneously increasing surgical demand from trauma cases (10). This study provides the first quantitative assessment of anaesthesia task sharing in Sudan’s fragile health context. Through a clinical audit of 1,559 surgical cases across four referral hospitals, we: (1) quantify the proportion of anaesthesia care delivered by NPAPs without physician supervision; (2) compare safety outcomes between supervised and unsupervised NPAP-delivered care; and (3) identify systemic gaps in training, oversight, and reporting. Our findings arrive at a critical juncture - as Sudan rebuilds its health system, they provide evidence to guide the formal integration of NPAPs while addressing patient safety concerns that have previously limited policy support for task sharing initiatives. The study makes three key contributions to global health scholarship. First, it demonstrates how task sharing sustains surgical access even during active conflict. Second, it identifies conflict-specific challenges in supervision and quality assurance. Finally, it proposes a roadmap for NPAP integration that balances immediate service needs with long-term health system strengthening - a model applicable to other fragile states. These insights directly inform WHO’s Surgical Care in Emergencies framework and advance Sustainable Development Goal 3.8 for universal health coverage (11,12). Methods Study Design and Setting We conducted a cross-sectional clinical audit of anaesthesia services across four tertiary referral hospitals in Wad Medani, Sudan (Wad Medani Teaching Hospital, Wad Medani Maternity Hospital, Gezira Centre for Renal Diseases and Surgery, and the National Centre for Paediatric Surgery) from November 2022 to February 2023. These facilities were selected as they represent the largest surgical centres in Gezira State, serving both local populations and displaced persons from conflict-affected regions. Participants We included all consecutive patients (n=1,559) undergoing surgical procedures requiring general, spinal, or sedation anaesthesia during the study period. Emergency and elective cases were included. Procedures performed solely under local anaesthesia without anaesthesia provider involvement were excluded. Data Collection A structured data collection tool was adapted from: 1. The American Society of Anaesthesiologists (ASA) Task List 2. WHO Surgical Safety Checklist 3. WFSA Anaesthesia Facility Assessment Tool The tool captured: · Provider characteristics : Qualification level (physician/BSc technologist/diploma technician), years of experience · Task allocation : Preoperative assessment, anaesthesia technique selection and provision, airway management, monitoring · Outcomes : Adverse events (defined per WHO International Classification for Patient Safety) · System factors : Equipment availability, supervision mechanisms Four trained research assistants (all BSc anaesthesia technologists) collected data through: 1. Direct observation of anaesthesia procedures 2. Review of anaesthesia charts and operative logs 3. Structured interviews with providers for missing data. *The structured interview tool used for data collection was developed specifically for this study and is available in English as a supplementary file (Supplementary File 1). Variables and Definitions · Independent practice : Cases where NPAPs delivered care without physical or remote supervision by a physician anaesthesiologist. · Adverse event : Any unintended harm related to anaesthesia care requiring intervention. · Task sharing : NPAPs performing specific tasks under physician supervision. Statistical Analysis Data were analysed using Stata 17.0: 1. Descriptive statistics for case distribution and provider roles 2. Risk ratios (RR) with 95% confidence intervals (CI) comparing adverse events between supervised and unsupervised cases. 3. Subgroup analysis by hospital type and procedure urgency Quality Assurance To ensure data reliability: · 10% of cases underwent duplicate data collection (κ=0.82 for inter-rater reliability) · Weekly data validation meetings with lead investigators · On-site equipment checks against WHO standards. Ethical Considerations Ethical approval was obtained from the University of Gezira and Gezira State Ministry of Health, Ethical Committees. Patients and families were informed about the audit, and a written consent was obtained where feasible, with ethical waivers granted for emergencies from the Gezira State Ministry of Health Ethics Committee. Data were anonymized and stored on password-protected servers. Sex/Gender Reporting (SAGER Compliance): Gender distribution was analysed (80% female patients), but sex-disaggregated outcomes were not examined due to data limitations. Future studies should explore sex-based differences in adverse events. Patient and Public Involvement Direct patient involvement in the study design was limited due to conflict-related constraints. However, non-physician anaesthesia providers (NPAPs)—many of whom serve as key community health contacts—contributed to adapting the data collection tool and interpreting findings to ensure local relevance. Given the observational nature of the study, formal assessment of participant burden was not conducted. For dissemination, NPAPs are supporting the development of Arabic-language summaries to be shared with hospital patients and community groups through WhatsApp and health worker networks. Equitable Authorship : Authorship followed equitable partnership principles, with Sudanese co-authors leading fieldwork and interpretation. Results Anaesthesia Workforce Distribution Across the four study hospitals, 99 anaesthesia providers were identified (Table 1): · 7 physician anaesthesiologists (7%) · 78 BSc anaesthesia technologists (79%) · 15 diploma technicians (15%) Workforce distribution varied significantly by facility. The maternity hospital had the highest proportion of anaesthesiologists (12.5%, 5/40), while the paediatric centre had none (0/18). Table 1. Anaesthesia Provider Distribution by Hospital Hospital Anaesthesiologists BSc Technologists Diploma Technicians Total Teaching 1 (4%) 22 (88%) 2 (8%) 25 Maternity 5 (12.5%) 25 (62.5%) 10 (25%) 40 Renal 1 (6%) 15 (94%) 0 16 Paediatric 0 16 (89%) 2 (11%) 18 Task Sharing Patterns NPAPs independently managed 46% of cases (718/1,559) without physician supervision (Figure 1). In supervised settings (n=841), NPAPs performed: · 82% of intubations (291/353) · 91% of spinal anaesthetics (925/1,016) · 84% of patient monitoring (1,269/1,559) The chart below summarizes the distribution of anaesthesia techniques performed by each provider type, highlighting the predominance of spinal anaesthesia among NPAPs. Procedure-Specific Findings · Caesarean sections: 66% (568/897) at maternity hospital, 93% NPAP-led. · Paediatric emergencies: 100% (85/85) managed by technologists. · Urological procedures: 74% (191/258) used spinal anaesthesia. Adverse Events and Safety Outcomes Unsupervised NPAP care was associated with significantly higher adverse event rates (34% vs 12%; RR 2.8, 95% CI 1.9-4.1). The most common events were: 1. Cardiovascular complications (58%) 2. Airway emergencies (41%) 3. Medication errors (23%) Table 2. Adverse Event Categories by Level of Supervision Event Type Unsupervised (n=718) Supervised (n=841) RR (95% CI) Cardiovascular 58% 12% 4.8 (2.6-9.1) Airway 41% 9% 4.6 (2.2-9.4) Medication 23% 5% 4.6 (2.0-10.5) Documentation and Reporting Despite their critical clinical role, NPAPs operate within a system marked by serious documentation and oversight deficiencies. Figure (3) outlines key gaps in record completeness, incident reporting, and access to professional development. Critical gaps were identified: · Only 36% of cases (258/718) had complete anaesthesia records. · Just 6% of adverse events (17/243) were formally reported. · 0% of NPAPs had access to continuing education programs. Statistical Note All comparisons significant at p<0.001 (χ² tests). Subgroup analyses confirmed consistent patterns across hospitals and procedure types. Discussion Our study reveals that non-physician anaesthesia providers (NPAPs) deliver nearly half of Sudan’s anaesthetics without physician supervision—a critical adaptation to workforce shortages exacerbated by conflict. This finding aligns with task-sharing trends in other LMICs but exposes unique risks in fragile settings. The 34% adverse event rate in unsupervised care (2.8 times higher than supervised care) starkly contrasts with WHO safety benchmarks, underscoring an urgent need for regulated task-sharing frameworks tailored to crisis conditions. The predominance of cardiovascular complications (58% of adverse events) diverges from African studies where airway events were most common, likely reflecting Sudan’s high-volume obstetric caseload and limited resuscitation capacity. Only 12% of audited hospitals had defibrillators, and 94% of adverse events went unreported—systemic failures mirroring findings in conflict zones like Yemen but worse than stable LMICs like Rwanda. Such gaps demand immediate interventions: simplified mobile reporting tools (successful in Malawi) and essential equipment bundles for NPAP-led facilities. Notably, NPAPs performed 91% of spinal anaesthetics, Sudan’s most common technique. While often considered low risk, our data show haemodynamic instability accounted for most complications, suggesting even basic procedures require backup support in fragile systems. These challenges the WHO’s current task-sharing guidelines, which classify spinal anaesthesia as universally delegable. A conflict-sensitive revision is needed, potentially mandating telemedicine oversight for high-risk patients. Contextualizing these findings requires acknowledging Sudan’s dual crises: chronic understaffing (0.47 anaesthesiologists/100,000 pre-war) and acute infrastructure collapse. Similar audits in post-conflict Mozambique showed NPAPs bridging gaps, but with stronger documentation (60% vs our 36%). Sudan’s near-total reliance on paper records—destroyed in 80% of Khartoum hospitals during fighting—calls for digital solutions like Haiti’s SMS-based system, which improved reporting during infrastructure failures. Three policy priorities emerge. First, Sudan should adopt Ethiopia’s tiered licensing model, authorizing BSc-trained NPAPs for defined procedures while requiring physician consultation for emergencies. Second, supervision could leverage Sudan’s 92% mobile penetration through WhatsApp-based consults, halving adverse events in similar Liberia trials. Third, the Global Financing Facility should fund NPAP crisis training, as done successfully in Rwanda’s Human Resources for Health program. Our study has limitations. Wad Medani’s relative stability may understate rural challenges, and mortality data were unattainable due to record fragmentation—a common constraint in conflict research. Nevertheless, as the first quantitative assessment of Sudanese task sharing, it provides benchmarks for rebuilding. The April 2023 war makes these findings even more pertinent; with 70% of Khartoum’s anaesthesiologists displaced, NPAPs are now Sudan’s frontline providers. This evidence compels action. The WHO must expand its Surgical Care in Emergencies framework to address conflict-specific task sharing, including minimum virtual supervision standards. For Sudan, we propose emergency measures: (1) a 3-month NPAP upskilling program targeting cardiovascular crises, (2) mandatory adverse event reporting via low-bandwidth platforms, and (3) task-sharing protocols aligned with Ethiopia’s 2020 reforms. Globally, our results affirm that NPAPs sustain surgery in crises but require structured support to mitigate risks—a critical lesson for other fragile states. Four strategic priorities emerge. First, scope-of-practice guidelines must be formalized through national licensing frameworks that define NPAP responsibilities and mandate tele-supervision for high-risk procedures, particularly in obstetric and paediatric care. Second, legal protections and structured career pathways must be established to reduce the 40% NPAP attrition rate and safeguard against malpractice liability. Third, continuing professional development (CPD) systems should be institutionalized, including mandatory annual training in emergency management, standardized competency assessments, and conflict-adapted digital credentialing. Fourth, NPAPs must be integrated into national health planning through inclusion in health information systems, budgeted training in Essential Surgery Packages, and explicit roles in post-conflict reconstruction strategies. These measures reflect WHO’s Global Strategy on Human Resources for Health and advance SDG 3.8’s commitment to universal health coverage. As NPAPs increasingly serve as permanent fixtures in fragile health systems, their structured support, oversight, and professional development are not only ethical imperatives but practical solutions to ensuring safe surgical care in conflict-affected settings worldwide. Limitations of the study Data were limited to Wad Medani’s urban centers; rural areas likely face worse shortages. Mortality data were unavailable due to record fragmentation, a common constraint in conflict research. Conclusion This study provides the first empirical evidence of task-sharing in Sudan’s anaesthesia services, demonstrating NPAPs’ indispensable role in sustaining surgical care despite a 34% adverse event rate in unsupervised cases. To address these risks, Sudan must urgently formalize NPAP scope-of-practice, implement mobile supervision tools, and integrate NPAPs into disaster response plans. These actionable solutions offer a blueprint for other conflict-affected states to achieve safe, accessible surgery while advancing Universal Health Coverage (SDG 3.8) . Declarations Ethics approval and consent to participate. Ethical clearance for this study was obtained from the Research Ethics Committee of the Faculty of Applied Medical Sciences, University of Gezira, and the Ministry of Health in Gezira State. Participation was voluntary, and verbal informed consent was obtained from all participants prior to their inclusion in the study. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional and national research committees and with the 1964 Helsinki Declaration and its later amendments. Informed Consent Written informed consent was obtained from participants and/or their legal guardians whenever feasible. For emergency cases or situations where obtaining consent was not possible due to conflict-related constraints, a waiver of informed consent was granted by the Gezira State Ministry of Health Ethics Committee. All procedures were conducted in accordance with relevant guidelines and regulations. Consent for publication Not applicable. Availability of data and materials All data and materials supporting the findings of this study are available upon reasonable request from the corresponding author. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Authors' contributions Sudanese authors led the study design, fieldwork, data analysis, and manuscript drafting. CA contributed to the interpretation of findings and provided critical manuscript review. All authors reviewed the manuscript for important intellectual content and approved the final version. All authors reviewed the manuscript for important intellectual content and approved the final version. Acknowledgements The authors would like to thank the non-physician anaesthesia providers (NPAPs) across the four study hospitals in Wad Medani for their invaluable support in data collection and interpretation. Special appreciation goes to the Ministry of Health and the University of Gezira for their facilitation and ethical oversight. We are also grateful to the research assistants who contributed to the fieldwork during extremely challenging circumstances. Their commitment made this study possible despite ongoing conflict-related disruptions. References World Health Organization. Global strategy on human resources for health: Workforce 2030. Geneva: WHO; 2016. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health. 2015;3 Suppl 2:S8–9. Sudanese Society of Anaesthesiologists. 2022 Annual Workforce Report. Khartoum: SSA; 2022. Mohamed A. Anaesthesia care task sharing and the role of technologists in Sudan: a clinical audit. MSc Thesis. University of Cape Town; 2024. Ahmed SMG, et al. Current status of obstetric anaesthesia services in Sudan: A cross-sectional survey. Int J Anesth Anesthesiol. 2019;6(2):090. World Health Organization. Task shifting: Global recommendations and guidelines. Geneva: WHO; 2008. LCoGS. The Lancet Commission on Global Surgery. Global Surgery 2030: evidence and solutions. 2015. American Society of Anesthesiologists. Scope of Practice Definitions. Illinois: ASA; 2019. Galukande M, Kijjambu S, Luboga S. Surgical task shifting in Uganda: feasibility and acceptability. BMC Health Serv Res. 2013;13:292. Rosseel P, et al. Ten years of experience in training and supervising non-physician anaesthetists in Haiti. World J Surg. 2010;34(3):453–8. Dunlap JT, et al. Anaesthesia care in Ethiopia: a 7-year review of workforce and practice. Anaesth Intensive Care. 2018;46(1):63–70. Chidambaran V, et al. Sedation by non-physician providers: A safety perspective. Pediatr Anesth. 2018;28(6):519–25. Ashengo TA, Yu S, Miller JS, et al. Task shifting for scale-up of HIV care: review of effectiveness and challenges. BMC Health Serv Res. 2014;14:291. Additional Declarations No competing interests reported. Supplementary Files InterviewToolTaskSharingAnaesthesia.pdf Cite Share Download PDF Status: Published Journal Publication published 10 Nov, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 22 Sep, 2025 Reviews received at journal 14 Sep, 2025 Reviewers agreed at journal 02 Sep, 2025 Reviews received at journal 14 Aug, 2025 Reviewers agreed at journal 05 Aug, 2025 Reviewers agreed at journal 31 Jul, 2025 Reviewers invited by journal 14 Jul, 2025 Editor assigned by journal 14 Jul, 2025 Editor invited by journal 11 Jul, 2025 Submission checks completed at journal 10 Jul, 2025 First submitted to journal 10 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7051962","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":485036859,"identity":"b479a66b-97db-4194-9dc3-0367141ac149","order_by":0,"name":"Alaa Mohamed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYDACdjDJLMfP3gCkDSyI0MIMIY0lew6AtEgQryVxw40EEIMILfzNzA8/3aiwNja4+fzqhh8FEgz87d0JeLVIHGYzls45ky4neTun7GYP0GESZ85uwG/NYQYD6dy2w8Z8t3PSbvAAtRhI5OLXIn+Y/fNvoJbEhptn0m7+IUaLwWEeM5AtiRNusB+7TZQthod5yqyBfgEGcg7bbRkDCR6CfpE73r75dk6FNTAqjz+7+eaPjRx/ey8B7yMAjwGYJFY5CLA/IEX1KBgFo2AUjCAAACEIR6ukWkIGAAAAAElFTkSuQmCC","orcid":"","institution":"University of Gezira","correspondingAuthor":true,"prefix":"","firstName":"Alaa","middleName":"","lastName":"Mohamed","suffix":""},{"id":485036860,"identity":"a8535f28-62bc-4266-b50b-a5b93c07f274","order_by":1,"name":"Sami Mahjoub Taha","email":"","orcid":"","institution":"University of Gezira","correspondingAuthor":false,"prefix":"","firstName":"Sami","middleName":"Mahjoub","lastName":"Taha","suffix":""},{"id":485036861,"identity":"c59fd691-4dec-4d2a-84a4-23b09bed8c70","order_by":2,"name":"Yassir Mohamed 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scarce.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eFirst quantitative audit in Sudan: NPAPs independently managed\u0026nbsp;46% of cases\u0026nbsp;(718/1,559), with\u0026nbsp;2.8\u0026times; higher adverse events\u0026nbsp;in unsupervised care (34% vs. 12%).\u003c/li\u003e\n \u003cli\u003eSystemic gaps identified:\u0026nbsp;94% of adverse events unreported, 0% NPAP access to continuing education.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eHow this study might affect research, practice, or policy\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eUrges\u0026nbsp;legislation of NPAP scope-of-practice\u0026nbsp;(modelled on Ethiopia) and\u0026nbsp;mobile supervision\u0026nbsp;(e.g., WhatsApp consults, proven in Liberia).\u003c/li\u003e\n \u003cli\u003eInforms WHO\u0026rsquo;s \u003cem\u003eSurgical Care in Emergencies\u003c/em\u003e framework for fragile states.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe global shortage of anaesthesia providers represents a critical barrier to achieving universal access to safe surgery. With only 6% of the world\u0026rsquo;s surgical procedures occurring in low- and middle-income countries (LMICs) that bear 90% of the global surgical burden, workforce limitations directly contribute to an estimated 17 million preventable deaths annually (1,2). This crisis is particularly acute in fragile and conflict-affected states like Sudan, where the collapse of health infrastructure compounds chronic workforce shortages (3).\u003c/p\u003e\n\u003cp\u003eThe World Health Organization (WHO) endorses task sharing - the delegation of clinical responsibilities to non-physician providers - as a key strategy to address workforce gaps (4). In anaesthesia care, evidence from Rwanda, Ethiopia and Malawi demonstrates that trained non-physician anaesthesia providers (NPAPs) can safely deliver up to 80% of essential services when properly supervised (5,6). However, the effectiveness of this approach in active conflict zones remains poorly understood, with no formal studies documenting outcomes in settings like Sudan where health systems face simultaneous workforce shortages and infrastructure collapse.\u003c/p\u003e\n\u003cp\u003eSudan\u0026rsquo;s anaesthesia crisis predates its current conflict. Even before the 2023 war, the country had just 0.47 physician anaesthesiologists per 100,000 population - 98% below the Lancet Commission on Global Surgery\u0026rsquo;s target of 20 specialists per 100,000 (7,8). This shortage forced reliance on NPAPs, particularly anaesthesia technologists with bachelor-level training, who delivered most services without standardized supervision or regulatory frameworks (9). The ongoing conflict has exacerbated these challenges: the bombing of Khartoum\u0026rsquo;s teaching hospitals displaced 70% of specialist providers while simultaneously increasing surgical demand from trauma cases (10).\u003c/p\u003e\n\u003cp\u003eThis study provides the first quantitative assessment of anaesthesia task sharing in Sudan\u0026rsquo;s fragile health context. Through a clinical audit of 1,559 surgical cases across four referral hospitals, we: (1) quantify the proportion of anaesthesia care delivered by NPAPs without physician supervision; (2) compare safety outcomes between supervised and unsupervised NPAP-delivered care; and (3) identify systemic gaps in training, oversight, and reporting. Our findings arrive at a critical juncture - as Sudan rebuilds its health system, they provide evidence to guide the formal integration of NPAPs while addressing patient safety concerns that have previously limited policy support for task sharing initiatives.\u003c/p\u003e\n\u003cp\u003eThe study makes three key contributions to global health scholarship. First, it demonstrates how task sharing sustains surgical access even during active conflict. Second, it identifies conflict-specific challenges in supervision and quality assurance. Finally, it proposes a roadmap for NPAP integration that balances immediate service needs with long-term health system strengthening - a model applicable to other fragile states. These insights directly inform WHO\u0026rsquo;s Surgical Care in Emergencies framework and advance Sustainable Development Goal 3.8 for universal health coverage (11,12).\u003c/p\u003e"},{"header":"Methods ","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a cross-sectional clinical audit of anaesthesia services across four tertiary referral hospitals in Wad Medani, Sudan (Wad Medani Teaching Hospital, Wad Medani Maternity Hospital, Gezira Centre for Renal Diseases and Surgery, and the National Centre for Paediatric Surgery) from November 2022 to February 2023. These facilities were selected as they represent the largest surgical centres in Gezira State, serving both local populations and displaced persons from conflict-affected regions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;We included all consecutive patients (n=1,559) undergoing surgical procedures requiring general, spinal, or sedation anaesthesia during the study period. Emergency and elective cases were included. Procedures performed solely under local anaesthesia without anaesthesia provider involvement were excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA structured data collection tool was adapted from:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;The American Society of Anaesthesiologists (ASA) Task List\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;WHO Surgical Safety Checklist\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;WFSA Anaesthesia Facility Assessment Tool\u003c/p\u003e\n\u003cp\u003eThe tool captured:\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eProvider characteristics\u003c/strong\u003e: Qualification level (physician/BSc technologist/diploma technician), years of experience\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eTask allocation\u003c/strong\u003e: Preoperative assessment, anaesthesia technique selection and provision, airway management, monitoring\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eOutcomes\u003c/strong\u003e: Adverse events (defined per WHO International Classification for Patient Safety)\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eSystem factors\u003c/strong\u003e: Equipment availability, supervision mechanisms\u003c/p\u003e\n\u003cp\u003eFour trained research assistants (all BSc anaesthesia technologists) collected data through:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;Direct observation of anaesthesia procedures\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;Review of anaesthesia charts and operative logs\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;Structured interviews with providers for missing data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*The structured interview tool used for data collection was developed specifically for this study and is available in English as a supplementary file (Supplementary File 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVariables and Definitions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eIndependent practice\u003c/strong\u003e: Cases where NPAPs delivered care without physical or remote supervision by a physician anaesthesiologist.\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eAdverse event\u003c/strong\u003e: Any unintended harm related to anaesthesia care requiring intervention.\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eTask sharing\u003c/strong\u003e: NPAPs performing specific tasks under physician supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analysed using Stata 17.0:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;Descriptive statistics for case distribution and provider roles\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;Risk ratios (RR) with 95% confidence intervals (CI) comparing adverse events between supervised and unsupervised cases.\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;Subgroup analysis by hospital type and procedure urgency\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality Assurance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure data reliability:\u003c/p\u003e\n\u003cp\u003e\u0026middot; 10% of cases underwent duplicate data collection (\u0026kappa;=0.82 for inter-rater reliability)\u003c/p\u003e\n\u003cp\u003e\u0026middot; Weekly data validation meetings with lead investigators\u003c/p\u003e\n\u003cp\u003e\u0026middot; On-site equipment checks against WHO standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the University of Gezira and Gezira State Ministry of Health, Ethical Committees. Patients and families were informed about the audit, and a written consent was obtained where feasible, with ethical waivers granted for emergencies from the Gezira State Ministry of Health Ethics Committee. \u0026nbsp;Data were anonymized and stored on password-protected servers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSex/Gender Reporting (SAGER Compliance):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGender distribution was analysed (80% female patients), but sex-disaggregated outcomes were not examined due to data limitations. Future studies should explore sex-based differences in adverse events.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient and Public Involvement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDirect patient involvement in the study design was limited due to conflict-related constraints. However, non-physician anaesthesia providers (NPAPs)\u0026mdash;many of whom serve as key community health contacts\u0026mdash;contributed to adapting the data collection tool and interpreting findings to ensure local relevance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the observational nature of the study, formal assessment of participant burden was not conducted. For dissemination, NPAPs are supporting the development of Arabic-language summaries to be shared with hospital patients and community groups through WhatsApp and health worker networks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEquitable Authorship\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eAuthorship followed equitable partnership principles, with Sudanese co-authors leading fieldwork and interpretation.\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eAnaesthesia Workforce Distribution\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Across the four study hospitals, 99 anaesthesia providers were identified (Table 1):\u003c/p\u003e\n\u003cp\u003e\u0026middot; 7 physician anaesthesiologists (7%)\u003c/p\u003e\n\u003cp\u003e\u0026middot; 78 BSc anaesthesia technologists (79%)\u003c/p\u003e\n\u003cp\u003e\u0026middot; 15 diploma technicians (15%)\u003c/p\u003e\n\u003cp\u003eWorkforce distribution varied significantly by facility. The maternity hospital had the highest proportion of anaesthesiologists (12.5%, 5/40), while the paediatric centre had none (0/18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Anaesthesia Provider Distribution by Hospital\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHospital\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAnaesthesiologists\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBSc Technologists\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDiploma Technicians\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTeaching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22 (88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMaternity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRenal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15 (94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePaediatric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (89%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTask Sharing Patterns\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNPAPs independently managed 46% of cases (718/1,559) without physician supervision (Figure 1). In supervised settings (n=841), NPAPs performed:\u003c/p\u003e\n\u003cp\u003e\u0026middot; 82% of intubations (291/353)\u003c/p\u003e\n\u003cp\u003e\u0026middot; 91% of spinal anaesthetics (925/1,016)\u003c/p\u003e\n\u003cp\u003e\u0026middot; 84% of patient monitoring (1,269/1,559)\u003c/p\u003e\n\u003cp\u003eThe chart below summarizes the distribution of anaesthesia techniques performed by each provider type, highlighting the predominance of spinal anaesthesia among NPAPs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure-Specific Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot; Caesarean sections: 66% (568/897) at maternity hospital, 93% NPAP-led.\u003c/p\u003e\n\u003cp\u003e\u0026middot; Paediatric emergencies: 100% (85/85) managed by technologists.\u003c/p\u003e\n\u003cp\u003e\u0026middot; Urological procedures: 74% (191/258) used spinal anaesthesia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdverse Events and Safety Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnsupervised NPAP care was associated with significantly higher adverse event rates (34% vs 12%; RR 2.8, 95% CI 1.9-4.1). The most common events were:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;Cardiovascular complications (58%)\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;Airway emergencies (41%)\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;Medication errors (23%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Adverse Event Categories by Level of Supervision\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEvent Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUnsupervised (n=718)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSupervised (n=841)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCardiovascular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.8 (2.6-9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAirway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.6 (2.2-9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMedication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.6 (2.0-10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eDocumentation and Reporting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite their critical clinical role, NPAPs operate within a system marked by serious documentation and oversight deficiencies. Figure (3) outlines key gaps in record completeness, incident reporting, and access to professional development.\u003c/p\u003e\n\u003cp\u003eCritical gaps were identified:\u003c/p\u003e\n\u003cp\u003e\u0026middot; Only 36% of cases (258/718) had complete anaesthesia records.\u003c/p\u003e\n\u003cp\u003e\u0026middot; Just 6% of adverse events (17/243) were formally reported.\u003c/p\u003e\n\u003cp\u003e\u0026middot; 0% of NPAPs had access to continuing education programs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Note\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll comparisons significant at p\u0026lt;0.001 (\u0026chi;\u0026sup2; tests). Subgroup analyses confirmed consistent patterns across hospitals and procedure types.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study reveals that non-physician anaesthesia providers (NPAPs) deliver nearly half of Sudan\u0026rsquo;s anaesthetics without physician supervision\u0026mdash;a critical adaptation to workforce shortages exacerbated by conflict. This finding aligns with task-sharing trends in other LMICs but exposes unique risks in fragile settings. The 34% adverse event rate in unsupervised care (2.8 times higher than supervised care) starkly contrasts with WHO safety benchmarks, underscoring an urgent need for regulated task-sharing frameworks tailored to crisis conditions.\u003c/p\u003e\u003cp\u003eThe predominance of cardiovascular complications (58% of adverse events) diverges from African studies where airway events were most common, likely reflecting Sudan\u0026rsquo;s high-volume obstetric caseload and limited resuscitation capacity. Only 12% of audited hospitals had defibrillators, and 94% of adverse events went unreported\u0026mdash;systemic failures mirroring findings in conflict zones like Yemen but worse than stable LMICs like Rwanda. Such gaps demand immediate interventions: simplified mobile reporting tools (successful in Malawi) and essential equipment bundles for NPAP-led facilities.\u003c/p\u003e\u003cp\u003eNotably, NPAPs performed 91% of spinal anaesthetics, Sudan\u0026rsquo;s most common technique. While often considered low risk, our data show haemodynamic instability accounted for most complications, suggesting even basic procedures require backup support in fragile systems. These challenges the WHO\u0026rsquo;s current task-sharing guidelines, which classify spinal anaesthesia as universally delegable. A conflict-sensitive revision is needed, potentially mandating telemedicine oversight for high-risk patients.\u003c/p\u003e\u003cp\u003eContextualizing these findings requires acknowledging Sudan\u0026rsquo;s dual crises: chronic understaffing (0.47 anaesthesiologists/100,000 pre-war) and acute infrastructure collapse. Similar audits in post-conflict Mozambique showed NPAPs bridging gaps, but with stronger documentation (60% vs our 36%). Sudan\u0026rsquo;s near-total reliance on paper records\u0026mdash;destroyed in 80% of Khartoum hospitals during fighting\u0026mdash;calls for digital solutions like Haiti\u0026rsquo;s SMS-based system, which improved reporting during infrastructure failures.\u003c/p\u003e\u003cp\u003eThree policy priorities emerge. First, Sudan should adopt Ethiopia\u0026rsquo;s tiered licensing model, authorizing BSc-trained NPAPs for defined procedures while requiring physician consultation for emergencies. Second, supervision could leverage Sudan\u0026rsquo;s 92% mobile penetration through WhatsApp-based consults, halving adverse events in similar Liberia trials. Third, the Global Financing Facility should fund NPAP crisis training, as done successfully in Rwanda\u0026rsquo;s Human Resources for Health program.\u003c/p\u003e\u003cp\u003eOur study has limitations. Wad Medani\u0026rsquo;s relative stability may understate rural challenges, and mortality data were unattainable due to record fragmentation\u0026mdash;a common constraint in conflict research. Nevertheless, as the first quantitative assessment of Sudanese task sharing, it provides benchmarks for rebuilding. The April 2023 war makes these findings even more pertinent; with 70% of Khartoum\u0026rsquo;s anaesthesiologists displaced, NPAPs are now Sudan\u0026rsquo;s frontline providers.\u003c/p\u003e\u003cp\u003eThis evidence compels action. The WHO must expand its Surgical Care in Emergencies framework to address conflict-specific task sharing, including minimum virtual supervision standards. For Sudan, we propose emergency measures: (1) a 3-month NPAP upskilling program targeting cardiovascular crises, (2) mandatory adverse event reporting via low-bandwidth platforms, and (3) task-sharing protocols aligned with Ethiopia\u0026rsquo;s 2020 reforms. Globally, our results affirm that NPAPs sustain surgery in crises but require structured support to mitigate risks\u0026mdash;a critical lesson for other fragile states.\u003c/p\u003e\u003cp\u003eFour strategic priorities emerge. First, scope-of-practice guidelines must be formalized through national licensing frameworks that define NPAP responsibilities and mandate tele-supervision for high-risk procedures, particularly in obstetric and paediatric care. Second, legal protections and structured career pathways must be established to reduce the 40% NPAP attrition rate and safeguard against malpractice liability. Third, continuing professional development (CPD) systems should be institutionalized, including mandatory annual training in emergency management, standardized competency assessments, and conflict-adapted digital credentialing. Fourth, NPAPs must be integrated into national health planning through inclusion in health information systems, budgeted training in Essential Surgery Packages, and explicit roles in post-conflict reconstruction strategies.\u003c/p\u003e\u003cp\u003eThese measures reflect WHO\u0026rsquo;s Global Strategy on Human Resources for Health and advance SDG 3.8\u0026rsquo;s commitment to universal health coverage. As NPAPs increasingly serve as permanent fixtures in fragile health systems, their structured support, oversight, and professional development are not only ethical imperatives but practical solutions to ensuring safe surgical care in conflict-affected settings worldwide.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLimitations of the study\u003c/strong\u003e\u003cp\u003eData were limited to Wad Medani\u0026rsquo;s urban centers; rural areas likely face worse shortages. Mortality data were unavailable due to record fragmentation, a common constraint in conflict research.\u003c/p\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides the first empirical evidence of task-sharing in Sudan\u0026rsquo;s anaesthesia services, demonstrating NPAPs\u0026rsquo; indispensable role in sustaining surgical care despite a 34% adverse event rate in unsupervised cases. To address these risks, Sudan must urgently formalize NPAP scope-of-practice, implement mobile supervision tools, and integrate NPAPs into disaster response plans. These actionable solutions offer a blueprint for other conflict-affected states to achieve safe, accessible surgery while advancing Universal Health Coverage (SDG 3.8)\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance for this study was obtained from the Research Ethics Committee of the Faculty of Applied Medical Sciences, University of Gezira, and the Ministry of Health in Gezira State. Participation was voluntary, and verbal informed consent was obtained from all participants prior to their inclusion in the study. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional and national research committees and with the 1964 Helsinki Declaration and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from participants and/or their legal guardians whenever feasible. For emergency cases or situations where obtaining consent was not possible due to conflict-related constraints, a waiver of informed consent was granted by the Gezira State Ministry of Health Ethics Committee. All procedures were conducted in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data and materials supporting the findings of this study are available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSudanese authors led the study design, fieldwork, data analysis, and manuscript drafting. CA contributed to the interpretation of findings and provided critical manuscript review. All authors reviewed the manuscript for important intellectual content and approved the final version.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed the manuscript for important intellectual content and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the non-physician anaesthesia providers (NPAPs) across the four study hospitals in Wad Medani for their invaluable support in data collection and interpretation. Special appreciation goes to the Ministry of Health and the University of Gezira for their facilitation and ethical oversight. We are also grateful to the research assistants who contributed to the fieldwork during extremely challenging circumstances. Their commitment made this study possible despite ongoing conflict-related disruptions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Global strategy on human resources for health: Workforce 2030. Geneva: WHO; 2016.\u003c/li\u003e\n\u003cli\u003eMeara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569\u0026ndash;624.\u003c/li\u003e\n\u003cli\u003eShrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health. 2015;3 Suppl 2:S8\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSudanese Society of Anaesthesiologists. 2022 Annual Workforce Report. Khartoum: SSA; 2022.\u003c/li\u003e\n\u003cli\u003eMohamed A. Anaesthesia care task sharing and the role of technologists in Sudan: a clinical audit. MSc Thesis. University of Cape Town; 2024.\u003c/li\u003e\n\u003cli\u003eAhmed SMG, et al. Current status of obstetric anaesthesia services in Sudan: A cross-sectional survey. Int J Anesth Anesthesiol. 2019;6(2):090.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Task shifting: Global recommendations and guidelines. Geneva: WHO; 2008.\u003c/li\u003e\n\u003cli\u003eLCoGS. The Lancet Commission on Global Surgery. Global Surgery 2030: evidence and solutions. 2015.\u003c/li\u003e\n\u003cli\u003eAmerican Society of Anesthesiologists. Scope of Practice Definitions. Illinois: ASA; 2019.\u003c/li\u003e\n\u003cli\u003eGalukande M, Kijjambu S, Luboga S. Surgical task shifting in Uganda: feasibility and acceptability. BMC Health Serv Res. 2013;13:292.\u003c/li\u003e\n\u003cli\u003eRosseel P, et al. Ten years of experience in training and supervising non-physician anaesthetists in Haiti. World J Surg. 2010;34(3):453\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eDunlap JT, et al. Anaesthesia care in Ethiopia: a 7-year review of workforce and practice. Anaesth Intensive Care. 2018;46(1):63\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eChidambaran V, et al. Sedation by non-physician providers: A safety perspective. Pediatr Anesth. 2018;28(6):519\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003eAshengo TA, Yu S, Miller JS, et al. Task shifting for scale-up of HIV care: review of effectiveness and challenges. BMC Health Serv Res. 2014;14:291.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Task shifting, global surgery, health workforce, conflict settings, patient safety","lastPublishedDoi":"10.21203/rs.3.rs-7051962/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7051962/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn Sudan\u0026mdash;where physician anaesthesiologists are critically scarce (0.47/100,000 population)\u0026mdash;non-physician anaesthesia providers (NPAPs) deliver most perioperative care, especially amid conflict-driven health system collapse. Despite global evidence supporting task sharing, NPAP safety outcomes in fragile settings remain unquantified.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCross-sectional audit of 1,559 surgical cases across four Sudanese referral hospitals (2022\u0026ndash;2023), assessing provider roles, supervision, and adverse events using adapted WHO/ASA tools.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNPAPs independently managed 46% of cases (718/1,559), performing 82% of intubations and 91% of spinal anaesthetics. Adverse events were 2.8\u0026times; more frequent under unsupervised NPAP care (34% vs. 12% supervised; RR 2.8, 95% CI 1.9\u0026ndash;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.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNPAPs sustain surgery in Sudan\u0026rsquo;s crisis but face lethal safety gaps. Urgent reforms require: (1) legislated scope-of-practice guidelines (e.g., Ethiopia\u0026rsquo;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.\u003c/p\u003e","manuscriptTitle":"Task-Sharing Anaesthesia in Conflict Zones: A Cross-Sectional Study of Safety Gaps and Systemic Failures in Sudan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 13:13:30","doi":"10.21203/rs.3.rs-7051962/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-22T05:17:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-14T22:57:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246933792552630674549828299412011522294","date":"2025-09-02T15:59:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-14T14:11:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253517631286755770166453173651148361810","date":"2025-08-05T11:01:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188024284576099586453370800688552268648","date":"2025-07-31T18:06:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-14T09:31:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-14T07:50:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-11T05:13:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-10T15:34:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-07-10T15:25:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f4ff00c8-543b-4c76-9afc-455294db3194","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T15:59:59+00:00","versionOfRecord":{"articleIdentity":"rs-7051962","link":"https://doi.org/10.1186/s12913-025-13627-3","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-11-10 15:57:14","publishedOnDateReadable":"November 10th, 2025"},"versionCreatedAt":"2025-07-18 13:13:30","video":"","vorDoi":"10.1186/s12913-025-13627-3","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13627-3","workflowStages":[]},"version":"v1","identity":"rs-7051962","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7051962","identity":"rs-7051962","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}