ArticleBMJ global health2026
The effect of deploying non-physician anaesthesia providers on surgical access and capacity across Nepal's primary and secondary government hospitals: a quasi-experimental mixed methods study.
Article in BMJ global health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundThe lack of skilled healthcare workers limits access to surgical care, with the greatest disparities in low- and middle-income countries. In Nepal, the 1-year anaesthesia assistant (AA) programme trains non-physician cadres in anaesthesia delivery to address this gap. We evaluated the deployment of AAs in primary and secondary government hospitals in Nepal during 2008/2009 to 2023/2024 on hospitals' ability to perform any major surgery and the number of major surgeries performed.
methodsQuasi-experimental mixed methods were employed. A two-way fixed effects regression model was used to assess surgery availability, and a staggered difference-in-difference approach was used to estimate the average treatment effect of AA deployment on surgical volume. Qualitative interviews were conducted in seven purposefully sampled hospitals to expand contextual factors not captured in the quantitative data. Results were triangulated.
resultsOf 98 government hospitals, 84 (85.7%) received an AA during the study period, contributing 330 pre-AA and 651 post-AA hospital-year observations, defined as a hospital's major surgery data in a given year. Hospitals were 45.4 times more likely to be performing any major surgery after AA deployment (adjusted OR (aOR)=45.40, 95% CI 23.48 to 92.15). AA deployment was associated with a threefold increase in the odds of performing Caesarean sections (CSs) compared with non-CS major surgeries (aOR=3.46; 95% CI 3.03 to 4.07). Among hospitals performing major surgery, hospitals performed an average of 99.94 (average treatment effect on the treated (ATT)=99.94, 95% CI 45.90 to 153.98) additional major surgeries per year after AA deployment. Qualitative interviews highlighted AAs' role expanding surgical services by enabling critical procedures, reducing referrals, increasing equitable surgical access and enhancing team efficiency.
conclusionAAs appear to enhance hospitals' ability to perform major surgeries, specifically CSs, while decreasing patient referrals and increasing surgical capacity. These results underscore the role of non-physician anaesthesia providers in surgical access in resource-limited settings.
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