Dr Emma Mutio is a Pediatric Anaesthesiologist from Kenya and the Financial Secretary of the Pan African Association of Cleft Lip and Palate (PAACLIP)
September 17 marks World Patient Safety Day. This year's global theme, "Safe care for noncommunicable diseases," rightly turns attention to the long, chronic conditions that quietly claim the most lives worldwide.
In my practice of putting children to sleep during surgery, this year's campaign applies with equal force to a much shorter, more acute encounter between a child and a health system: the operating table.
For a child born with a cleft, a clubfoot, hydrocephalus, or a traumatic injury, the single most dangerous moment of their treatment is often not the surgery itself, but the anaesthesia that makes it possible.
Kenya illustrates an alarming gap in pediatric anesthesiology. Out ofthe country's roughly 52 million people, an estimated 18.5 million are children under 15 who represent more than a third of the population.
Kenyan clinical estimates suggest that up to 11% of child patients presenting to hospital require surgery, and that roughly 90% of these conditions are correctable if treated.
A Kenyan population-based study of more than 5,500 children found a prevalence of selected congenital surgical anomalies of 6.3 per 1,000 children, carrying a burden of 54 to 120 disability-adjusted life years per 1,000 children.
Trauma adds further pressure: in one Kenyan paediatric trauma registry, 6 out of 10 of children required an operation during their hospital stay, and a separate tertiary-hospital series put that figure above 70%.
Yet Kenya currently has an estimated 20 paediatric anaesthesiologists for the entire country, a severe shortage that itself needs formal validation against a national registry.
Set against 18.5 million children, that works out to roughly one paediatric anaesthesia specialist for every 925,000 children. This is not a workload calculation; it is an awakening illustration of how thin the safety net is.
Specialist capacity is also concentrated in a handful of referral hospitals, meaning most county facilities rely on general anaesthetists whose exposure to complex paediatric and neonatal cases varies widely.
Kenya's broader surgical, anaesthesia and obstetric workforce has been estimated at 2.35 per 100,000 people against a Lancet Commission on Global Surgery benchmark of 20 per 100,000.
This is not a uniquely Kenyan story. Across Sub-Saharan Africa, a shortage of trained personnel, inadequate infrastructure, and limited access to basic monitoring technology combine to put millions of children undergoing surgery at unnecessary risk, regardless of how skilled the surgeon holding the scalpel may be.
Cleft lip and palate is often framed as a "simple" condition, correctable with a single operation that costs a few hundred dollars. However, in my experience, cleft surgery is, in anaesthetic terms, one of the more demanding paediatric cases: it involves a shared, distorted airway, a young or newborn patient with a small physiological reserve, and a surgical field that sits directly on top of the breathing tube.
Airway compromise and delayed bleeding are the complications anaesthesia and surgical teams most fear in these children. Get the anaesthesia wrong, and a routine, life-changing procedure can become a life-threatening emergency.
This is precisely why cleft care has become one of the sharpest global test cases for paediatric anaesthesia safety, and why Smile Train, the world's largest cleft-focused organisation, has spent the past several years investing as heavily in anaesthesia safety as it has in surgery itself.
In Kenya alone, its network of around 21 to 22 partner hospitals has provided free treatment to more than 14,000 patients since the programme began in 2002. The Smile Train model has been toward the systems that make each of those operations safe, not just available.
Three interventions stand out. The first is Capnography. A capnograph is a device that monitors the carbon dioxide a patient exhales under anaesthesia. Without it, it’s like flying blind through a patient’s airway.
It is considered standard of care in wealthy countries because it is often the earliest warning sign that a child's airway has become obstructed or that ventilation has failed, sometimes minutes before a pulse oximeter would show a drop in oxygen.
Yet, it has historically been unavailable in most low- and middle-income hospitals, largely because commercial devices are too expensive, too fragile, or unsuited to paediatric use. Since 2020, the Smile Train-Lifebox Safe Surgery and Anaesthesia Initiative has worked to close that gap, developing and field-testing an affordable, durable capnograph built for low-resource operating theatres and paediatric patients.
Roll-outs are already under way, pairing each new device with hands-on training for the anaesthesia providers who will use it. The two organisations are advocating at global level for capnography to be adopted as a requirement in every operating theatre.
Second is investment in training the anaesthesia workforce, not just the surgeons. Smile Train Africa runs a suite of structured courses aimed squarely at the bottleneck identified above: the shortage of providers confident and competent in paediatric anaesthesia.
Its "Safe Anaesthesia Delivers Smiles" course is a four-day programme for anaesthesia providers of varying seniority who deliver anaesthesia for cleft surgery; its curriculum has been recognized by international anaesthesia bodies as a training standard for cleft anaesthesia in low- and middle-income countries, and has been translated into French and Portuguese to extend its reach across the continent.
A companion "Safe Pediatrics" course refreshes both physician and non-physician anaesthetists on airway management, fluid resuscitation, and paediatric life support.
Alongside The ELMA Foundation and Vanderbilt University Medical Center, Smile Train has also launched the Paediatric Anaesthesia Training in Africa fellowship, a year-long, WFSA-endorsed programme now running at institutions in Zambia, Nigeria and Uganda, designed to grow a home-grown specialist workforce rather than one dependent on visiting missions.
Third is building the infrastructure around the operating table. Smile Train has invested heavily in supporting over 100 pediatric operating rooms with stand-alone solar theatres that keep a child ‘breathing’ even in unpredictable power outages.
Safety in the operating room rests on systemic investment that determines whether a child survives their surgery. Smile Train's model offers a template for exactly this kind of investment. It will not, on its own, close the gap between 20 paediatric anaesthesiologists and the workforce Kenya's children actually need.
However, it demonstrates what closing that gap looks like in practice: capnographs in operating rooms, fellows completing year-long training programmes, and trained anaesthesia providers in the local communities or under-resourced settings.
Health financing and safety systems face the same underlying truth as monetary systems: resilience is built long before the crisis, through investment in institutions, standards and human capacity.
Kenya's own situation should expand the specialist paediatric anaesthesia workforce from roughly 20 toward at least 40 within three to five years; establish regional paediatric surgical hubs with proper anaesthesia, recovery and critical-care support; strengthen the skills of the non-specialist providers who deliver most paediatric anaesthesia in practice; and make perioperative safety from monitoring, trained staff, appropriate equipment, and a referral pathway- a non-negotiable national standard, not an aspiration reserved for referral hospitals in Nairobi.
Every child who needs surgery deserves not only access to an operating table, but the assurance that the anaesthesia keeping them safely asleep through it has been delivered by a trained provider, monitored by equipment built for their small bodies, and backed by a system designed to catch trouble before it becomes tragedy.
Dr Emma Mutio is a Pediatric Anaesthesiologist from Kenya and the Financial Secretary of the Pan African Association of Cleft Lip and Palate (PAACLIP)
