In the early 1800s surgery was a gruesome affair that most people avoided. In the absence of anaesthetic, patients experienced severe pain and trauma. Most surgeries took place in hospitals in a theatre setting, with an audience of 150 scholars who were learning how to become surgeons. The pain and humiliation experienced by patients , were compounded by the fact that post-operative infections accounted for 25% mortality rate of all patients who had surgery. It will not surprise you then to learn that surgery was an infrequent occurrence, for example in Massachusetts General Hospital in Boston which opened its doors in 1821, only one operation a week was performed up to 16th October 1846. It was on that day that one of the most significant events in the history of medicine took place with the first public demonstration of ether anaesthesia performed by Boston dentist William T.G. Morton, making pain-free surgery possible. After this historic event, operations not only increased significantly, but Morton's work spread quickly throughout the world and forever changed the surgical experience of patients. The news of the successful demonstration of the use of ether as an anaesthetic travelled fast to Ireland, with John MacDonnell, a surgeon from the Richmond Hospital using the anaesthetic on an 18 year old patient Mary Kane, from Drogheda, who underwent an amputation and when she woke up as the last sutures were put in place, declared that she had felt no pain, as was reported in a case report in the Dublin Medical Press on 6th January 1847. Over the past 150 years Anaesthesiology has developed into a sophisticated specialist branch of medicine concerned with the total perioperative care of patients, before , during and after surgery. Anaesthesiologists now comprise the largest single cohort of doctors in hospitals, with their role extending beyond the walls of the operating theatre to areas such as prehospital emergency medicine, intensive care units, transporting critically ill children and adults between care facilities and prehabilitation programmes to optimise patients for surgery. However even though in Ireland we would regard access to safe surgery and safe anaesthesia a basic human right, the same rights do not extend to all global citizens equally. Today five billion people, very often the poor, marginalized and rural , face impossible obstacles and for all practical purposes are excluded from what often is life-saving or disability-averting treatment. For many, it is simply a lack of money; for others, it is the tyranny of distance and poor transportation infrastructure. For the remainder who can afford it and can travel the distance, they arrive to find a feeble health care system with too few surgeons or anesthetists, no medications, no oxygen, and no blood for needed transfusion . On World Anaesthesia Day I would like to draw attention to ongoing efforts to build capacity and tackle inequities to improve universal access to safe, affordable, surgical and anaesthesia care when needed. Inequalities in child and adult mortality are large , are growing, and are related to several economic, social and health sector variables. Global efforts to deal with this problem require attention to the countries hardest hit, geographic concentrations and adopt a multidimensional approaches to develop. One such country is Malawi. 83.1% of Malawians live in rural areas. Rural populations, with a huge burden of surgical disease, have particularly poor access to safe, timely, and affordable surgical care in Malawi. District-level hospitals almost never have specialists in surgery, obstetrics, or anaesthesia. During medical school and internship, the general practitioners (GPs) who staff district hospitals have some training in surgical skills; for example, they are expected to be able to perform caesarean deliveries. However, these GPs are not trained in anaesthesia. In Malawi most anaesthesia care is provided by non-physician anaesthesia providers (NPAPs) , usually from a clinical officer/assistant medical officer or nursing background. However their numbers are low, and these essential workers are overworked and often leave rural practice. To date there are only 4 Malawian- trained Anesthesiologists, in a country with a population of 18.14 million. In 2008 our College, with support from Irish Aid, established a programme of educational assistance in the management of Trauma-related obstetric emergencies in Malawi with a focus on Thyolo and Chinadzulu District hospitals . The project was established to support health care workers in Malawi to better respond to critically ill obstetric and trauma patients in Malawi . The project has helped to increase capacity and develop leadership in Anaesthesia in Malawi. Phase one resulted in a strengthened department of anaesthesia in the College of Medicine in Blantyre with six faculties by 2010, alongside the development of a national standardised Anaesthetic officer training programme. In recognition of the centrality of “teamwork” to safer patient care, phase two of the project focused on ensuring that medical workers in Malawi can respond to trauma and related emergencies. The project delivered a trauma training programme , based in the Welcome trust Unit in Queen Elizabeth Medical Centre, Blantyre, training 72 resuscitation providers, and establishing a monitoring, evaluation and audit system to measure the impact of training activity in Thyolo and Chinadzulu Hospitals. The College of Anaesthesiologists of Ireland and the Queen Elizabeth Medical Centre , Blantyre have collaborated with the district health management team towards reducing maternal , perinatal and trauma mortality in Thyolo and Chinadzulu Districts by a joint programme of education support for first responders in assessment, transport and resuscitation of emergency and trauma patients. To date, over 6oo team members (NPAPS) have completed this training programme successfully. One person who has been there from the beginning is Mr Cyril Goddia, from the College of Medicine in Blantyre who was conferred with an Honorary Fellowship of the College of Anaesthesiologists of Ireland in 2019. In February 2020 a new multi-national anaesthesia partnership programme for East , Central and Southern Africa was launched. This Department of Foreign Affairs and Trade funded programme aims to provide access to safer and more affordable anaesthesia care for those in need of surgery in the region. Developed in collaboration between RCSI’s Institute of Global Surgery , the College of Surgeons of East, Central and Southern Africa (COSECSA) and the College of Anaesthesiologists of Ireland (CAI), the programme aims to build the capacity of the College of Anaesthesiologists of East, Central and Southern Africa (CANECSA) to address the most significant barrier to safe surgery in the region. The programme recognises that the shortage of safe anaesthesia providers is one of the most significant barriers to the provision of safe surgery in East, Central and Southern Africa. In its first year of operation , CANESCA , COSECSA, RCSI and CAI have worked together to establish training sites in the region, developed a suitable curricula and developed plans to hold internationally benchmarked Anaesthesiology Fellowship examinations. We are committed to harnessing the support of our global network of Fellows to deliver initiatives in low and middle income countries in line with the Lancet commission findings and UN Sustainable Development Goals to improve access to safer Anaesthesia and safer surgery. We welcome this partnership with RCSI, CANESCA and COSECSA to increase patient safety for all and on World Anaesthesia Day , it is particularly timely to thank all of the individuals , teams and partnerships who have contributed to advancing education, standards and research in safe anaesthesia and critical care in Sub Saharan Africa. Your work , your contribution will allow the delivery of safe anaesthesia to those who need it most.