PURPOSE: Provision of anesthesia care must go hand in hand with surgical care to equitably widen surgical coverage of underserved populations, especially the rural segments of low- and middle-income countries. The aim of this study was to assess the availability of key items and infrastructure needed for anesthesia care. METHODS: We conducted a cross-sectional survey at ten subdistrict or taluqa headquarter (THQ) hospitals and five district headquarter (DHQ) hospitals in six rural districts of the Sindh province of Pakistan using the Anesthesia Facility Assessment Tool. We assessed the domains of infrastructure, workforce, service delivery, conduct of anesthesia, equipment, and medications. We also scored these components and then compared the difference in mean scores. RESULTS: Three hospitals did not meet the minimum bed number required for a secondary hospital. Four hospitals had nonfunctioning operating rooms and conducted procedures elsewhere. Ten had full-time, certified anesthesiologists, while 11 had a postanesthesia care unit. There were only two hospitals with critical care units providing mechanical ventilation, and only one hospital conducting telemetry. Six hospitals did not have a dedicated anesthesia provider present at all times. Thirteen hospitals did not use the World Health Organization preoperative checklist before performing procedures. There were deficiencies in drugs such as hypnotics, opioids, and vasopressors. CONCLUSION: There are many shortcomings in anesthesia care provision among these rural hospitals. Greater attention and investment are needed to safely conduct anesthesia in this setting.