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CRITICAL CARE DEVELOPMENT IN
AFRICA
Emirates Critical Care Conference, Dubai, April 2010
Dr Hala Abuzeid Ahmed, FRCPConsultant in Critical Care, Sudan
Facts to be considered about Africa
Poorest continent, emerging new diseases
Inhabited by 1/3 of the world’s population
Resources are limited and therefore the critical care practice is extremely challenging
Wars, injustices, corruption produced late and inadequate investments into health and act as limitations to adequate care delivery.
Twenty-nine of 31 countries lowest in the United Nations human development index are in Africa.
Life expectancy in these countries has been falling in recent years , the Botswana crisis!!!
Annual spending on health in African countries 3-8 % of the GDP
USA = 16% (WHO International spending as percent of gross domestic product 2006)
South Africa is unique and is considered the highest spender on health ( 8%-10%)
Sudan invests < $100/ individual/year on health issues
Sudan spends > $1000/ personnel/month on security and defense issues
Huge in-cordination between all public, military and police medical services.
Critical Care in SE Asia
Most rapid economic growth. Countries vary widely in their income and
spending In some countries, critical care compete for
resources with basic public health programs and primary care limiting public sector resources
Well established in private sectors, but still evolving regarding organizational structure
Few full time-time intensivists Specialist Training in Critical Care Medicine is
established in Hong Kong Taiwan and Philippines
Statistical figuresICU/HDU facilities
National Distribution of facilities• 20% ICU in public hospitals Vs 80% ICU in
private hospitals (1.7% of total bed proportion in public Vs 10% in Private)
• Most ICU beds are in the urban areas rather than rural
• Person : ICU bed ratio can range from 1:20 to as high as 1: 30000
• 2-5% of all commissioned beds were not in use
Transfer Practices in Hospitals with no ICU/ HDU Facilities
70% of public hospitals don't have ICU facilities , leading to the need to transfer BUT
Transport Vehicles are uncommon in the majority
Delays in transportation have been shown to increase mortality and morbidity
Nursing Care Resources
Deficit in ICU nurses is huge ( In Sudan 62000, Vs SA 7920)
ICU nurses lack the experience ( 40% = 0-5 years)
Non retention of experienced nurses due to migration
Lack of incentives act as a repellent Capacity building is a rare event Lack of motivation amongst staff
Open Vs Closed Units
Open systems are the dominant Around 4% of ICUs in Africa are run by an
intensivist In Sudan the deficit of intensivists is
estimated to be around 500 ( 1200 Hospitals, < 320 Urban)
With the current rate of production will take at least 50 years
Oxygen, Water & Electricity Supply
Very expensive Uganda has Oxygen in only 635 of its hospitals
Difficult logistics Oxygen generators Vs Electricity supply
and sustainability Back up generators may take significant
time to connect Staff need training of the local conditions
Equipments
Mortality in ICUs is related to the availability of appropriate technical equipments ( Bastos PG et al Brazil APACHE III study group, Intensive care medicine 1996;22:664-9)
Appropriate Ventilators independent of compressed gases and disposable circuits are ideal
Invasive arterial blood pressure monitoring and haemodyialsis require a lot of consumables.
Supporting Services
Laboratory Radiology Routine investigations might be a luxury
in most of the rural areas APACHE Scoring will be affected Blood Transfusion Services and
International Standards Microbiological Services Imaging
Disease Spectrum & Outcome
Overall Mortality 25% , surgical patients True in most of the African countries Future planning should consider t to be
close to Ors Tetanus remains a major challenge Malaria and MODS
Critical care services in Africa had been hampered by economic reversals
Practice is in an early stage of development
Short Term Recommendations
Regionalization & Integration
Protocols and Guidelines
CPD & Outreach
Retention Strategies
Medium- term
Dealing with the gross deficiency in HR 2 tiered programmes:Programme 1:Driven by nurses and doctors with
intermediate skills and experienceProgramme 2 :Driven by intensivists and fully trained
nursesBoth should have clear scope of practice,
training and incentive schemes
Medium-term
Telemedicine Tier 1 units to have access to Tier 2 units
as and when required Maximizing use of existing beds
Long-term
Changing open to closed units New Units National Database to help with ongoing
evaluation , to plan for proper strategies