Critical Care Development in Africa Emirates Critical Care Conference, Dubai, April 2010 Dr Hala Abuzeid Ahmed, FRCP Consultant in Critical Care, Sudan

KharToum @ Night sudan

Khartoum @ night Africa

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 figures ICU/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

Polio Epidemic 1952 Copenhagen, Kommune Hospital

Critical care services in Africa had been hampered by economic reversals Practice is in an early stage of development

So don’t we need to act? YES

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 experience Programme 2 : Driven by intensivists and fully trained nurses Both 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

Possible??