Lower middle income Mongolia Lower middle income New Caledonia High income New Zealand High income Northern Mariana Papua New Guinea Lower middle income Philippines Lower middle income
Trang 1The world by income
Classified according to World Bank estimates of 2016 GNI per capita (current US dollars, Atlas method)
Low income (less than $1,005)
Lower middle income ($1,006–$3,955)
Upper middle income ($3,956–$12,235)
High income (more than $12,235)
No data
Note: The World Bank classifies economies as low-income, lower-middle-income, upper-middle-income or high-income based on gross national income (GNI) per capita For more information see https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.
East Asia and Pacific
American Samoa Upper middle income
Brunei Darussalam High income
Cambodia Lower middle income
Fiji Upper middle income
French Polynesia High income
Guam High income
Hong Kong SAR, China High income
Indonesia Lower middle income
Kiribati Lower middle income
Korea, Dem
People’s Rep. Low income
Korea, Rep. High income
Macao SAR, China High income
Malaysia Upper middle income
Marshall Islands Upper middle income
Micronesia, Fed Sts. Lower middle income
Mongolia Lower middle income
New Caledonia High income
New Zealand High income
Northern Mariana
Papua New Guinea Lower middle income
Philippines Lower middle income
Solomon Islands Lower middle income
Thailand Upper middle income
Timor-Leste Lower middle income
Europe and Central Asia Albania Upper middle income
Armenia Lower middle income
Azerbaijan Upper middle income
Belarus Upper middle income
Bosnia and Herzegovina Upper middle income
Bulgaria Upper middle income
Channel Islands High income
Croatia Upper middle income
Czech Republic High income
Faroe Islands High income
Montenegro Upper middle income
Netherlands High income
Romania Upper middle income
Russian Federation Upper middle income
San Marino High income
Slovak Republic High income
Switzerland High income
Tajikistan Lower middle income
Turkmenistan Upper middle income
Ukraine Lower middle income
United Kingdom High income
Uzbekistan Lower middle income
Latin America and the Caribbean Antigua and Barbuda High income
Argentina Upper middle income
Bahamas, The High income
Bolivia Lower middle income
British Virgin Islands High income
Cayman Islands High income
Colombia Upper middle income
Costa Rica Upper middle income
Cuba Upper middle income
Dominica Upper middle income
Dominican Republic Upper middle income
Ecuador Upper middle income
El Salvador Lower middle income
Georgia Lower middle income
Gibraltar High income
Greenland High income
Isle of Man High income
Kazakhstan Upper middle income
Kosovo Lower middle income
Kyrgyz Republic Lower middle income
Liechtenstein High income
Lithuania High income
Luxembourg High income
Macedonia, FYR Upper middle income
Moldova Lower middle income
• eFig. 8.1 The world by income. The World Bank classifies economies as low income, lower middle
income,uppermiddleincomeorhighincomebasedongrossnationalincome(GNI)percapita 3
Trang 2However, in regions such as sub-Saharan Africa, 1 out of every
12 children still dies before age 5 years, nearly 16 times the average
rate in HICs.7 The majority of childhood deaths under the age of
5 years are related to neonatal problems (34%), followed by lower
respiratory (16%) and diarrheal illnesses (11%), as well as malaria
(7%) In 5- to 14-year-old children, road injuries (8%) also play
an important role (see Fig 8.2) The five countries with the highest
number of under-5-years-old deaths in 2017 were Somalia, Chad,
Central African Republic, Sierra Leone, and Mali.1 In more than a
quarter of all countries globally, urgent action is needed to
acceler-ate reductions in child mortality to reach the Sustainable
Develop-ment Goals (SDG) targets These targets include ending
prevent-able child deaths and decreasing under-5-years-old mortality to at
least as low as 25 deaths per 1000 live births by 2030.8 It is
pos-sible that critical care services will be necessary in combination
with more basic public health measures to achieve this goal
Criti-cal care is just the continuum of care provided to any child with a
life-threatening illness or injury beginning with the time of presen-tation to a healthcare facility However, extracting optimal value from critical care treatment in LMICs depends on a deep under-standing of the resources required to provide incremental levels of care to critically ill children, as well as a focus on the interventions that will make the most difference
Justification for Critical Care
in Resource-Poor Settings
The full scope of the burden of critical illness in resource-limited settings is unknown, but the majority of global child deaths occur
in LRSs.9 , 10 Additionally, children younger than 15 years repre-sent 50% of the population in LMICs.11 Deficiencies in timely and equal access to quality healthcare, emergency triage and trans-port, and lack of early recognition contribute to increased child deaths in LRSs.12–14 The need for critical care support is likely to
Neonatal disorders 34%
Liver and digestive disorders
1%
Sexually transmitted
infections excluding HIV 2%
Typhoid and other Salmonella 1%
CAUSES OF UNDER-5 DEATHS IN LMIC
Drowning 1%
Protein-energy malnutrition
2%
Tuberculosis 1%
Other infections 1%
Whooping cough 1%
Measles 2%
HIV/AIDS 2%
Others 5%
Injuries and falls 2%
SIDS 1%
Lower respiratory infections
16%
Diarrheal diseases 11%
Congenital birth defects 8%
Malaria 7%
Meningitis 3%
• Fig. 8.2 Causesofunder-5-years-oldmortalityinlowtomiddlesociodemographicindex(SDI)settings
globally 4 HIV/AIDS,Humanimmunodeficiencyvirus/acquiredimmunodeficiencysyndrome;LMICs,lower-middle-incomecountries;SIDS,suddeninfantdeathsyndrome.
Trang 3rise with increasing urbanization, more frequent epidemics, and
natural disasters.15–17 More work is necessary to better define the
burden of pediatric critical illness in LRSs to support provision of
resources for critical care delivery Current approaches to estimate
the global burden of critical illness have significant limitations18:
(1) counting patients admitted to ICUs around the world,
(2) extrapolating from resource-rich countries’ epidemiology, and
(3) using the assumption that all deaths occurring in a region had
a critical illness at some stage before their demise The first two
approaches will likely lead to an underestimation; the third
will lead to an overestimation of the burden of critical illness in
resource-poor settings
Effective, low-cost strategies for the management of critical
illnesses are becoming more available, providing ample rationale
for expanding pediatric critical care services to LRSs, especially in
countries with under-5-years-old mortality rates of less than 30
per 1000, while regions with higher mortality rates are advised to
focus on public health capacity.19
State of Critical and Intensive Care Delivery
in Resource-Limited Settings
In HICs, critical care services usually involve “a coordinated
sys-tem of triage, emergency management, and ICUs” providing
contemporary standards of care to the population.20 While some
urban university and private hospitals in sub-Saharan Africa,
In-dia, and China may offer critical and intensive care services
ap-proaching that of HICs, in many LMICs, healthcare systems are
less organized, human and material resources are scant, and
inten-sive care services are few or nonexistent—especially at
district-level hospitals, where about 50% of medical care in Africa is
ad-ministered.21–25 Even quality of care for common childhood
illnesses such as pneumonia and diarrheal diseases is poor in these
settings.26 Logistic and financial limitations, poorly resourced
supporting disciplines (e.g., laboratories, radiology, nursing),
un-derlying malnutrition, delayed presentation of severely sick
chil-dren, and suboptimal care contribute to comparatively high
mortality.25–28 An ICU in a public hospital in LRSs may provide
pressurized air or oxygen, but mechanical ventilation, renal
re-placement therapy, and basic supplies are limited.29 Systematic
efforts to understand the disease epidemiology of a region, its
prognosis, and development of policies and guidelines of critical
care in LRSs are required to best use available resources.27
Most pediatric intensive care in LMICs is performed in mixed
adult-pediatric ICUs The majority of the pediatric ICUs (PICUs)
are staffed by general pediatricians and lack specialized services.30
Where ICUs are available, the most common reasons for
admis-sion are for postsurgical and trauma care, infectious diseases, and
peripartum maternal or neonatal complications.27 These
condi-tions are major contributors to the global burden of disease
Hence, building intensive care capacity around the relevant
disci-plines where they already exist is a reasonable method to increase
capacity
Approach to Basic Critical Care
in Resource-Limited Settings
Pediatric critical care services do not have to be costly, nor do they
need to be overtly reliant on high-end technology Critically ill
children in LMICs may benefit from timely care and closer
monitoring even without an ICU Critical care services can help
improve outcomes if combined with a focus on community
recognition of serious illness, early access to care, referral, and safe transport.30 Some successful interventions include training villag-ers in basic first aid and resuscitation31; provision of low-cost simplified antimicrobial regimens and rapid diagnostic tests to rural healthcare workers, day clinics, and homes32 , 33; quality im-provement of district hospital services34 , 35; reorganization of emergency services at referral hospitals36 , 37; provision of oxygen therapy for hypoxemic children with pneumonia in district clin-ics; and medical treatment given by village workers or parents.38–40 Noninvasive respiratory support, such as bubble-CPAP (continu-ous positive airway pressure) has been successfully and cost-effec-tively introduced for support of neonates and infants with respira-tory compromise in LRSs.41–47 Use of simple nurse-initiated CPAP protocols for children up to 5 years of age has been safely introduced to nontertiary care hospitals in Ghana, where invasive mechanical ventilation is not routinely available, and has led to significantly decreased mortality for infants in the CPAP group.48
Cost Considerations in Critical Care Delivery
Intensive care involving ICUs and mechanical ventilation is ex-pensive, in contrast to the much lower-cost basic critical care in-terventions described earlier in this chapter It is important to consider the relative costs of intensive care services.49 For example,
it is estimated that the costs of 1 day in an HIC ICU in 2009 was around $1000.20 This would be equivalent to approximately 20%
of the annual per capita expenditure on health in an HIC, but approximately 30 times the annual per capita expenditure on health in a low-income country (LIC) The cost of delivering some aspects of critical care in poorer countries may be substan-tially lower than this: in India, 1 day in a private ICU for cancer patients was reported as $57 However, in settings where a sub-stantial proportion of healthcare costs is covered by families’ out-of-pocket expenditure, that amount has to be related to the family income, here estimated to be approximately 100 times the average per capita household income.50 Hence, intensive care services have the potential to devastate the financial structure of a family
in LMICs.51 Cost-effectiveness analyses for intensive care in LICs must also consider the potential hidden infrastructure costs re-quired (e.g., transport, electricity, water provision and sewage disposal, medical gas supply systems, technical maintenance sup-port) to support complex medical care.49 The real cost of provid-ing intensive care in poorer countries may be substantially higher
in these circumstances, although possibly offset by the lower sala-ries for healthcare workers
The differences in access to high-cost healthcare between rich and poor people may vary substantially in many LMICs, with a small proportion of the population having access to state-of-the-art medical services while the majority of people within the same country may have limited or virtually nonexistent access to healthcare services.52 Hence, cost-effectiveness of intensive care services in LMICs is complex Care must be taken to not burden fragile systems with costly interventions that may take away lim-ited resources from other public healthcare sectors while having only a limited impact or poor outcomes with long-term cost It is important to note, however, that ICUs in high-income countries function in large part by admitting and caring for complex pa-tients with often incurable or chronic diseases, whereas in many resource-limited settings, the ICU provides basic rescue interven-tions for children and young adults who are ill with curable dis-eases Hence, a short duration of intensive care that (selectively) treats reversible acute life-threatening illnesses affecting millions
Trang 4of young people in LRSs worldwide may be cost-effective long
term.53 Examples of some high-cost interventions associated with
excellent outcomes and minimal long-term costs might be
me-chanical ventilation for pneumonia in an otherwise healthy child
or intensive care to enable a major curative surgery
As mentioned earlier, there is evidence that relatively low-cost
interventions in the care of critically ill children and improved
organization of emergency services within a hospital36 may be
as-sociated with substantial reductions in mortality without
signifi-cant added expense Implementation of nasal CPAP in Nicaragua
could provide improved outcomes while reducing invasive
me-chanical ventilation,54 while mechanical ventilation in LICs, on
the other hand, has been associated with relatively high
mortal-ity.55 , 56
Research into cost-effective interventions in the setting of
cur-able diseases is needed to further understand which high- versus
low-cost interventions are appropriate and sustainable and related
to good versus less desirable outcomes This approach could help
allocate resources, mutually benefiting HICs and LMICs in
re-ducing the cost of care and improving quality of care.57
Ethics of Intensive Care in
Resource-Poor Settings
There is no ethical justification for differences in healthcare access
for children across the world However, dealing with the realities
of those differences remains profoundly challenging, especially in
terms of development of publicly funded intensive care services in
resource-poor settings The focus areas include global justice, family
and cultural preferences, and resource allocation
1 Global justice: According to the global justice argument,
healthcare services are a fundamental and universal human
right that must be available to everyone.27 The just distribution
of healthcare services across all human populations remains a
serious challenge Global justice would imply that those in
resource-rich regions have a responsibility to combat critical
illness and strengthen healthcare infrastructure for those in
resource-poor settings.58 In countries with per-capita
health-care investments less than $100 per person per year, the cost of
intensive care renders its provision for everyone impractical
To attempt to provide access to ICUs at the standard of care
accepted generally in the HICs will lead to serious distortion
of healthcare budgets and have detrimental effects on overall
health of the nation Alternatively, access to different standards
of care or differences in quality and breadth of critical care will
develop or already has developed in LMICs In such an
inegal-itarian healthcare policy, which is common in many
develop-ing nations, “centers of excellence can be maintained where
critical care technologies can be nurtured so that as a country
develops and increases its standards of care, it will have its
home-grown critical care resources on which to draw.”59 Such
centers can harbor the skilled personnel within a country who
can serve as catalysts in expanding high-quality care as
eco-nomic resources increase and mortality gains are realized In
these systems, the key lies in extreme efficiency measures and
meticulous attention to balancing the needs of individuals
versus those of the population
2 Family and cultural preferences: Providing ICU-level care also
requires respecting family, cultural, and religious preferences
Different practices are present in different countries with
re-spect to who is accepted as the appropriate decision maker on
initiation or discontinuance of critical care services In particu-lar, such decisions are often made by the family rather than patient.60 In many African countries, the idea of advanced di-rectives and code status have yet to be discussed at the medical community and national judicial level.61 If the outcome is long-term morbidity or death, the decision to provide ad-vanced or further care needs to be made based on the risk of impoverishment of the family.62Financial nonaffordability is being stated as reason for withdrawal of care even for patients improving in their course of illness in some countries.63
3 Resource allocation: Resource allocation of intensive care
ser-vices in deprived areas of the world is challenging Children must not come to the ICU to die, yet many who are critically ill, with an increased risk of death, may have a better chance
of recovery if treated in the ICU.64 Hence, each institution offering ICU-level care should define ICU admission and ex-clusion criteria As an example, the Red Cross War Memorial Hospital in South Africa published explicit patient exclusion criteria for offering critical care in an attempt to provide a reasonable process for fair and equitable utilization of scarce resources.65 Some of these exclusion criteria include children declared brain dead or status post–cardiac arrest without estab-lishment of normal respiratory pattern; children with underly-ing lethal conditions, such as children with burns on more than 60% of their body surface area; children with chronic renal failure with no ability to commit to long-term dialysis; children with severe/lethal chromosomal anomalies; children with malignancies nonresponsive to therapy; or inoperable cardiac lesions Implementation of such ICU admission poli-cies should be undertaken with great sensitivity to both the family and staff or it is likely to lead to failure, anger, and cynicism Careful decisions regarding the extent of ICU sup-port need to be made in the context of potential impoverish-ment of the entire extended family, especially if the end result
is a child’s death or long-term morbidity
Suggested ways to address ethical dilemmas of resource allocation
in resource-poor settings include the following: obtaining data on disease prognosis with and without ICU care to inform clinical decision-making; development of procedures for addressing level-of-care decisions openly and honestly; and articulating hospital policies on the use of critical care services, including policies re-garding appropriate ICU admissions, cardiopulmonary resuscita-tion, and ventilator candidates.61
Strengthening Critical Care Infrastructure
Healthcare Systems
The Ebola epidemic in 2014 to 2016 brought to light the fragile state of healthcare systems in the affected LMICs.27 The needs of Ebola patients are what constitute the basics of public health: early identification, good supportive care along with transport services and isolation practices, and safe disposal of medical waste Building critical care services in LICs requires a tiered approach focused on delivering evidence-based, basic, effective healthcare interventions to scale and carefully making decisions about how
to improve existing care.66 , 67 To inform such decisions, informa-tion is needed on local and regional major causes of morbidity and mortality, what interventions are being delivered to whom, and with what outcomes Marked variability in care and out-comes may demonstrate the need for efforts to support imple-mentation of key interventions or wider system strengthening in
Trang 5LICs In Kenya, a clinical information network (CIN) focused on
hospitals’ inpatient pediatric units has been established to foster
better generation and ultimately better use of information, since
more comprehensive health information systems remain
lim-ited.68 , 69 Partners in this effort include the Ministry of Health, the
Kenya Paediatric Association, local hospitals, and a research team
Initial data from this CIN in Kenya show that quality of care
in district hospitals varies across hospitals Disease conditions and
processes of care suggest that there is significant opportunity for
quality improvement in pediatric care.68 These CINs and health
information systems can then play an important cross-cutting role
in supporting local improvement efforts, benchmarking, and
tracking adoption of interventions.70 , 71
As an example, a survey of Kenyan government hospitals
re-vealed a median availability of essential antibiotics in only 36% of
the 22 surveyed facilities, with a wide range of essential resource
availability from 49% to 93%.26 Health workers at these hospitals
were unable to provide appropriate care for severely ill newborns
or children owing to inadequacies in key tasks, such as
prescrip-tion of antibiotics and feeds, even when resources were available
In attempting to rectify these deficiencies in care, the level of
en-gagement of senior and particularly midlevel clinical managers
was important.72
The simple availability of authoritative World Health
Organi-zation and national guidelines alone does not improve hospital
care for children as hoped Broader, more system-oriented
inter-ventions addressing the many important influences on provider or
user behavior are necessary.73 A multifaceted approach addressing
deficiencies in knowledge, skills, motivation, and organization of
care using face-to-face feedback on performance, supportive
su-pervision, and provision of a local facilitator resulted in more
sustained improvements of pediatric care in Kenya.35
Building regional centers of excellence to grow publicly funded
intensive care resources and capacity over time may be a
reason-able first step However, there is no approach to improve
health-care systems that is suitable for all countries, and not all
ap-proaches are congruent with local values and ideologies or
acceptable to all governments or their constituencies Thus,
healthcare strengthening must be seen as a long-term process that
involves complex systems and requires carefully orchestrated
ac-tion on a number of fronts.58
Over the last 2 decades, there has been increasing private
par-ticipation in the healthcare systems of LMICs, especially
in-ser-vice delivery The increase in the number of private providers is
driven by both rising incomes and the failure of public services to
meet expectations.74 The engagement of the private sector is a
topic of considerable controversy, seen by some as inviting the
privatization of healthcare and making it a commodity However,
when the capacity of the public sector is limited and there is a
concentration of human resources in the private sector, seeking a
mix of public and private provision of services can be seen as a
pragmatic response and may spur increases in public services and
care delivery.75
Pediatric Critical Care Capacity Building
Through Education
The health workforce shortage remains a huge problem in
LMICs.76 Insufficient training capacity and the “brain drain”
of health professionals from Africa are principal drivers of the
current situation.76 , 77 Health professional schools in LMICs
face notable limitations in physical space, equipment, curricula,
training materials, faculty, administrative staff, and funding,78–80 making it challenging to expand the number and diversity of train-ing programs and to improve the quality of traintrain-ing Practictrain-ing health professionals are often overwhelmed by the grinding work
of delivering health services in undersupplied and overcrowded healthcare facilities, inadequately compensated for their work, and demoralized by a lack of career opportunities.76 , 77 , 81 Several inno-vative training initiatives in sub-Saharan Africa funded by the US government have tried to address these issues, including the Medical Education Training Partnership Initiative, Nursing Train-ing Partnership Initiative, Rwanda Human Resources for Health Program, and the Global Health Service Partnership The best practices adopted by these initiatives are (1) alignment to local priorities; (2) country ownership; (3) competency-based training; (4) institutional capacity building; and (5) the establishment of long-lasting partnerships with international stakeholders.82 While some of these programs support components of emer-gency medicine and critical care, pediatric critical care training opportunities in LMICs are limited (Table 8.1) Most of the world’s sickest children are cared for outside of conventional ICUs (pediatric or mixed) by caregivers without pediatric or critical care training.30 , 83 The African Paediatric Fellowship Programme at the University of Cape Town provides pediatric subspecialty training for African child health professionals, by Africans, within Africa.84 Trainees identified by partner academic institutions spend 6 months
to 2 years training in a pediatric subspecialty, including pediatric critical care Graduates then return to their home institution
to build practice, training, research, and advocacy Similarly, the University of Nairobi, in collaboration with the University
of Washington, have recently implemented the first pediatric emergency and critical care fellowship program in East Africa for African pediatricians.85 In this model, the limited number of pe-diatric emergency and critical care physicians in Kenya are sup-ported in the teaching process by visiting subspecialists and online educational resources Pediatric critical care nursing and midlevel provider training programs are also scarce in LMICs and much needed In Nigeria, for example, there are only 380 ICU-trained nurses in a country of 140 million people.86 “Training the trainer”
is widely used as an efficient and effective approach to addressing the shortage of healthcare workers in LMICs through upskilling and to improving their performance, commitment, and— ultimately—retention However, long-term sustainability of this model depends on multiple factors.87
Standardized pediatric emergency and critical care curricula— such as emergency, triage, assessment and treatment; pediatric basic assessment and support intensive care; and pediatric funda-mentals of critical care study—are other educational initiatives used for supporting critical care training in resource-limited set-tings.88 These courses provide a number of advantages even if they require some degree of adaptation to be effective in resource-poor settings Standardized courses are readily deployable for various training levels in a range of settings; they are consistent and com-prehensive.89 , 90 Short courses—such as the pediatric, emergency, assessment, recognition and stabilization, and pediatric advanced life support courses—have been bundled and used on system-wide levels to improve the care of sick children in Botswana and India.91 However, data on the utility of short-term training pro-grams, both in HICs and LMICs, are limited—they have been shown to improve short-term knowledge in emergency and criti-cal care in resource-poor settings.92 , 93 Short courses on trauma care have been shown to identify deficiencies, increase provider skills, and improve trauma outcomes—including mortality—in