51.e1 The 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 Australia Brunei Darussalam Cambodia China Fiji French Polynesia Guam Hong Kong SAR, China Indonesia Japan Kiribati Korea, Dem People’s Rep Korea, Rep Lao PDR Macao SAR, China Malaysia Marshall Islands Micronesia, Fed Sts Mongolia Myanmar Nauru New Caledonia New Zealand Northern Mariana Islands Palau Papua New Guinea Philippines Samoa Singapore Solomon Islands Thailand Timor-Leste Tonga Tuvalu Vanuatu Vietnam Europe and Central Asia Upper middle income High income High income Lower middle income Upper middle income Upper middle income High income High income High income Lower middle income High income Lower middle income Low income High income Lower middle income High income Upper middle income Upper middle income Lower middle income Lower middle income Lower middle income Upper middle income High income High income High income High income Lower middle income Lower middle income Upper middle income High income Lower middle income Upper middle income Lower middle income Upper middle income Upper middle income Lower middle income Lower middle income • eFig 8.1 Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Channel Islands Croatia Cyprus Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Gibraltar Greece Greenland Hungary Iceland Ireland Isle of Man Italy Kazakhstan Kosovo Kyrgyz Republic Latvia Liechtenstein Lithuania Luxembourg Macedonia, FYR Moldova Monaco Upper middle income High income Lower middle income High income Upper middle income Upper middle income High income Upper middle income Upper middle income High income Upper middle income High income High income High income High income High income High income High income Lower middle income High income High income High income High income High income High income High income High income High income Upper middle income Lower middle income Lower middle income High income High income High income High income Upper middle income Lower middle income High income Montenegro Netherlands Norway Poland Portugal Romania Russian Federation San Marino Serbia Slovak Republic Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Upper middle income High income High income High income High income Upper middle income Upper middle income High income Upper middle income High income High income High income High income High income Lower middle income Upper middle income Upper middle income Lower middle income High income Lower middle income Latin America and the Caribbean Antigua and Barbuda Argentina Aruba Bahamas, The Barbados Belize Bolivia Brazil British Virgin Islands Cayman Islands Chile Colombia Costa Rica Cuba Curaỗao Dominica Dominican Republic Ecuador El Salvador High income Upper middle income High income High income High income Upper middle income Lower middle income Upper middle income High income High income High income Upper middle income Upper middle income Upper middle income High income Upper middle income Upper middle income Upper middle income Lower middle income The world by income 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.3 52 S E C T I O N I Pediatric Critical Care: The Discipline CAUSES OF UNDER-5 DEATHS IN LMIC Typhoid and other SIDS 1% Salmonella 1% Liver and digestive disorders Other infections 1% 1% Drowning 1% Tuberculosis 1% Whooping cough 1% Measles 2% HIV/AIDS 2% Others 5% Injuries and falls 2% Neonatal disorders 34% Sexually transmitted infections excluding HIV 2% Protein-energy malnutrition 2% Meningitis 3% Malaria 7% Congenital birth defects 8% Diarrheal diseases 11% Lower respiratory infections 16% • Fig 8.2 Causes of under-5-years-old mortality in low to middle sociodemographic index (SDI) settings globally.4 HIV/AIDS, Human immunodeficiency virus/acquired immunodeficiency syndrome; LMICs, lowermiddle-income countries; SIDS, sudden infant death syndrome However, in regions such as sub-Saharan Africa, out of every 12 children still dies before age years, nearly 16 times the average rate in HICs.7 The majority of childhood deaths under the age of 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 accelerate reductions in child mortality to reach the Sustainable Development Goals (SDG) targets These targets include ending preventable 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 possible that critical care services will be necessary in combination with more basic public health measures to achieve this goal Critical care is just the continuum of care provided to any child with a life-threatening illness or injury beginning with the time of presentation to a healthcare facility However, extracting optimal value from critical care treatment in LMICs depends on a deep understanding 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 represent 50% of the population in LMICs.11 Deficiencies in timely and equal access to quality healthcare, emergency triage and transport, and lack of early recognition contribute to increased child deaths in LRSs.12–14 The need for critical care support is likely to CHAPTER 8 Challenges of Pediatric Critical Care in Resource-Poor Settings rise 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 system 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, India, and China may offer critical and intensive care services approaching that of HICs, in many LMICs, healthcare systems are less organized, human and material resources are scant, and intensive care services are few or nonexistent—especially at districtlevel hospitals, where about 50% of medical care in Africa is administered.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), underlying malnutrition, delayed presentation of severely sick children, 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 replacement 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 admission are for postsurgical and trauma care, infectious diseases, and peripartum maternal or neonatal complications.27 These conditions are major contributors to the global burden of disease Hence, building intensive care capacity around the relevant disciplines where they already exist is a reasonable method to increase capacity Approach to Basic Critical Care in Resource-Limited Settings Pediatric critical care services not have to be costly, nor 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 53 recognition of serious illness, early access to care, referral, and safe transport.30 Some successful interventions include training villagers 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 improvement of district hospital services34,35; reorganization of emergency services at referral hospitals36,37; provision of oxygen therapy for hypoxemic children with pneumonia in district clinics; and medical treatment given by village workers or parents.38–40 Noninvasive respiratory support, such as bubble-CPAP (continuous positive airway pressure) has been successfully and cost-effectively introduced for support of neonates and infants with respiratory compromise in LRSs.41–47 Use of simple nurse-initiated CPAP protocols for children up to 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 expensive, in contrast to the much lower-cost basic critical care interventions 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 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 substantially lower than this: in India, day in a private ICU for cancer patients was reported as $57 However, in settings where a substantial proportion of healthcare costs is covered by families’ outof-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 required (e.g., transport, electricity, water provision and sewage disposal, medical gas supply systems, technical maintenance support) to support complex medical care.49 The real cost of providing intensive care in poorer countries may be substantially higher in these circumstances, although possibly offset by the lower salaries 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-theart 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 limited 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 patients with often incurable or chronic diseases, whereas in many resource-limited settings, the ICU provides basic rescue interventions for children and young adults who are ill with curable diseases Hence, a short duration of intensive care that (selectively) treats reversible acute life-threatening illnesses affecting millions 54 S E C T I O N I Pediatric Critical Care: The Discipline of 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 mechanical 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 associated with substantial reductions in mortality without significant added expense Implementation of nasal CPAP in Nicaragua could provide improved outcomes while reducing invasive mechanical ventilation,54 while mechanical ventilation in LICs, on the other hand, has been associated with relatively high mortality.55,56 Research into cost-effective interventions in the setting of curable 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 reducing the cost of care and improving quality of care.57 Ethics of Intensive Care in ResourcePoor 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 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 healthcare 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 inegalitarian healthcare policy, which is common in many developing 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 economic 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 Family and cultural preferences: Providing ICU-level care also requires respecting family, cultural, and religious preferences Different practices are present in different countries with respect to who is accepted as the appropriate decision maker on initiation or discontinuance of critical care services In particular, such decisions are often made by the family rather than patient.60 In many African countries, the idea of advanced directives 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 advanced or further care needs to be made based on the risk of impoverishment of the family.62 Financial nonaffordability is being stated as reason for withdrawal of care even for patients improving in their course of illness in some countries.63 Resource allocation: Resource allocation of intensive care services 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 exclusion 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 establishment of normal respiratory pattern; children with underlying 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 policies 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 support need to be made in the context of potential impoverishment 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 levelof-care decisions openly and honestly; and articulating hospital policies on the use of critical care services, including policies regarding appropriate ICU admissions, cardiopulmonary resuscitation, 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, information 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 outcomes may demonstrate the need for efforts to support implementation of key interventions or wider system strengthening in CHAPTER 8 Challenges of Pediatric Critical Care in Resource-Poor Settings LICs 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 limited.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 revealed 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 prescription of antibiotics and feeds, even when resources were available In attempting to rectify these deficiencies in care, the level of engagement of senior and particularly midlevel clinical managers was important.72 The simple availability of authoritative World Health Organization and national guidelines alone does not improve hospital care for children as hoped Broader, more system-oriented interventions 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 supervision, 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 reasonable first step However, there is no approach to improve healthcare systems that is suitable for all countries, and not all approaches 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 action on a number of fronts.58 Over the last decades, there has been increasing private participation in the healthcare systems of LMICs, especially in-service 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, 55 training materials, faculty, administrative staff, and funding,78–80 making it challenging to expand the number and diversity of training programs and to improve the quality of training Practicing 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 innovative 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 Training 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 emergency 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 months to 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 pediatric emergency and critical care physicians in Kenya are supported 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 fundamentals of critical care study—are other educational initiatives used for supporting critical care training in resource-limited settings.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 comprehensive.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 systemwide levels to improve the care of sick children in Botswana and India.91 However, data on the utility of short-term training programs, both in HICs and LMICs, are limited—they have been shown to improve short-term knowledge in emergency and critical 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 ... 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 day in an HIC ICU in 2009 was around $1000.20 This... less desirable outcomes This approach could help allocate resources, mutually benefiting HICs and LMICs in reducing the cost of care and improving quality of care.57 Ethics of Intensive Care... remain limited.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