Understanding the scale of critical illness in Africa and the need for universal access to emergency and critical care
Nazir I Lone, John A Masterson, Swagata Tripathy
Lancet 2025; 405: 674-675
Timely access to critical care saves lives in any health-care context. In high-income settings, the term critical care is associated with a geographically defined location within a hospital, equipped with advanced technologies requiring substantial financial resourcing. However, technology-driven care delivered in critical care units is not the same as providing timely and appropriate care to critically ill patients regardless of location, especially in resource-limited settings.1 Broadening this concept to people at risk of, or having developed, critical illness, allows the focus to move to acute management strategies which can be delivered to critically ill people across heath-care settings. Components of such emergency and critical care interventions include recognition of organ dysfunction, early clinical diagnosis, and emergency management (consisting of oxygen therapy, intravenous fluids, simple manoeuvres to maintain airway patency, and vasoactive medication).2 These are low-cost interventions that do not require highly specialist training to deliver.
Such factors are important given the burden of critical illness in low-income and middle-income countries (LMICs). For example, estimates of sepsis incidence (only one of many causes of critical illness), are ten times higher in sub-Saharan Africa than western Europe (age-standardised incidence 1527 per 100 000 population in sub-Saharan Africa vs 168 per 100 000 population in western Europe).3 This higher burden is not reflected in the number of critical care beds per capita in LMICs compared with high-income countries.4
Understanding the scale of critical illness in an African context, while recognising that critical illness occurs outside of critical care facilities, and investigating the availability of emergency and critical care interventions are fundamental to inform future service needs and provision. In The Lancet, the African Critical Illness Outcomes Study (ACIOS) Investigators report their continent-wide, cross-sectional point prevalence study to bridge this knowledge gap.5 Between September and December, 2023, local groups collected data from 180 hospitals across 22 African countries. To establish the first coprimary outcome of prevalence of critical illness, the investigators recorded patient physiological data on a single census date. Critical illness was defined as having one or more severely deranged vital sign. Patients were followed up for 7 days post-census to measure inpatient mortality, the second coprimary outcome. Secondary outcomes comprised resources available to hospitals and their capacity to provide essential emergency and critical care (EECC).
The ACIOS study recruited 19 872 adult patients from general hospital, maternity, and emergency departments. This population had a median age of 40 years (IQR 29–59) and 55·8% (11 078 of 19 862) were women. The majority of patients were managed within university, central, or national hospitals (66·3% [12 717/19 920]) and 20·0% (3846/19 920) and 13·3% (2657/19 920) were managed within regional and district centres, respectively. 12·5% (2461/19 743) of patients were critically ill on census day, with 17·1% (421/2459) of these patients managed in intensive care unit environments and 14·2% (350/2459) managed in high care unit environments. 7-day inpatient mortality was 20·7% (507/2450) in patients with critical illness, compared with 2·7% (458/17 205) in patients without critical illness, with an adjusted odds ratio of 7·72 (95% CI 6·65–8·95). Notably, 55·6% (1369/2461) of critically ill patients received partial or no EECC treatment and only 7·5% (13/173) of hospitals had access to all EECC resources.
Strengths of the study include the use of a practical measure to define critical illness, which relied on clinician assessment and objective physiology, and had been previously developed and validated by some of the authorship group.6 This measure showed predictive validity, identifying patients at highest risk of dying, and is highly replicable in all health-care contexts. In addition, although not all African nations contributed to the study, the 22 countries with participating hospitals represent around two-thirds of the African population, indicating that the findings are likely to be generalisable. In approximately 30% of participating hospitals not all wards were able to contribute data, raising the possibility of selection bias should the reason for non-participation be insufficient resource in these areas. However, a post-hoc analysis restricted to hospitals with participation from all wards demonstrated that findings were robust to this risk.
One limitation is that the point prevalence cross-sectional study design is prone to underestimate the frequency of critical illness compared with study designs that measure disease frequency over a longer timeframe, for example, period prevalence over 24 h, or designs that measure incidence. In the context of this study, this would be particularly problematic if a substantial proportion of critically ill patients had a short timeframe from hospital admission to death or resolution of critical illness.
The study's findings reinforce the ongoing acute health-care challenges associated with development, urbanisation, and climate change in LMICs. Although there is evidence of progress in tackling preventable deaths due to maternal complications, the burden of non-communicable diseases such as cardiovascular disease and diabetes is rising.7 Among communicable diseases, HIV with its related issues of stigma has historically dominated as a barrier to preventing, managing, and accessing care in Africa and unsurprisingly emerged as a substantial contributor to mortality.8
The ability to ensure preparedness and effective response to the expanding burden of acute illness throughout the health-care system aligns with the World Health Assembly's resolution 76.2 on integrated emergency, critical, and operative care.9 This confirms that critical care should not be considered an elite component of health-care systems, but instead should be a core component of universal health-care provision.
The complex challenges of implementing these recommendations will require strong multi-agency partnerships, persistent advocacy, and engaging governments at all levels. Resource and needs-appropriate expansion of services to prioritise the implementation of essential critical care will need to be supported by strategies to implement low-cost technologies to improve triage efficiency and educational programmes to expand the trained workforce in LMICs.10,11 These must be underpinned by frugal innovation to deliver acute care and leveraging information systems for capacity assessment, quality improvement, and context-sensitive research in LMICs.12
The ACIOS Investigators have established the scale of critical illness in African hospitals and draw attention to the substantial gap in service provision of emergency and critical care interventions. Many, if not all, of these interventions have already established effectiveness as live-saving, low-cost interventions. The next steps are clear—urgent efforts must now focus on infrastructure, education, and workforce development in preparation for the next public health emergency.
