Intensive care unit capacity in low-income countries: a systematic review

Abstract

Purpose: Access to critical care is a crucial component of healthcare systems. In low-income countries, the burden of critical illness is substantial, but the capacity to provide care for critically ill patients in intensive care units (ICUs) is unknown. Our aim was to systematically review the published literature to estimate the current ICU capacity in low-income countries.

Methods: We searched 11 databases and included studies of any design, published 2004-August 2014, with data on ICU capacity for pediatric and adult patients in 36 low-income countries (as defined by World Bank criteria; population 850 million). Neonatal, temporary, and military ICUs were excluded. We extracted data on ICU bed numbers, capacity for mechanical ventilation, and information about the hospital, including referral population size, public accessibility, and the source of funding. Analyses were descriptive.

Results: Of 1,759 citations, 43 studies from 15 low-income countries met inclusion criteria. They described 36 individual ICUs in 31 cities, of which 16 had population greater than 500,000, and 14 were capital cities. The median annual ICU admission rate was 401 (IQR 234-711; 24 ICUs with data) and median ICU size was 8 beds (IQR 5-10; 32 ICUs with data). The mean ratio of adult and pediatric ICU beds to hospital beds was 1.5% (SD 0.9%; 15 hospitals with data). Nepal and Uganda, the only countries with national ICU bed data, had 16.7 and 1.0 ICU beds per million population, respectively. National data from other countries were not available.

Conclusions: Low-income countries lack ICU beds, and more than 50% of these countries lack any published data on ICU capacity. Most ICUs in low-income countries are located in large referral hospitals in cities. A central database of ICU resources is required to evaluate health system performance, both within and between countries, and may help to develop related health policy.

Figure 1. Flow diagram of study selection.

References for the citations excluded after full-text review are provided in S1 File.

Figure 2. Thirty-six low-income countries included in the search strategy with (n = 15, red) and without (n = 21, yellow) published data on ICU resource availability.

Figure 3. Comparison of the relationship between ICU beds and hospital beds (panel a), and between ICU beds and national healthcare expenditure per capita (panel b) in low versus selected high-income countries.

There is a non-significant trend between ICU beds and hospital beds (R² = 0.11, p = 0.37; R² = 0.24, p = 0.12 if USA is excluded) and a significant trend between ICU beds and national healthcare expenditure per capita (R² = 0.76, p = 0.002). Supplementary data are from [26,27].