The Malawi emergency and critical care survey: A cross-sectional national facility assessment

Abstract

Background: Data on emergency and critical care (ECC) capacity in low-income countries (LICs) are needed to improve outcomes and make progress towards realizing the goal of Universal Health Coverage.

Methods: We developed a novel research instrument to assess public sector ECC capacity and service readiness in LICs. From January 20th to February 18th, 2020 we administered the instrument at all four central hospitals and a simple random sample of nine of 24 district hospitals in Malawi, a landlocked and predominantly rural LIC of 19·1 million people in Southern Africa. The instrument contained questions on the availability of key resources across three domains and was administered to hospital administrators and clinicians from outpatient departments, emergency departments, and inpatient units. Results were used to generate an ECC Readiness Score, with a possible range of 0 to 1, for each facility.

Findings: A total of 114 staff members across 13 hospitals completed interviews for this study. Three (33%) district hospitals and all four central hospitals had ECC Readiness Scores above 0·5 (p-value 0·070). Absent equipment was identified as the most common barrier to ECC Readiness. Central hospitals had higher median ECC Readiness Scores with less variability 0·82 (interquartile range: 0·80-0·89) than district hospitals (0·33, 0·23 to 0·50, p-value 0·021).

Interpretation: This is the first study to employ a systematic approach to assessing ECC capacity and service readiness at both district and central hospitals in Malawi and provides a framework for measuring ECC capacity in other LICs. Prior ECC assessments potentially overestimated equipment availability and our methodology may provide a more accurate approach. There is an urgent need for investments in ECC services, particularly at district hospitals which are more accessible to Malawi's predominantly rural population. These findings highlight the need for long-term investments in health systems strengthening and underscore the importance of understanding capacity in LIC settings to inform these efforts.

Funding: Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Department of Emergency Medicine, Brigham and Women's Hospital.

Keywords: Emergency and critical care; Health systems strengthening; Intensive care; Malawi; Service readiness; Universal health coverage.

Figure 1

Domain composition of ECC readiness score by facility. The bar charts represent ECC Readiness Scores and domain sub-scores by hospital. Each bar represents one of the 13 facilities included in the MECC survey. The larger figure to the right shows each facility’s ECC Readiness Score broken down by colors representing relative contributions from each of the three domain sub-scores. The three smaller figures on the left show each domain sub-score by hospital.

Figure 2

Facility level barriers. Box plot of facility level barrier data displaying percentage the six most common barrier categories were identified. Horizontal whisker lines represent upper and lower adjacent values. Upper adjacent values, n_u, defined as n_u< 75th percentile + 1.5*interquartile range and n_u+1 >75th percentile + 1.5*interquartile range. Lower adjacent values, n_l, defined as n_l > 25th percentile - 1.5*interquartile range and n_l-1 < 25th percentile - 1.5*interquartile range. The numerator for a given facility level barrier category is calculated as the number of times the barrier category was identified by a participant at the facility for signal functions included in the ECC Readiness Score. The denominator is the number of times participants at the facility were asked to identify barriers for those signal functions (ie, the number of times participants rated any of the signal functions as “generally unavailable” or “somewhat available”). (Signal functions included in the ECC Readiness Score: Administration of therapies for reactive airway disease, place peripheral intravenous access, place urinary catheter, administration of adrenaline, diagnose and treat hypoglycemia, perform portable xray, perform non-portable xray, availability of ultrasound machine, check electrolytes, check blood urea nitrogen/creatinine, check hemoglobin, perform transfusion, administration of intravenous fluids, administration of intravenous or intramuscular antibiotics, and administration of intravenous vasopressors.)