An assessment of critical care capacity in the Gambia

Accepted Manuscript An assessment of critical care capacity in the Gambia

Sunkaru Touray, Baboucarr Sanyang, Gregory Zandrow, Fatoumatta Dibba, Kaddy Fadera, Ebrima Kanteh, Madikoi Danso, Landing N. Sanyang, Masirending Njie, Grey Johnson, Awa Sanyang, Awa Touray PII: DOI: Reference:

S0883-9441(18)30573-2 doi:10.1016/j.jcrc.2018.07.022 YJCRC 52982

To appear in:

Journal of Critical Care

Please cite this article as: Sunkaru Touray, Baboucarr Sanyang, Gregory Zandrow, Fatoumatta Dibba, Kaddy Fadera, Ebrima Kanteh, Madikoi Danso, Landing N. Sanyang, Masirending Njie, Grey Johnson, Awa Sanyang, Awa Touray , An assessment of critical care capacity in the Gambia. Yjcrc (2018), doi:10.1016/j.jcrc.2018.07.022

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An Assessment of Critical Care Capacity in The Gambia Sunkaru Touray, MB, ChB, MSc,1 Baboucarr Sanyang, MBBS,2 Gregory Zandrow, BS, EMTB,1 Fatoumatta Dibba MB, ChB,4 Kaddy Fadera, SRN,8 Ebrima Kanteh, MB, ChB,5 Madikoi Danso, MB, ChB,6 Landing N. Sanyang, MB, ChB,4 Masirending Njie, MD,2 Grey Johnson, MD,2 Awa Sanyang, MB, ChB,7 and Awa Touray, MD,1,3

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1: University of Massachusetts Medical School, Worcester, Massachusetts 2: Serekunda General Hospital, Kanifing, The Gambia 3: Umass Memorial Medical Center, Worcester, Massachusetts 4: Bundung Maternal and Child Health Hospital, Bundung, The Gambia 5: Sukuta Health Centre, Sukuta, The Gambia 6: Medical Research Council, Fajara, The Gambia 7: Edward Francis Small Teaching Hospital, Banjul, The Gambia 8: Gunjur Health Center, Gunjur, The Gambia

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Title of first author 1 Clinical Fellow in Pulmonary Diseases & Critical Care Medicine

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Correspondence to: Sunkaru Touray, MB. ChB, MSc University of Massachusetts Medical School Department of Pulmonary Allergy & Critical Care Medicine Worcester MA 01605 Email: [email protected]

ACCEPTED MANUSCRIPT Abstract Purpose: Critical illnesses are a major cause of morbidity and mortality in The Gambia, yet national data on critical care capacity is lacking.

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Materials and Methods: We surveyed eight of the eleven government-owned health facilities providing secondary and tertiary care in The Gambia’s public health sector. At each hospital, a designated respondent completed a questionnaire reporting information on the presence of an intensive care unit, the number of critical care beds where available, monitoring equipment, and the ability to provide basic critical care services at their respective hospitals.

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Results: The response rate was 88% (7/8 hospitals). Only one hospital had a dedicated intensive care unit with eight ICU beds, resulting in an estimated 0.4 ICU beds/100,000 population in the country. All hospitals reported treating more than 50 critically ill patients a month, with trauma, obstetric emergencies, hypertensive emergencies and stroke accounting for the leading causes of admission respectively. The country lacks any trained specialists and resources to diagnose and treat critically ill patients.

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Conclusions: The Gambia has a very low ICU bed capacity and lacks the human resources and equipment necessary to diagnose and treat the large number of critically ill patients admitted to public hospitals in the country.

ACCEPTED MANUSCRIPT Background Critical illnesses are acute and potentially reversible conditions that require prompt recognition and treatment. They remain a leading cause of mortality and disability worldwide, particularly in the developing world.1–3 There are limited critical care data from developing countries, largely due to a combination of paucity or absence of skilled critical care providers, researchers, funding, academic mentorship, and infrastructure to perform research.1–5

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While communicable diseases used to be the primary focus of health systems in the developing world, health systems are now increasingly burdened with non-communicable diseases; the socalled double burden of disease. This epidemiological shift is exemplified by The Gambia where non-communicable diseases are now the leading cause of morbidity and mortality among adults.6–10 At the same time, infectious diseases including Tuberculosis (TB), Human Immunodeficiency virus (HIV), Ebola virus disease (EVD) and cholera remain an ever present threat to the health system.11–14 Taken together, these conditions threaten to undermine achievements in childhood vaccinations, maternal mortality, women’s empowerment, malnutrition,15 and economic growth,16 making critical care a necessary resource, whose design and implementation is fundamental to the achievement of Gambia’s Sustainable Development Goals (SDG).

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Material and Methods

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Reliable population-based estimates on the incidence and outcomes of critical illness are limited in low and middle-income countries (LMICs), like The Gambia.1,17–19 To date, there have been no previously reported data on number of critical care beds, and critical care is notably absent in The Gambia National Health Sector Strategic Plan 2014-2020 (GHSSP),13 the Sustainable Development Goals (SDGs), and other major global health policy.20 In this study, we surveyed eight secondary and tertiary care hospitals in The Gambia and assessed their critical care bed capacity as well as their ability to provide basic critical care services.

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Study Area The Gambia is the smallest country on the African mainland with an estimated population of 2.1 million people living on an 11,000 Km2 (Figure 1).21 The country is divided into two halves by the river Gambia and surrounded by Senegal except for a 60 km coastline on the Atlantic Ocean. Seventy percent of the workforce is employed in agriculture, and it is among the Least Developed Countries (LDCs) in the world with a Gross Domestic Product (GDP) per capita of US$1676. About 60% of the population resides in three administrative districts near the coastline, namely- Banjul, Kanifing, and Brikama local government areas (LGAs).

The Gambia has a three-tiered health care system that provides primary, secondary and tertiary services. Primary health care is provided through a network of village health posts. At this level, services include basic antenatal care and home deliveries in villages provided by Village Health Workers (VHW’s) and Community Birth Companions (CBC’s) under the supervision of Community Health Nurses (CHN’s). The secondary health care system is comprised of a network of major and minor health centers and community clinics. Major Health Centers (MHCs) provide comprehensive Emergency Obstetric Care (EMOC) services, while Minor

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Health Centers provide basic EMOC, reproductive and child health services. Community health nurses run community clinics with basic equipment providing routine preventive and curative services for conditions such as malaria and acute respiratory infections (ARI), diarrheal diseases and basic antenatal care. Tertiary care is provided through a network of five general hospitals (also known as district hospitals) and six major health centers with a total bed capacity of 4,450 acute care beds, defined in general terms by the Ministry of Health & Social Welfare (MoHSW) as a hospital bed or cot specifically defined for hospitalized patients or others in need of some form of health care.6 The range of services provided in these hospitals is variable and includes general anesthesia, surgery, comprehensive EMOC, and trauma services. The country has only one trauma center- Edward Francis Small Teaching Hospital (EFSTH), which is the national referral center, and teaching hospital for the School of Medicine and Allied Health Sciences of the University of The Gambia. There are 10 non-governmental organization (NGO) health facilities in the country and 14 private clinics according to the MoHSW.6

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Health care in The Gambia is financed by the government through budgetary allocations to the MoHSW and supplemented by donor aid and private out-of-pocket expenditures (See Supplementary Table 5). At the point of care, a flat prescription user fee of 25 Dalasi (US $0.5) is levied on outpatients to cover consultations and prescriptions available in government-owned hospitals, while hospitalized patients pay a weekly bed fee of 100 Dalasi (US$ 2) and a laboratory fee of 50 Dalasi (US$ 1).22 Out of pocket expenditure for a chest x-ray is 50 Dalasi (US $4.24), while a CT scan costs 2000 Dalasi (US $42.38)

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Questionnaire Development We developed a survey instrument to assess the number of ICU beds and availability of equipment at each facility. The questionnaire covered six domains. The first domain covered information on the presence of a ward or location within the hospital designated as an ICU. This section also included information on number of ICU beds (if an ICU was present), the availability of an isolation unit, personal protective equipment, supplemental oxygen, and respiratory facemasks. The second domain covered point of care testing and treatment including availability of thermometers, blood pressure monitoring devices, pulse oximeters, infusion pumps, blood glucose monitors, electrocardiograms (EKG), and nebulizers. The third domain covered procedures performed at the facility, while the fourth covered oxygen supply and mechanical ventilation. The fifth domain covered patient safety issues, while the sixth covered issues around patient transfer during a critical illness with a focus on communication between providers and hospitals. We also collected information on the cost of patient transfer in this section (see online supplement).

Respondents and Survey Completion The survey was conducted from November 20th to December 25th, 2017. The sample frame was the eleven government-owned general hospitals and Major Health Centers providing secondary

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and/or tertiary health care services in the country. In each hospital, we identified one participant among physicians stationed as Medical Officers at the respective hospitals. Medical Officers are non-intensivist general physicians who have completed basic medical and housemanship training, and are fully registered to practice medicine independently by The Gambia Medical & Dental Council. They are primarily involved in direct patient care, although some may serve in an administrative capacity. In facilities were there were no physicians (some Major Health Centers), we contacted a nurse stationed there who was involved in direct patient care. We contacted potential participants by email and telephone for recruitment. Next, we emailed the questionnaire directly to those who agreed to participate in the survey for self-administration. All respondents received instruction on specific terminology used in the survey instrument prior to completion of the questionnaire. We verified data manually before entry from the source documents and after data entry.

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Physician Workforce Needs and Future Projections

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To ascertain the number of physicians working in the country, we obtained data from the Ministry of Health and Social Welfare’s annual statistical report as well as The Gambia Medical and Dental Council (GMDC). We obtained data on the number of medical students enrolled and graduating from the School of Medicine and Allied Health Sciences (SMAHS) of the University of The Gambia since its inception in 1999.23 Using the aforementioned data and population census data published by the Gambia Bureau of statistics (GBoS), we calculated the current physician workforce per 1,000 population and estimated future needs based on population projections.24

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To assess the effect of an increased medical school enrollment on closing the physician workforce gap and achieving the WHO recommended target of 1 physician per 1,000 population, we calculated the physician work force growth for three scenarios: i.) current graduation rate at a median of 18 physicians per year; ii.) a graduation rate of 100 physicians per year (representing a 5-fold increase); and iii.) a graduation rate of 180 physicians per year (representing 10-fold increase in current graduation rates). We then assessed the time it will take to meet the physician workforce needs of the country under the aforementioned scenarios (see statistical analysis section for model parameters and assumptions).

Definition of Terms We used the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU in this survey. The WFSICCM defines an ICU as a specialized unit or location in a hospital or health facility with a 1:3 nurse patient ratio, where patients are able to receive skilled nursing care, close heart and respiratory monitoring and treatment including noninvasive and invasive mechanical ventilation provided by a physician as needed.19 We defined a critical illness as any medical condition that requires urgent diagnostic evaluation, monitoring and treatment without which the patient will suffer loss of limb or life. Examples include ruptured appendicitis, ruptured ectopic pregnancy, eclampsia, placental abruption, stroke,

ACCEPTED MANUSCRIPT heart attack, seizures, sepsis, trauma, severe asthma or COPD exacerbation, or respiratory failure due to any cause.

Statistical Analysis

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In reporting survey findings, we summarize responses from each respondent as count (percentages) and reported continuous data as mean (standard deviation, SD) if normally distributed or median (interquartile range, IQR) if not normally distributed. Because of the small number of respondents, we did not use inferential statistics.

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To calculate population projections, we used an exponential population growth model using the following variables:

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N= population in a given year N0= 2018 population (2120000) e= is a mathematical constant, approximately equal to 2.71828 t= time elapsed, (year) r= annual population growth rate of 3% as reported by the Gambia Bureau of Statistics during the intercensal period 2003 - 2013. 24

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   

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Where:

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All statistical analyses and plots were performed using STATA version 10 (StataCorp; College Station, TX).

Ethical Approval

Results

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This project was reviewed by the University of Massachusetts Institutional Review Board (IRB #H00013199) and approved by the Ministry of Health and Social Welfare (MoHSW) of the Republic of The Gambia.

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We sent the questionnaire to eight individuals, each stationed at one health facility providing secondary or tertiary health care services in the public health system. Of these, seven agreed to participate in the survey and returned the questionnaire, representing a response rate of 88%. This survey thus covered 64% of The Gambia’s eleven government-owned hospitals providing secondary and tertiary care services. Hospital Characteristics We present hospital characteristics in Table 1. There is only one dedicated intensive care unit capable of providing level 1 intensive care in the country’s public health system, located at the EFSTH with eight ICU beds. There are no ICUs in the country capable of providing level 2 or 3 intensive care. Thus, the population-based estimate of ICU bed capacity is 0.4 ICU beds/100,000 population (Table 2). Five hospitals reported admitting at least 50 patients meeting the defined

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criteria for a critical illness every month, while the two Major Health Centers reported between 10 – 25 critically ill admissions per month (Table 2). Taking these findings together, we estimate the total number of critically ill patients seen across these hospitals to be in excess 3,000 patients annually. The average clinician self-reported length of hospital stay (LOHS) for acutely hospitalized patients was 7 days (± 2). Only three hospitals had an isolation unit with a total capacity of 27 beds resulting in population estimate of about 1.3 isolation beds/100,000 population (Table 1). The median daily census, or patient load, per physician was 20 patients (IQR: 3 – 26).

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Table 3 shows the equipment available in the ICU at the EFSTH. There were three mechanical ventilators, and oxygen supply is unreliable and only available sometimes. The ICU lacks basic non-invasive respiratory and hemodynamic monitoring equipment including telemetry, pulse oximetry, and electrocardiography. Ultrasound was sometimes available. With regard to therapeutic interventions, non-rebreather masks, high-flow nasal cannula oxygen, and noninvasive positive pressure ventilation was not available, neither was arterial blood gas analysis.

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Hospital Procedures Table 4 summarizes findings on the ability to perform lifesaving interventions in critically ill patients at the facilities surveyed. None of the hospitals surveyed had a functioning defibrillator at the time of the survey; therefore, none of the hospitals can perform CPR by Advanced Cardiac Life Support (ACLS) standards. Only one respondent reported their facility always performed endotracheal intubation for airway management of respiratory failure, while three reported intubating sometimes and two never performed intubations. Similarly, only one respondent reported that they could always perform central venous catheterization and thoracentesis when indicated. Four of the respondents reported that these procedures were never performed at their facility. None of the hospitals surveyed have the ability to perform bronchoscopy.

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Despite trauma being the most common reason for transfer of critically ill patients, only two respondents reported performing cervical spine stabilization, noting this was done rarely. The other five respondents reported that this intervention was never performed in trauma patients. Similarly, in patients with long bone fractures, only one respondent reported their facility performed stabilization often, while three reported it was performed sometimes.

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Hospital Transfers We present responses to questions on inter-hospital transfers of critically ill patients in Table 5. Five respondents (72%) reported transferring more than 10 critically ill patients in the preceding 90 days. Trauma was the most common reason for transfer among four of the seven respondents surveyed, followed by obstetric emergencies, hypertensive emergencies, and stroke. In all patient transfers, the reason for transfer was for specialized care. Direct communication among providers did not always occur before transfer of critically ill patients. Four respondents (57%) stated that they “sometimes” communicate directly with the receiving hospital before a patient is transferred. Five respondents (71%) reported that they were able to identify the on-call physician at the destination hospital beforehand, and a similar number always had access to an ambulance for transfers. The cost of transfer was variable ranging from

ACCEPTED MANUSCRIPT D840 - D17,640 Dalasi (US $18 - $373). While six respondents (86%) kept records of transfers, only one used an inter-hospital transfer checklist.

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Point of Care Testing and Venous Thromboembolic disease prophylaxis We present findings on the availability of point of care tests necessary for the diagnosis of sepsis and respiratory failure in Table 2 of the online supplement. All respondents reported that they had thermometers present at their hospital, however availability was variable. Two respondents reported that it is always available when needed, while another two reported that it is often available. Three stated that it is sometimes available. Pulse oximetry was always available at only one hospital, and often available at another. Two respondents reported that it was never available, while one reported that it was rarely available. Similarly, blood pressure measuring devices were reported to be always available at one hospital, often available in two, and sometimes available in the four other hospitals.

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X-ray services were always available in only two hospitals, often available in one and sometimes at another. Three hospitals (43 %) did not have x-ray services. Four respondents (57 %) reported that they did not have an EKG at their hospital, while three (43 %) reported that it was rarely available. Six respondents stated that they could not do blood cultures at their hospital, while one reported that it was rarely available. Less than half of the respondents reported that their hospitals had the required equipment necessary for the diagnosis of sepsis and respiratory failure including thermometers, blood pressure monitoring devices, blood culture tests, and X-ray services. None of the hospitals had an EKG machine consistently available. Supplemental oxygen was always available in four of the seven health facilities surveyed; and only two of the respondents stated that they had pharmacological deep vein thrombosis prophylaxis at their hospitals.

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Patient Safety We report responses to questions on patient safety in Table 3 of the online supplement. Five respondents (71%) reported significant patient safety problems at their hospital and four (58%) stated that their hospital management were routinely informed about medical errors (Table 3 online supplement). Five respondents (71%) reported that they never used a time-out process before surgery or procedures at their hospital. Only one respondent (14%) reported having a standardized consent form signed by patients for all operations performed at their hospital. Similarly, patient safety checklists were absent in four of the hospitals (57%) and rarely used in 2 (29%). Only one respondent stated that their facility had enough staff to handle the workload. The average self-reported weekly duty hours among physicians was 90-hours (IQR 20 – 104) and respondents reported that direct face-to-face or written communication inconsistently occurred between providers during transitions of care.

Physician Workforce There are about 254 physicians registered to practice medicine in The Gambia, which, when situated in the context of an estimated population of 2,120,000 in 2018, results in 0.1 physician

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per 1,000 population (Table 6). According to data from the School of Medicine and Allied Health Sciences (SMAHS), it has produced 204 physicians since its inception in 1999 (Table 5, Online supplement). The median number of graduating physicians has remained relatively stable at approximately 18 physicians per year. Using the World Health Organization threshold of one physician per 1,000 population, we estimate the current physician workforce deficit for the country at 1,866 physicians (Table 6). Based on our model projections, this deficit will increase to over 5,000 physicians by 2053 given the exponential population growth rate the country is about to experience (Figure 2).

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Figure 3 shows that, at current enrollment rates or with a 5-fold increase in class size, the country will not be able to meet the physician workforce needs by 2050. However, 10-fold increase in graduation rates would result in achieving the workforce needs in about 25 years. Even after lowering the projected need to a target of 1 physician per 4,500 population as planned by the MoHSW in 2005, the current estimate and future projections falls short of that target (See Figure 1 in Online supplemental material).

Discussion

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To the best of our knowledge, this is the first study looking specifically at critical care capacity in The Gambia. The key finding of this survey is that The Gambia lacks ICU beds and resources to care for a large number of critically ill patients in the public health system. At the one institution with an ICU, we found a lack of basic equipment necessary for close monitoring of critically ill patients. In many countries, data on critical care resources are not available and this is particularly true in sub-Saharan Africa.19,25–27 Of the few countries that have published data on ICU bed capacities, our estimate of 0.4 beds/100,000 is similar to those in the sub-region. For instance, Uganda has about 0.1 ICU beds/100,000, and Zambia has an estimated 0.6 ICU beds/100,000). These estimates are significantly lower than those reported for highly industrialized countries like South Africa (8.9/100,000), Sweden (5/100,000), Germany (29/100,000) and the United States (33/100,000).28–31 Although this survey did not cover all the secondary and tertiary care institutions in the country, we know that none of the other public health facilities have an ICU (personal communications). The ICU bed shortage in The Gambia is compounded by a lack of trained specialists in critical care and anesthesiology. 3,6

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Although critical care beds and services are lacking in The Gambia, there is substantial need as illustrated by the observation that most respondents reported admitting more than 50 patients a month who met criteria for a critical illness. This suggests an estimated 3,000 critically care admissions per year. Indeed, this is a conservative estimate given the lack of data on acute inpatient admissions in the health system. Similar to other African countries, most critically ill patients in The Gambia are managed in regular acute care beds, with low frequency monitoring and nurse-patient ratios resulting in an increased risk of mortality.32 In a recent study by Andrews et al, Early Goal Directed Therapy (EGDT) resulted in a higher mortality rate in the intervention group, in part due to deficiencies in critical care. This paradoxical observation may also be due to case-mix differences and potential harm from the fluid intervention.33 Regardless of the cause, global efforts to improve sepsis survival will require the development of critical care resources in low and middle income countries. 34

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The present study also sheds light on a substantial lack of equipment required for the diagnosis and treatment of critical illnesses. Based on the findings of our surveys, septic shock, respiratory failure, and potentially fatal cardiac rhythms can neither be diagnosed nor adequately treated with the existing infrastructure. These shortages have clear mortality consequences. In 2016 MoHSW reported 329 non-communicable disease (NCD) deaths nationwide due to complications of hypertension, cardiovascular and other diseases, (Table 1 online supplement), yet our survey found that defibrillation is never performed in any hospitals surveyed and none of the hospitals reported a consistently available EKG machine or sphygmomanometers (Table 2).6 Similarly, although trauma was the most common reason for referral to other hospitals, cervical spine and long bone fracture stabilization is rarely performed during transfers. The ministry reports that burns and road traffic accidents are the most common cause of emergency admissions, accounting for over 50% of cases; however, providers in these hospitals are not trained in advanced trauma life support (ATLS).6 Taken together, these findings demonstrate a lack of resuscitation skills among providers in the Gambian health system.35–37 Currently, health care providers are not required to undergo training and certification in ATLS, or basic and advanced cardiac life support training, presenting opportunities for the scale up of these skills across the spectrum of health providers through continuous medical education, short courses and simulation based learning.38–40

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Our projections show that the current physician shortage in The Gambia is likely to continue to grow, both because of an increasing population and an insufficient rate of producing, recruiting and retaining physicians. These estimates assume a median graduation rate of 18 physicians per year and negligible net emigration in the last 10 years. Our projections also demonstrate that anything less than a 10-fold increase in medical school enrollment will fail to close the health workforce gap; therefore, alternative solutions would have to be sought. Such a shortage is not unique to The Gambia, and other African countries, like Ghana, have successfully addressed this issue with the expansion of advanced practitioners, such as physician assistants (PA) and nurse practitioners (NP), doubling the essential health workforce from 1.07/1,000 in 2005 to 2.14/1,000; in part through the expansion of training for midlevel providers with an excess of 2,500 PAs registered and practicing in various health facilities in the country.41–43 Similarly, Ethiopia, Kenya and Uganda have implemented cost-effective programs that train community based advanced practitioners to provide varying levels of primary care services to communities.44,45 The United States has also employed a similar strategy, training NPs and PAs to address the primary care physician shortage which resulted in improvements in access to healthcare, especially in rural areas.46,47 Such non-physician providers can be trained to provide Level I critical care, under the supervision of a physician trained in the fundamentals of critical care support. The Society of Critical Care Medicine (SCCM) has a Fundamental Critical Care Support (FCCS) curriculum targeted at non-critical care providers on the management of the critically ill patient.48 There is also the Basic Assessment and Support in Intensive Care (BASIC) course which is designed for non-intensivist providers.49 These programs could be adapted to The Gambia, in the short term, to scale up competency in critical care while long-term solutions are being implemented. Long term solutions could include the establishment of training partnerships such as the East African Training Initiative (EATI)- a collaborative effort between Addis Ababa University and Columbia and Brown Universities that has trained seven Ethiopian

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specialists in Critical Care Medicine since its inception in 2013.50 The Africa Research Excellence Fund (AREF) is another initiative aimed at building the capacity of African health workers by providing mentorship through workshops in grantsmanship and scientific writing, resulting in publication of original scientific research by recipients of this fellowship.51 The Gambian government, through the Ministries of Health & Social Welfare and the Ministry of Higher Education, Research, Science and Technology (MOHERST) should include the scale up of critical care training and resources as a major priority in the National Health Sector Strategic Plan, and the National Science, Technology and Innovation Policy (NSTIP). 13,52

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Medical errors are a leading cause of death in health care. This is especially true for critically ill patients because they require high intensity monitoring, complex treatment, and rely on a multidisciplinary healthcare team with frequent transitions that are subject to a high rate of medical error.53–56 Little is known about patient safety in African healthcare systems. Most of the data on the subject were gathered from highly industrialized countries where medical errors have been reported as the third leading cause of death among hospitalized patients.56 The present study provides some insights in The Gambian context by highlighting several important patient safety concerns. First, the majority of respondents (5/7, 71%) expressed concerns about patient safety problems at their respective hospitals. Second, hospitals rarely, if ever, use standardized patient consent forms, patient safety checklists, and a timeout process in surgical patients. Third, physicians work an average of 90 hours a week (IQR 20 - 104) and care for about 20 patients at time, which both increase the risk of medical errors.57,58 Fourth, direct effective communication between providers during transitions of care occurs consistently in only two (29%) hospitals surveyed.

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The Gambia currently does not collect data on patient safety matrices and there is no national policy or guidelines for patient safety in The Gambia National Health Sector Strategic Plan (GHSSP), highlighting a pressing need to incorporate patient safety awareness and training in the aforementioned national policies and in the education curriculum of health workers.13,52 The introduction of simple, low-cost interventions such as time-out processes, use of patient safety checklists, and consent forms have been shown to dramatically reduce medical errors and adverse outcomes in medical systems. Thus, it is our opinion that these changes would be low cost and produce significant improvements if implemented in the Gambian health system.59–64 We have therefore summarized a series of actions that can be taken to improve the critical care capacity in the country in Table 7, key among which is the incorporation of critical care in the GHSSP and the NSTIP as an initial step.

Limitations There are several important limitations to our survey results. First, we were unable to cover all health facilities in the country providing secondary and tertiary level care; the four major health centers not included in this survey were excluded because they did not have internet access and thus could not be contacted by study protocol. However, based on personal communications these facilities do not have ICUs; therefore, our estimates of bed capacity are not affected by their exclusion. Secondly, our data did not cover private and non-governmental institutions that

ACCEPTED MANUSCRIPT form a significant part of the health system. Although we were informed that at least one private clinic and one NGO clinic each had an ICU, we could not verify this information.

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Our estimates of the physician workforce need are based on assumptions such as negligible net emigration and death among physicians, stable population growth, and the absence of severe epidemics or other catastrophic political and environmental events such as war and famine, all of which can alter the number of physicians in the country. Furthermore, the WHO recommended threshold of one physician per 1,000 population has a number inherent limitations that has been contested by others. 65 It is unclear whether this number is optimal given significant differences between health systems. In spite of these uncertainties, our estimates are a reasonable attempt to quantify the deficit and make reasonable projections on the effect of increasing medical school enrollment while suggesting alternative methods of meeting the health worker shortages in the country. Finally, the summary of recommendations given in this paper represent opinions of the authors and is not the result of a multi-stakeholder consultation on the topic.

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Conclusion

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Authors contributions

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In conclusion, The Gambia lacks ICU beds and the capacity to deliver basic critical care to patients presenting to its public health institutions even though critical illnesses are among the leading causes of adult acute care admissions and deaths. Improvements in life expectancy cannot be reasonably achieved without the inclusion of critical care in The Gambia National Health Strategic Plan. Our findings also highlight a need for training of health workers in resuscitation of the critically ill patient and patient safety standards. Finally, there is a severe shortage of equipment necessary to provide basic critical care in public hospitals. More research on the epidemiology and clinical outcomes of critically ill patients are needed to identify costeffective interventions to reduce the associated mortality.

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ST and BS designed the study and contributed to analysis and draft manuscripts. FD, KF, EK, GJ, AS, MN, LNS and AT were involved in data collection. ST, GZ and BS were involved data extraction, analysis and initial write up. All authors were involved in the final corrections of the manuscript.

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Conflict of interest

The authors have no conflicts of interest with regard to the content of this manuscript

Acknowledgements We would like to thank Tumani Corrah, M.D., Ph.D., F.R.C.P., P.P.W.A.C.P, of the Africa Research Excellence Fund and the Bill & Melinda Gates Foundation Scientific Advisory Committee for his mentorship and guidance in the conception of this study. We would also like to acknowledge Saffie Lowe-Ceesay, Cherno Omar Barry, PhD, Permanent Secretary MoHSW, Dr. Isatou Touray Minister of Health & Social Welfare and Scott E. Kopec, MD, FCCP for their support in the conduct of this study.

ACCEPTED MANUSCRIPT Funding This study was funded in part by a generous grant from the University of Massachusetts Medical School Office of Global Health: Grant #125823.

Data Sharing Statement No additional data are available.

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Hospital Name

Hospital type

LGA

Population Served β

Bundung Maternal & Child Hospital

General hospital

Kanifing

55,360

No

Bansang General Hospital

General hospital

Janjanbureh

126,910

No

ICU Present

General hospital

Basse

239,916

No

Edward Francis Small Hospital

Teaching hospital

Banjul

1,882,450

Yes

Serekunda General Hospital

General hospital

Kanifing

382,096

No

Sukuta Major Health Center

Major health facility

Brikama

42,955

No

Gunjur Major Health Center

Major health facility

Brikama

108,773

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Basse District Hospital

No

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Table 1: Characteristics of hospitals with responses to survey. LGA: Local Government Area, ICU: Intensive Care Unit; β: Based on 2013 Census data from The Gambia Bureau of Statistics.

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ICU Capacity (n=7) Number of hospitals with an intensive care unit (ICU) 1 (14 %) Number of ICU beds β 8 ICU beds per 100,000 population 0.4 ICU beds as % of acute care beds µ 0.2 Estimated number of critically ill patients admitted per month Less than 10 1 (14 %) 10 – 25 1 (14 %) More than 50 5 (72 %) Length of hospital stay (days) ╫ 7 (± 2 ) Availability of an isolation unit ƪ 3 (43 %) Total number of isolation beds available ƪ 27 Isolation beds per 100,000 population * 1.3 Patient census per physician (median, IQR)** 20 (3 – 26) Table 2: Aggregated findings from each respondent at health facilities surveyed. β: All beds were situated at the EFSTH hospitals; µ: estimated as fraction of 4,450 acute care beds reported by the MoHSW. ╫: Length of stay is for all acutely hospitalized patients. ƪ: Isolation unit is for all patients, regardless of whether they were critically ill or not. * Isolation beds are for all patients. ** Summary of self-reported daily patient census per medical provider

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ICU Equipment at the EFSTH ICU Number of ICU beds 8 Number of mechanical ventilators 3 Controlled oxygen Sometimes available Telemetry monitoring Not available Pulse oximetry Rarely available EKG Rarely available Non-rebreather masks Rarely available High flow nasal cannula Not available Non-invasive positive pressure ventilation Not available X-ray services Sometimes available Computed tomography Sometimes available Arterial blood gas Not available Ultrasound Sometimes available Personal protective equipment** Not available Infusion pump Rarely available Table 3 ** Includes: sterile gloves, facemask and gowns. EFSTH: Edward Francis Small Teaching Hospital

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Procedures Performed Across Hospitals (n=7) Critical care interventions Number of Hospitals Performing Intervention Cardiopulmonary resuscitation (CPR) 0 (0 %) Endotracheal intubation Never performed 2 (29 %) Rarely performed 0 (0 %) Sometimes performed 3 (43 %) Often performed 1 (14 %) Always performed 1 (14 %) Non-invasive positive pressure ventilation Never performed 6 (86 %) Rarely available 1 (14 %) Sometimes performed 0 (0 %) Often performed 0 (0 %) Always performed 0 (0 %) Bag mask ventilation Never performed 0 (0 %) Rarely performed 0 (0 %) Sometimes 5 (71 %) Often performed 1 (14 %) Always performed 1 (14 %) Administration of vasopressors in patients with shock Never performed 2 (29 %) Rarely performed 2 (29 %) Sometimes performed 2 (29 %) Often performed 0 (0 %) Always performed 1 (14 %) Central venous catheterization Never performed 4 (57 %) Rarely performed 1 (14 %) Sometimes performed 0 (0 %) Often performed 1 (14 %) Always performed 1 (14 %) Bronchoscopy Never performed 7 (100 %) Rarely performed 0 (0 %) Sometimes performed 0 (0 %) Often performed 0 (0 %) Always performed 0 (0 %) Thoracentesis Never performed 4 (57 %) Rarely performed 0 (0 %) Sometimes performed 1 (14 %) Often performed 1 (14 %) Always performed 1 (14 %) Cervical spine stabilization for trauma patients Never performed 5 (71 %) Rarely performed 2 (29 %) Sometimes 0 (0 %) Often performed 0 (0 %) Always performed 0 (0 %) Long bone fracture stabilization in trauma patients Never performed 2 (29 %) Rarely performed 1 (14 %) Sometimes performed 3 (43 %) Often performed 1 (14 %) Always performed 0 (0 %)

Table 4

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Inter-hospital Transfer of Critically Ill Patients (N= 7) Number of critically ill transfers in the preceding 90 days** 1–5 1 (14 %) 6 – 10 1 (14 %) More than 10 5 (72 %) Most common transfer diagnosis Trauma 4 (58 %) Obstetric emergency 1 (14 %) Hypertensive emergency 1 (14 %) Stroke 1 (14 %) Frequency of direct communication between physicians during inter-hospital transfer of critically ill patients Never 1 (14 %) Rarely 1 (14 %) Sometimes 4 (57 %) Often 1 (14 %) Always 0 (0 %) How often are physicians able to identify and contact the receiving hospitals on call physician prior to transfer? Never 2 (29 %) Rarely 0 (0%) Sometimes 3 (42 %) Often 2 (29 %) Always 0 (0%) Availability of ambulances for transfer of critically ill patients Never 0 (0%) Rarely 0 (0%) Sometimes 1 (14 %) Often 1 (14 %) Always 5 (72 %) Cost of ambulance transfer (Median, IQR; US$) $24 (IQR, 18 - 373) Availability or use of an inter-hospital transfer checklist 1 (14 %) Keep records of inter-hospital transfers of critically ill patients 6 (86 %) Table 5: Responses to questions on how each hospital handled patient transfers for critically patients. **Refers to transfers going out of the hospital of the responding physician to another hospital for a higher level of care.

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Physician Workforce in The Gambia Number of physicians registered with the Medical & Dental Council 254 Estimated population (2018) † 2,120,000 Median number of graduating doctors per year ƒ 18 (IQR 12–27) Physicians per 1,000 population 0.1 Physicians per 4,500 population ** 0.5 Number of Physicians required to achieve WHO target of 1 per 1,000 population 1,866 Table 6: ƒ: Median number of physicians graduating from SMAHS/UTG from 2006 – 2017. † World Bank Data projections. ** These are based on targets set by the MoHSW (Human Resources for Health 2005 – 2020 Report)

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Summary of Recommendations to develop Critical Care Capacity in Gambia Critical care should be included in the Gambia National Health Sector Strategic Plan as a major priority for the improvement of health outcomes. There should be a prospective registry collecting data on outcomes for trauma, obstetric emergencies, strokes, and cardiovascular emergencies at all general hospitals. There is an urgent need to train specialist physicians and nurses in critical care medicine and critical care should be included as a major priority in the National Health Sector Strategic Plan, and the National Science, Technology and Innovation Policy (NSTIP). There is an urgent need to scale up competency in resuscitation among physicians and nurses using Basic Life Support, Advanced Cardiac Life Support and Advanced Trauma Life Support certification courses in partnership with institutions in highly industrialized countries where these skills are available. This should be in tandem with the provision of equipment for resuscitation of critically ill patients. To close the physician workforce deficit, the country needs an emergency medical system (EMS) manned by trained paramedics, mid-level providers and emergency medicine physicians. Patient safety should be made a national priority and included in the Gambia National Health Sector Strategic Plan (GHSSP); and the ministry should establish a mechanism to collect data on medical errors, and incorporate best practices aimed at reducing their occurrence in the health system Government should leverage the power of mobile technology in partnership with private enterprise and non-governmental organizations to establish a central, toll-free telemedicine care coordination center aimed at improving communication between hospitals during transitions of care, and provide teleconsultation services to remote hospitals as part of a strategy to improve the triage of critically ill patients. Table 7

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Figure 1: Map of the The Gambia with population densities of the Local Government Areas

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Physician Deficit

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Figure 2: Projected population growth and physician workforce deficit. Red line shows projected number of additional physicians required to meet the WHO target of 1 physician per 1,000 population.

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Figure 3: Simulated projections illustrating three scenarios of an increased medical school enrollment on physician workforce per 1,000 population. The three scenarios are: i.) current enrollment rates, b.) a 5-fold increase in current enrollment, and c.) a 10-fold increase in current enrollment.

ACCEPTED MANUSCRIPT What is already known on this topic 

Most low-income countries lack any published data on critical care capacity.

What this study adds 

The Gambia currently has only 8 ICU beds in the public health system with an estimated 0.4 ICU beds/100,000 population. There are neither trained specialists in critical care and anesthesiology nor resuscitation training programs for non-specialist providers. Critical illnesses including trauma, stroke, hypertensive and obstetric emergencies are leading

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causes of adult emergency admissions and deaths in The Gambian public health system with an estimated 3,000 cases annually.

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Based on the World Health Organization recommended target of 1 physician per 1000 population, The Gambia’s current physician workforce deficit stands at 1,866 physicians and is expected to

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increase to over 5,000 physicians by 2050 if current conditions persist.

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