Policies and resources for strengthening of emergency and critical care services in the context of the global COVID-19 pandemic in Kenya

Abstract

Critical illnesses cause several million deaths annually, with many of these occurring in low-resource settings like Kenya. Great efforts have been made worldwide to scale up critical care to reduce deaths from COVID-19. Lower income countries with fragile health systems may not have had sufficient resources to upscale their critical care. We aimed to review how efforts to strengthen emergency and critical care were operationalised during the pandemic in Kenya to point towards how future emergencies should be approached. This was an exploratory study that involved document reviews, and discussions with key stakeholders (donors, international agencies, professional associations, government actors), during the first year of the pandemic in Kenya. Our findings suggest that pre-pandemic health services for the critically ill in Kenya were sparse and unable to meet rising demand, with major limitations noted in human resources and infrastructure. The pandemic response saw galvanised action by the Government of Kenya and other agencies to mobilise resources (approximately USD 218 million). Earlier efforts were largely directed towards advanced critical care but since the human resource gap could not be reduced immediately, a lot of equipment remained unused. We also note that despite strong policies on what resources should be available, the reality on the ground was that there were often critical shortages. While emergency response mechanisms are not conducive to addressing long-term health system issues, the pandemic increased global recognition of the need to fund care for the critically ill. Limited resources may be best prioritised towards a public health approach with focus on provision of relatively basic, lower cost essential emergency and critical care (EECC) that can potentially save the most lives amongst critically ill patients.

Hospital care for critical illness in low-resource settings: lessons learned during the COVID-19 pandemic

“…Making wise investments should be a priority of countries and the global community. Reactive responses in the first months of the pandemic resulting in a focus to supply advanced equipment for critical illness were often inappropriate 19 20 28. We propose a five-part strategy to guide development and implementation of EECC as part of the broader strengthening of health systems to address the needs of the critically ill patients.…”

“…With rich countries’ ICUs flooded with patients early in the pandemic, initial global attention focused on how to rapidly scale up advanced respiratory support in low-resource settings 18. The result was national governments, multilateral agencies and private philanthropy urgently sourcing and distributing equipment such as ventilators 19 20. Unfortunately, in our opinion, this response ignored prior information from existing health facility readiness assessments and research 3 6 21.…”

“…Unfortunately, in our opinion, this response ignored prior information from existing health facility readiness assessments and research 3 6 21. While it was true that Kenya and Tanzania had very few ventilators, it was also known they had an extreme shortage of medical, nursing and other specially trained personnel able to manage ventilated patients 20 22. Seconding personnel from another hospital area to address gaps in the critical care workforce and attempting to upskill them with extensive virtual training risked more pronounced workforce deficits elsewhere.…”

“…Seconding personnel from another hospital area to address gaps in the critical care workforce and attempting to upskill them with extensive virtual training risked more pronounced workforce deficits elsewhere. This actually threatens provision of EECC more widely, especially as emergency hiring programmes to increase staffing levels were typically short-lived 20…”

“…This actually threatens provision of EECC more widely, especially as emergency hiring programmes to increase staffing levels were typically short-lived. 20 Recognition that attention had to be paid to apparently basic forms of care for critically ill patients with BMJ Global Health COVID-19 rather than advanced respiratory support was slow. In our facility surveys, sometimes many months after the onset of the pandemic, access to oxygen remained low.…”