Overall, only four Malawi hospitals were fully equipped to provide basic paediatric emergency care according to the study definition. More than one-quarter (27%) of Malawi’s population – or approximately 4.7 million people – must travel more than 120 minutes to reach an emergency-equipped hospital with significant regional differences in travel times.
Our findings are more pessimistic than previous studies that estimated only 7% of Malawi’s population live more than two hours from a public hospital with emergency care.(5) Another recent study found that 92.5% of the sub-Saharan African population lived within two hours of a major hospital for surgical procedures.(3) However, actual services provided by each hospital were not known in the aforementioned studies and those results likely overestimate health system capacity to provide emergency care. The current study is the first to our knowledge to map travel times to emergency care for critically ill children in a low-income country by linking a national facility census that combined comprehensive inventory audits with global road network datasets to more accurately estimate population accessibility both nationally and at sub-national levels.
Insufficiencies of equipment and supplies for emergency care within hospitals in sub-Saharan Africa is a well-described problem,(2, 19) and constitutes a major barrier to the provision of quality care and adherence to international guidelines.(20) Lack of basic equipment with associated failures to provide the care needed may create a vicious cycle whereby patients’ experienced and perceived poor quality care at healthcare settings can further contribute to treatment failures.(21) A hospital’s ability to provide the care required by visiting clients is important since it may lead to improved and more timely utilization of services and thus better patient outcomes.
While our study showed great improvements in hospital readiness to manage severe malaria compared to previous ETAT evaluations in Malawi,(13) other deficiencies were found in these results. Specifically, least available items were nasogastric tubes, blood typing services, injectable hydrocortisone, micro nebulizers or spacer inhalers and radiology. These deficiencies are especially disconcerting considering that low- and middle-income countries bear the greatest burden of death from lung disease,(22) and paediatric anaemia.(23) Insufficiencies in the health infrastructure reduces both quantity and safety of blood supplies in low- and middle-income countries,(24) and improved capacity to provide blood transfusions would be life-saving since mortality from anaemia remains high.(25) Our study also found nasogastric tubes commonly lacking in hospitals, which may pose a barrier to delivering quality care for dehydrated and malnourished children. However, this result could partly reflect data collection issues since only specific sizes of nasogastric tubes were audited with common child sizes (6 and 8G) not assessed.
Paediatric asthma is commonly underdiagnosed in low-income settings with associated high mortality rates,(26) and most Malawi facilities lack equipment and medications needed to manage an asthma exacerbation. While oxygen was commonly available in Malawi hospitals, only 15% of lower-level facilities reported oxygen availability despite its inclusion in the WHO essential medicines list.(27) The cost effectiveness of an oxygen system strategy has been shown to compare favourably with other child survival interventions.(28) An implementation effectiveness trial of sustainable and renewable oxygen and power systems in remote areas of low-income countries is underway and could provide promising results.(29)
The recent WHO report on quality of care recommends timely referral for every child with conditions that cannot be managed effectively at first-level facilities.(30) This is an obvious challenge in the Malawi health system where only one-third of facilities have a functional ambulance. Minimum standards for paediatric emergency care in remote and resource-poor settings are not well-defined but pre-referral management using simple equipment and supplies could improve survival chances of very sick patients.(31) Recent studies show that improved pre-hospital care was achieved by training commercial taxi/minibus drivers to provide basic emergency care.(32) Implementation of motorcycle ambulances have also reduced referral times for obstetric care in Malawi.(33) Other innovations to address referral challenges should be explored.
While our results indicate that 73% of Malawi’s population live within 120 minutes travel time to an emergency-equipped hospital, this apparently high figure must be considered in light of related issues. First, there are significant in-country regional differences in access to basic paediatric emergency care with worse population accessibility in North and South than Central regions. Similar inequities have been demonstrated in paediatric pneumonia assessment practises.(34) Second, the purpose of emergency care is to provide urgent medical interventions for time-critical health problems making prompt care essential for entire populations. Third, while travel times are estimated based on road networks, other barriers likely impede travel to hospitals such as financial and physical availability of transport and additional difficulties of transporting severely sick children.(35) Malawi roads may also not be fully developed or there could be other road difficulties that further reduce travel times or require people to walk rather than using other transport means. It is thus expected that actual travel times are longer than ones presented here. Indeed, while travel time are useful in a relative sense (e.g. distinguishing highly accessible areas from remote ones) they provide best-case-scenario values that cannot be considered universally applicable.
Malawi has achieved impressive reductions in child mortality and achieved Millennium Development Goal Four (MDG4) by 2013.(36) This progress has mainly been explained by high and equitable coverage with high-impact preventive interventions including malaria bed net distribution and reductions in malnutrition. While preventive efforts must be sustained, further decreases in child mortality in Malawi and other low-income countries will require substantial investments to expand emergency care to better manage critically ill children at highest mortality risk.
There are a number of methodological considerations in this study. First, equipment and supplies were assessed through audits of general outpatient departments and other service delivery sites. SPA did not specifically audit emergency departments although minor surgery sites were assessed in every facility. This should mainly affect larger hospitals more likely to have a divided organisation of care. Training, management and organisation of emergency care within each facility were not assessed, nor were quality of care or service utilization outcomes. Second, the emergency-equipped definition included items that were either observed or reported available as well as either functioning or not functioning/don’t know on the interview date. This definition may misclassify some facilities as emergency-equipped if items were reported available/functioning but were not. Third, only Malawi facilities were included in the analysis and some populations may have shorter travel times to facilities in neighbouring countries. Fourth, emergencies requiring surgical and/or orthopaedic interventions were not included and involve additional management challenges that should be considered in developing emergency care capacity of a health system. Fifth, data were collected during 2013-2014 and may not reflect current ETAT+ readiness in Malawi hospitals. However, it is not expected that paediatric emergency medicine has substantially improved since this time given the lack of major sector-specific investments. Finally, and as previously discussed, travel time estimates are best-case scenario values that indicate relative distances to emergency care for different populations and geographic areas within Malawi. These estimates are not universally applicable such that individual access to emergency care depends on use (or not) of motorised transport, as one example, that would greatly facilitate or impede individual travel times to emergency care.