When someone falls critically ill, hospitals are expected to provide life-saving care – but in many African countries, ICUs are rare. Critically-ill patients are treated in general wards, and the provision of essential emergency and critical care is limited.
The prevalence of critical illness and associated mortality is high in these hospitals, with one in eight in-patients being critically ill, and one in five of them dying, write Tim Baker and Karima Khalid in The Conversation.
They urge governments in Africa to make essential critical and emergency care a core part of universal health coverage and integrate this into policies and health benefit packages.
They write:
Critical illness has been neglected in healthcare policy, research, and implementation, and improving the care of these patients has the potential to save many lives from acute diseases of every aetiology.
Critical illness refers to any life-threatening condition where at least one vital organ – like the heart, lungs, or brain – is failing. It can arise from any underlying condition including infections, injuries, or non-communicable diseases such as heart attacks and strokes, and can affect anyone of any age.
In high-resourced settings, some critically ill patients are treated in intensive care units. They receive continuous monitoring, oxygen support, medication to stabilise their blood pressure, and other life-saving treatments.
Until now, most data on critical illness and critical care in Africa has come from small, single-hospital studies. These studies hinted at a serious problem.
For example, a study in Uganda found that 11.7% of in-patients were critically ill, with a 22.6% chance of dying within a week. However, there was no large-scale research showing how widespread this was across the continent.
For this reason, we, as a collaboration of clinical researchers across Africa, conducted the African Critical Illness Outcomes Study, providing the first large-scale look at the state of critical illness care across the continent.
The study builds on a network of clinicians, researchers and policy makers that has been growing for more than a decade now, working out how to identify and treat patients who are critically ill.
The findings, published in The Lancet, are striking. One in eight hospital in-patients in Africa is critically ill, more than two-thirds of these patients are in general wards, and one in five dies within a week.
Most of them do not receive the essential emergency and critical care – like oxygen and fluids – that could save their lives.
What we found
The African Critical Illness Outcomes Study investigated 20 000 patients in 180 hospitals in 22 countries across Africa: from Tunisia in the north to South Africa in the south, from Ghana in the west to Tanzania in the east.
Between September and December 2023, all adult in-patients in each hospital were examined on a single day to collect data about their clinical condition and treatments, and then a week later, their in-hospital outcomes.
The key findings were:
- 12.5% of hospital inpatients were critically ill;
- 69% of critically ill patients were treated in general hospital wards, not intensive care units;
- more than half of critically ill patients didn’t receive the treatments they needed; and
- critically ill patients were eight times more likely to die in hospital than other patients.
The study also revealed gaps in the most basic life-saving interventions:
- only 48% of patients with respiratory failure received oxygen therapy;
- just 54% of patients with circulatory failure (like shock) received fluids or medications to stabilise blood pressure; and
- less than half of patients with a dangerously low level of consciousness received airway protection or were placed in the recovery position.
These findings highlight a clear and urgent problem: many critically ill patients in Africa are not receiving the essential treatments that could keep them alive.
What can be done?
The study suggests that thousands of lives could be saved if hospitals had better access to essential emergency and critical care. This is a set of simple, low-cost interventions that can prevent deaths from critical illness.
The care interventions include:
- ensuring oxygen is available for patients struggling to breathe;
- providing fluids or medications to stabilise blood pressure; and
- training healthcare workers in basic life-support techniques to manage unconscious patients.
Unlike high-tech intensive care unit treatments, essential emergency and critical care can be given in general wards with minimal resources.
Strengthening these systems could dramatically reduce preventable deaths from conditions such as pneumonia, sepsis and trauma.
Urgent action is needed
This study sheds light on a healthcare crisis affecting millions of people, yet one that has remained largely overlooked.
Every critically ill patient, no matter where they are treated, should receive the basic life-saving care they need.
We call for urgent action.
Governments in Africa should make essential emergency and critical care a core part of universal health coverage. It should be integrated into policies and health benefit packages.
The World Health Organisation should embed essential emergency and critical care measures into its resolutions.
African health funders should support studies and implementation of essential emergency and critical care.
Professional medical societies and institutions should include this care in clinical guidelines and training. Frontline healthcare workers must have the tools they need to save lives.
The EECC Network, a global community dedicated to sharing knowledge, research and best practices, has been started to help prevent needless deaths.
Tim Baker –Associate Professor, Karolinska Institutet;
Karima Khalid – Lecturer, researcher, and consultant in anaesthesiology and critical care, Muhimbili University of Health and Allied Sciences.
Study details
The African Critical Illness Outcomes Study (ACIOS): a point prevalence study of critical illness in 22 nations in Africa
ACIOS Investigators
Published in The Lancet on 1 March 2025
Summary
Background
Critical illness represents a major global healthcare burden and critical care is an essential component of hospital care. There are few data describing the prevalence, treatment, and outcomes of critically ill patients in African hospitals.
Methods
This was an international, prospective, point prevalence study in acute hospitals across Africa. Investigators examined all inpatients aged 18 years or older, regardless of location, to assess the co-primary outcomes of critical illness and seven-day mortality. Patients were classified as critically ill if at least one vital sign was severely deranged. Data were collected for the available resources at each hospital and care provided to patients.
Findings
We included 19 872 patients from 180 hospitals in 22 African countries or territories between September 2023 and December 2023. The median age was 40 (IQR 29–59) years, and 11 078/19 862 (55·8%) patients were women. There were 967/19 780 (4·9%) deaths. On census day, 2461/19 743 (12·5%) patients were critically ill, with 1688/2459 (68·6%) cared for in general wards. Among the critically ill, 507/2450 (20·7%) patients died in hospital. Mortality for non-critically ill patients was 458/17 205 (2·7%). Critical illness on census day was independently associated with subsequent in-hospital mortality (adjusted odds ratio 7·72 [6·65–8·95]). Of the critically ill patients with respiratory failure, 557/1151 (48·4%) were receiving oxygen; of the patients with circulatory failure, 521/965 (54·0%) were receiving intravenous fluids or vasopressors; and of patients with low conscious level, 387/784 (49·4%) were receiving an airway intervention or placed in the recovery position.
Interpretation
One in eight patients in hospitals in Africa are critically ill, of whom one in five dies within seven days. Most critically ill patients are cared for in general wards, and most do not receive the essential emergency and critical care treatments they require. Our findings suggest a high burden of critical illness in Africa and that improving the care of critically ill patients would have the potential to save many lives.
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