Tim Baker

Conditions requiring emergency, critical and operative (ECO) care account for a substantial proportion of preventable mortality and disability worldwide, yet ECO systems remain fragmented and underdeveloped in many settings. Recent global policy advances, including the adoption of the World Health Organization (WHO) Global Strategy and Action Plan for Integrated ECO Care by the World Health Assembly, provide an important opportunity to strengthen these systems. However, implementation must prioritise equity. ECO care spans a wide spectrum of complexity and cost, from basic triage, oxygen therapy and essential operations to advanced intensive care and specialised surgery. Given finite resources, health systems should first ensure universal access to foundational ECO care: early recognition of illness, basic airway and oxygen support, essential medications, monitoring, infection prevention, and timely referral. Approaches such as Essential Emergency and Critical Care (EECC) offer a feasible, highly cost-effective minimum standard of care, and prioritising such foundational ECO care is both an ethical imperative and the most effective pathway to achieving equitable population-level health gains.

Introduction Access to medical oxygen remains a challenge, with 60% of the world’s population lacking access to quality oxygen services. We explored whether ‘outsourced oxygen to the bedside’ (O2B), where private providers offer bundles of oxygen services to health facilities, could be adopted and scaled across diverse health systems, to improve patient access to oxygen.Methods Qualitative interviews were conducted with healthcare workers (HCWs), facility management staff and district medical officers in India, Nigeria, Tanzania, Kenya and Uganda, who had taken part in an O2B pilot. Interviews were conducted between 19 November 2024 and 25 January 2025 and explored the feasibility, fidelity, acceptability, perceived benefits and weaknesses of five O2B models. Analysis used a pragmatic codebook approach, with inductive and deductive coding, informed by implementation science frameworks.Results We conducted 59 interviews across 20 health facilities. We identified five themes relating to the potential for O2B pilots to be adopted within the health system: a positive effect on oxygen culture, feasibility of whole of facility solutions, promotion of local ownership, lack of feasible payment schemes and the desire for hybrid tailored service models. HCWs and facility staff raised several positive factors within these themes but highlighted that understanding local facility needs and tailoring the services to embed within existing structures were important for sustainability.Conclusions Overall, the O2B service approach was feasible and perceived positively by health facility managers and HCWs. However, the effective scale of O2B services will require intentional tailoring to individual facility needs and improved strategies for financial affordability and sustainability.

Introduction: Critical illness is a leading cause of mortality worldwide with the highest burden in low- and middle-income countries. Essential Emergency and Critical Care (EECC) is the foundational, low-cost care needed by all critically ill patients that is feasible to deliver in all health facilities globally. Unfortunately, EECC is often not provided. This study aimed to assess the determinants of non-provision of EECC in primary health care in the United Republic of Tanzania to inform a national EECC scale-up program.Methods: A convergent mixed-methods assessment was conducted in 24 purposively selected health facilities in five regions of mainland Tanzania and Zanzibar. Quantitative resource-readiness and clinical-process assessments were combined with 24 individual interviews and six focus group discussions, and converged using the capability, opportunity, motivation, behavior construct in the Consolidated Framework for Implementation Research: Findings Only 27%-34% of critically ill patients received EECC. Nine determinants of non-provision emerged: gaps in knowledge and skills; inefficient use of staff time; misperceived roles of lower-level facilities; emphasis on advanced care without EECC; poor availability and distribution of resources; oxygen not in place or in use; service organization barriers; low motivation and disincentives to care for the critically ill; and vertical programs determine managers’ priorities.Interpretation: Non-provision of EECC is not primarily an individual failing, but reflects how the foundational care of critical illness is poorly supported and prioritized within the health system, through a self-reinforcing cycle of limited knowledge, weak readiness and system-level acceptance. Strengthening care to reduce preventable mortality necessitates a targeting of context-specific determinants, and an embedding of EECC into health systems and patient management at all levels of health facilities.

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Acute pain in hospitalised patients is common, yet African data are scarce. We conducted a prospective point-prevalence study of hospitalised adult patients across Africa to determine acute pain prevalence and severity and investigate associations of pain with critical illness and 7-day mortality. On a single day, investigators assessed patients' worst pain in the preceding 24 hours using a 0 to 10 visual-numerical scale and recorded vital signs. Critical illness was defined as ≥1 vital sign out of range, in line with an international consensus definition. In-hospital mortality was assessed at day 7. Data are presented as median [interquartile range], n (%), and odds ratios with 95% confidence intervals. Between September and December 2023, 19,438 patients from 180 hospitals in 22 African nations were included (age 40 [29; 59] years; 10,874 [56%] female). Pain prevalence [95% CI] was 67.9% [67.9-68.5], with 2795 (14.4%) patients reporting severe pain (≥7/10). Pain was more common among patients admitted for emergency or trauma care and in surgical and high-care wards. Pain severity did not differ meaningfully between sexes. There was no evidence of an association between pain severity and critical illness; however, increasing pain severity was associated with a higher likelihood of 7-day mortality. These findings are comparable to data from high-income countries despite substantial differences in healthcare resources, suggesting that acute pain remains a persistent and underaddressed problem globally. This study provides the first large-scale evidence of acute pain burden in African hospitals and lays a foundation for future research aimed at comprehensively characterising in-hospital pain.

Background: Medical oxygen is an essential medicine that is often unavailable for patients when they need it. We explored if ‘outsourced oxygen to the bedside’ (O2B) pilots, where private providers deliver a package of services, were successful in ensuring reliable oxygen access at the patient bedside. Methods: We conducted a sequential explanatory mixed-methods assessment of O2B pilots in Kenya, Nigeria, India, Tanzania and Uganda from September 2024 to January 2025. A quantitative cross-sectional facility audit described facility contexts, tested equipment functionality and assessed healthcare worker (HCW) oxygen knowledge. Qualitative interviews with HCWs and managers explored experiences of O2B pilots. Results: We studied 28 of the 80 facilities participating in the pilots, 179 HCWs completed the knowledge survey and 59 qualitative interviews were conducted. In the audit, we found O2B provided oxygen equipment more functional and usable than non-O2B equipment: 64.5% vs 40.9%, p<0.001 for cylinders, 95.0% vs 25.7% (p<0.001) for concentrators and 84.0% vs 70.0% (p value=0.172) for pulse oximeters. Overall, 21.8% (39/179) of HCWs had received training from O2B providers, and their oxygen knowledge was slightly higher than those who had not (mean score 15.3/24 vs 13.9/24, p value=0.002). Qualitative interviews highlighted positive changes in oxygen access and the ability to treat patients, but also mixed understandings of the O2B services being provided, and requests for additional services. Conclusion: O2B pilots appear to improve medical oxygen access, with effective maintenance and repair services being a key mechanism. However, tailoring to local needs and remaining gaps in HCW capacity need to be addressed.

Critical illness leads to millions of preventable deaths each year. Essential Emergency and Critical Care (EECC) is a pragmatic, globally relevant approach designed to address critical gaps in basic life-saving care. This study identified the top ten research priorities to guide the development of EECC over the next five years. At the first global EECC Research Conference in November 2024, 46 clinicians, researchers, and policymakers representing nine predominantly high-income countries participated in a structured priority-setting process. Participants formed four thematic groups focused on the current state, implementation, impact, and refinement of EECC. Throughout five sessions, groups developed sub-themes, generated research questions, and identified key priorities. An anonymous survey was used to rank questions within each theme, followed by a final selection of the top ten. Participants developed 28 research questions across four themes. The final top ten included four on EECC implementation, four on its current state, and two on impact. No top-ranked questions emerged from the refinement theme. The top ten EECC research priorities focused on estimating the burden of critical illness and on implementing programs effectively. Advancing these priorities through collaborative research is essential to strengthen health systems and improve outcomes for critically ill patients globally.

Background: Low blood glucose concentration is a well-recognized risk factor for mortality in children admitted to hospitals in low-income settings. Current WHO guidelines define hypoglycaemia as a blood glucose level below 2.5 mmol/L; however, this threshold has been questioned. In a trial conducted in Malawian hospitals, increasing the treatment threshold to 5.0 mmol/L did not reduce in-hospital mortality among children aged 1 month to 5 years. The physiological response to low glucose and dextrose treatment in older children may differ yet remains understudied. This exploratory analysis was conducted to assess potential effects of dextrose treatment in severely ill children aged 5–12 years with blood glucose concentrations between 2.5 and 5.0 mmol/L. Methods: The study is an exploratory extension of a pragmatic randomised controlled trial where all eligible children were randomised to receive either a 5 ml/kg intravenous bolus followed by maintenance infusion of 10% dextrose (intervention group) or observation and standard care (control group). The primary outcome was in-hospital mortality; the secondary outcome was 24-hour mortality. Results: Seventy-two children were enrolled with 36 allocated to each group. In-hospital mortality was 8% (3/36) in the intervention group and 19% (7/36) in the control group with an odds ratio (OR) for mortality of 0.8 (95% CI 0.46–2.25). The mortality after 24 h was 3% (1/36) in the intervention group and 8% (3/36) in the control group, with an OR of 0.4 (95% CI. 0.06–2.90). Adverse events occurred in 19% (7/36) in the intervention group and 39% (14/36) in the control group. Conclusion: This exploratory analysis suggests a potential reduction in mortality when intravenous dextrose treatment is administered to severely ill children aged 5–12 years who present to hospital with a low blood glucose. However, as the parent trial was powered for children less than 5 years the sample size for this older age group was insufficient to draw definitive conclusions. Larger, age-specific studies are warranted to determine the potential benefit of dextrose treatment in this population. Trial Registration: The study is registered with ClinicalTrials.gov, NCT02989675 on 7th December 2016.

Objective To describe the lessons learnt during the promotion of a new approach to the care of critically ill patients in TanzaniaEssential Emergency and Critical Care (EECC). Design A descriptive qualitative study using thematic analysis of structured interviews. Setting and participants The study was conducted in Tanzania, involving 11 policymakers, researchers and senior clinicians who participated in the promotion of EECC in the country. Findings Five inter-related themes emerged from the promotion of EECC in Tanzania: (1) early and close collaboration with the government and stakeholders; (2) conduct research and use evidence; (3) prioritise advocacy and address misconceptions about EECC; (4) leverage events and embed activities in other health system interventions; and (5) employ a multifaceted implementation strategy. The themes map to the normalisation process theory domains of coherence, cognitive participation, collective action and reflexive monitoring. Conclusion The integration of EECC into Tanzania’s health policy is a result of a multidisciplinary collaboration including government and partners that has used evidence, advocacy and context and included multifaceted implementation strategies. The lessons from Tanzania’s experience provide guidance for adoption in similar settings to improve critical care systems, foster access to care and optimal outcomes for all critically ill patients.