PREPRINT: National estimates of critical care capacity in 54 African countries.

The coronavirus disease (COVID-19) pandemic is an emerging threat across the African continent where national critical care capacity is underdeveloped or unknown. In this paper, we compile data on critical care capacity — including number of ICU beds, number of ventilators, and number of physician and non-physician anesthesia providers — for 54 African countries.

Methods Data was compiled from a variety of resources including World Bank databases, local and international news media, government reports, local healthcare workers, and published scientific literature.

Results Overall, data on number of ICU beds were available for 49 (91%) countries and on number of ventilators for 46 (85%) countries, respectively. Data on physician anesthesia providers and nonphysician providers was available for 47 (87%) and 37 (69%) of the 54 African countries.

Conclusion Most low and lower middle-income African countries have limited critical care capacity available to cope with potential surges in critical care demand due to COVID-19 outbreaks.

On March 11, 2020, the World Health Organization (WHO) declared the novel coronavirus outbreak a pandemic. Since it first appeared in late 2019, there have been over 4 million cumulative confirmed COVID-19 cases and over 270,000 deaths reported globally. Many countries have implemented measures to reduce COVID-19 transmission and to prevent health facilities from being overwhelmed by demand for hospital care, intensive care unit (ICU) beds, and ventilator therapies needed to treat severe infections. Despite these interventions, many wellequipped countries have faced shortages in health equipment and trained personnel. the first confirmed COVID-19 case in Africa occurred in Egypt on February 14, 2020. Thus far, African countries have reported lower disease incidence with only 46,829 confirmed COVID-19 cases and 1,449 deaths across the continent as of 12 May 2020 (WHO, 2020). Most African countries implemented airport closures, curfews, lockdowns, and other social distancing measures in March or April 2020 (WHO, 2020). However, infectious disease surveillance and reporting infrastructure remains highly underdeveloped in many African countries, and COVID19 testing is limited given the shortage of human resources and appropriate laboratory facilities. In addition, projections of COVID-19 case burden predict that most African countries will  experience an uptick in total and severe COVID-19 infections in the next one to three months (CDDEP, 2020).
Across Africa, critical care capacity is far below international norms and public health officials
have suggested there is a severe lack of ICU beds and ventilators (Murthy, 2015; Dunser, 2016;
Okafor, 2009). According to a COVID-19 Readiness Survey conducted by WHO in March 2020,
an estimated 9 ICU beds are available per 1 million people across the continent (WHO, 2020).
However, self-reported information from 34 out of the 47 WHO member countries gave a largely
incomplete picture of the current situation with regards to the region’s critical care capacity.
To better understand critical care capacity across the continent, we compiled data on number of
ICU beds, number of ventilators, and number of physician anesthesia providers (PAP) and nonPAP, among other datapoints, for 54 African countries. This data is intended to inform and assist
policy makers and public health officials at the national, regional, and international levels in
equipping and preparing African countries to tackle the COVID-19 pandemic.
Data and Methods
National critical care capacity datapoints relevant to COVID-19 treatment included in the
database were number of ICU beds, number of ventilators, and number of PAP and non-PAP.
The estimated numbers of ICU beds and ventilators were obtained from published government
reports or statements, published scientific literature, reports or statements from aide and other
non-governmental organizations, local and international media (in all major continental
languages), and in-country informants including government or public health officials and other
local researchers and healthcare workers (Appendix 1, 2). Where possible, we cross-checked
ICU bed and ventilator estimates with multiple sources.
It is made available under a CC-BY-NC-ND 4.0 International license .
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
medRxiv preprint doi: https://doi.org/10.1101/2020.05.13.20100727.this version posted May 16, 2020. The copyright holder for this preprint
The number of PAP and non-PAP was obtained from the World Federation of Societies of
Anaesthesiologists Global Anesthesia Workforce Survey (World Federation of Societies of
Anaesthesiologists, 2019; Kempthorne, 2017).
National demographic and economic information for the most recent year for which data was
available was obtained from a variety of sources. Gross domestic product (GDP) at purchasing
power parity (PPP) per capita in current international dollar for each country was obtained from
the World Bank (The World Bank International Comparison Program Database, 2020).
Population data and hospital beds per 1,000 people, and physicians per 1,000 people were
obtained from the World Bank’s World Development Indicators database (The World Bank,
2020).
Regional sub-groupings of African countries followed those of the United Nations Statistics
Division and do not represent official endorsement or geopolitical position (United Nations
Population Division, 2020). Disputed and dependent territories were excluded.
For comparisons across countries and regions, we translated available count data and data
reported per 1,000 people into rate data reported per 100,000 people.
Results
Data Availability
Data availability is summarized in Table 1, and a complete index of data availability is provided
in Appendices 1 and 2. Data on GDP PPP per capita, population, hospital beds per 100,000
people, and physicians per 100,00 people were available for over 90% of the 54 African
countries.
Local and international news media were the major sources for data on number of ICU beds and
ventilators. Data on number of ICU beds were available for 49 (91%) countries and on number
of ventilators for 46 (85%) countries. Data on physician anesthesia providers (PAP) and nonphysician providers (non-PAP) was available for 47 (87%) and 37 (69%) countries, respectively.
It was not possible to discern equipment and human resources capacity at public versus private
health facilities or in rural versus urban settings. In addition, we were unable to separately
estimate equipment and human resources available for pediatric versus adult patient populations.
Therefore, numbers presented here represent total equipment and human resources availability
across country and patient segments.
It is made available under a CC-BY-NC-ND 4.0 International license .
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
medRxiv preprint doi: https://doi.org/10.1101/2020.05.13.20100727.this version posted May 16, 2020. The copyright holder for this preprint
Table 1. Summary of Data Availability
Data Point Year(s)
Number of Countries with Available Data,
out of 54 (Percent)
GDP at PPP per capita
in current international
dollar
2018 except for
Djibouti (2011), Eritrea (2011),
and South Sudan (2014)
53 (98%)
Data not available for Somalia.
Income group
classification
2018 54 (100%)
Population
2018 except for Eritrea (2011)
54 (100%)
Hospital beds per
100,000
2004 to 2015 52 (96%)
Data not available for Eswatini, South Sudan
Physicians per
100,000
2014 to 2017 except for
Eritrea (2004), Cameroon
(2011), Congo (2011),
Comoros (2012), and DRC
(2013)
50 (93%)
Data not available for Lesotho, Namibia, Sierra
Leone, and South Sudan.
Number of ICU beds
per 100,000
2015 to 2020 49 (91%)
Data not available for Benin, Comoros,
Equatorial Guinea, Madagascar, and
Mozambique.
Number of ventilators
per 100,000
2017 to 2020 46 (85%)
Data not available for Benin, Comoros, Congo,
Lesotho, Malawi, Mauritius, Seychelles, and
Tanzania.
PAP per 100,000 2015 to 2016 47 (87%)
Data not available for Central African
Republic, Comoros, Equatorial Guinea,
Eswatini, Liberia, Sao Tome and Principe, and
Somalia.
Non-PAP per 100,000 2015 to 2016 37 (69%)
Data not available for Cabo Verde, Central
African Republic, Comoros, Congo, Djibouti,
Equatorial Guinea, Eritrea, Eswatini, Gabon,
Guinea-Bissau, Lesotho, Liberia, Mauritius,
Sao Tome and Principe, Seychelles, Somalia,
and South Africa.
It is made available under a CC-BY-NC-ND 4.0 International license .
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
medRxiv preprint doi: https://doi.org/10.1101/2020.05.13.20100727.this version posted May 16, 2020. The copyright holder for this preprint
Critical Care Capacity
Critical care capacity data segregated by income and region is summarized in Figures 1 and 2
and Table 2, and a complete listing of data is available in Appendix 2. (Of the 54 countries
included in the analysis, there was only one country, Seychelles, classified as high income. It is
therefore omitted from Table 2 which reports averages across income groups.)
Across the continent, there were an average of 135.19 hospital beds and 35.36 physicians per
100,000 people ranging from 67.39 beds and 9.57 physicians per 100,000 people in low-income
countries to 302.50 beds and 115.24 physicians in upper middle-income countries. The average
number of hospital beds per 100,000 was highest in Southern Africa and lowest in West Africa
while the average number of physicians per 100,000 was highest in North Africa and lowest in
West and Middle Africa.
Across all 54 countries included in the analysis, there was an average of 3.10 ICU beds and 0.97
ventilators per 100,000 people. The average number of ICU beds per 100,000 people ranged
from 0.53 in low-income countries to 8.59 in upper-middle countries and 33.07 in Seychelles, the
sole high-income country included in this analysis. The average number of ventilators per
100,000 people ranged from 0.14 in low-income countries to 2.49 in upper-middle income
countries. The average number of ICU beds was lowest in West Africa with only 1.10 ICU bed
per 100,000 people, and the average number of ventilators was lowest in East Africa with only
0.23 ventilators per 100,000 people.
Overall, there was an average of 2.42 total (physician and non-physician) anesthesia providers
per 100,000 people ranging from 1.24 and 0.66 in low-income countries and in the Middle
African region, respectively, to 6.91 and 6.64 providers per 100,000 in upper middle-income
countries and the North Africa region, respectively.
It is made available under a CC-BY-NC-ND 4.0 International license .
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
medRxiv preprint doi: https://doi.org/10.1101/2020.05.13.20100727.this version posted May 16, 2020. The copyright holder for this preprint
Figure 1. Summary of critical care capacity by income classification.
Figure 2. Summary of critical care capacity by region.
0.1
1
10
100
1000
Hospital
Beds
Physicians ICU Beds Ventilators PAP non-PAP Total
Anesthesia
Providers
Average number per 100,000
Low
Lower-middle
Upper-middle
Average across Continent
Critical Care Capacity by Income Group
0
1
10
100
1000
Hospital Beds Physicians ICU Beds Ventilators PAP non-PAP Total
Anesthesia
Providers
Average number per 100,000
North
West
Middle
East
Southern
Critical Care Capacity by Region
It is made available under a CC-BY-NC-ND 4.0 International license .
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
medRxiv preprint doi: https://doi.org/10.1101/2020.05.13.20100727.this version posted May 16, 2020. The copyright holder for this preprint
Table 2. Summary of Critical Care Capacity by Income Group and Geographic
Region
Income
Average Number
(per 100,000)
Low
(n=24)
Lowermiddle
(n=21)
Uppermiddle
(n=8)
Average across
all 54 Countries
Hospital Beds 67.39 135.00 302.50 135.19
Physicians 9.57 33.05 115.24 35.36
ICU Beds 0.53 2.38 8.59 3.10
Ventilators 0.14 1.29 2.49 0.97
PAP 0.21 1.13 4.64 1.31
Non-PAP 1.03 0.83 2.27 1.11
Total Anesthesia 1.24 1.96 6.91 2.42
Region
Average Number
(per 100,000)
North
(n=6)
West
(n=16)
Middle
(n=9)
East
(n=18)
Southern
(n=5)
Hospital Beds 190.00 63.75 191.11 137.65 202.50
Physicians 119.80 18.71 19.42 26.95 45.28
ICU Beds 3.65 1.10 6.28 3.10 3.37
Ventilators 1.45 0.75 1.17 0.23 2.85
PAP 3.56 0.40 0.31 0.84 4.69
Non-PAP 3.07 1.12 0.35 0.81 0.49
Total Anesthesia Providers 6.64 1.52 0.66 1.65 5.18
Discussion and Limitations
Overall, the availability of hospital beds, physicians, ICU beds, ventilators, and anesthesia
providers in 54 African countries is far below the capacities of other countries where the demand
from COVID-19 has exceeded existing resources. As expected, there is particularly
limited critical care capacity in low and lower middle-income African countries. For comparison,
in the US, Italy, Germany, and China, there are between 280 and 1,200 total hospital
beds and between 240 and 710 ICU beds per 100,000 people (Kamal, 2020; Wunsch, 2008)
For most countries included in this analysis, there was a lack of verified data available from
published scientific papers and reports, or from government Ministries of Health, or other
equivalent national agencies. Where possible, we attempted to cross-check our data with multiple
sources. In addition, for several countries, we were unable to identify various data
points. Despite these limitations, this database on African critical care capacity is the most
comprehensive available to our knowledge, and alongside COVID-19 case burden projections,
may be useful in guiding and informing national, regional, and continental outbreak preparedness
and response.

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