Pediatric Critical Care in Botswana

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Una Mulale

Una Mulale

Dr. Una Mulale is the first Pediatric Critical Care Specialist from Botswana. She recently completed a year as a Pediatric Global Health fellow at Boston Children's Hospital, and plans to return to Botswana to begin the first Pediatric ICU. Her goal is to implement tertiary healthcare structures in low-resource countries in Africa and around the world.
Una Mulale

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Botswana is a small, landlocked country in Southern Africa that is widely considered a development success story. Although the country is hailed for its impressive economic growth, good governance, fiscal management, and robust primary healthcare delivery, vast improvements in tertiary healthcare are urgently needed.

Since 1978, Botswana has embraced the primary healthcare model and made some remarkable progress in providing universal care. 95% of the country’s population lives within 8km of a healthcare facility, with the lowest coverage of high-impact interventions not less than 80%. A nominal fee is charged for services, but no one is denied care on the basis of inability to pay. Botswana boasts vaccination rates, clean water coverage, and youth literacy rates of over 95%. Sexual reproductive health services and antiretroviral therapy services are free and widely available and accessible.


Despite this impressive coverage of primary health care, HIV prevalence, under-5 mortality, and maternal mortality have remained significant with gains seemingly lost in recent years. 54% of the under-5 mortality occurs in the first 28 days of life, with the largest percentages of deaths attributed to prematurity and birth asphyxia. Of the 46% of deaths that occur in the 1-59 months age group, pneumonia, non-communicable diseases, diarrhea, and ‘other conditions’ account for 70% of deaths.

Botswana’s annual rate of reduction in under-5 mortality between 1990-2012 was -0.5%, and the country did not reach its MDG 4 goal. For a non-western country that is praised for its political and economic stability as well as widespread provision and access to primary healthcare, this is an enormous inconsistency. I believe the deficit stems from a lack of tertiary healthcare systems, including neonatal and pediatric critical care services.

The WHO developed the Emergency Triage Assessment and Treatment (ETAT) course to educate and assist healthcare workers in recognizing emergency and critical situations. The course teaches healthcare workers to triage patients according to emergency and priority signs and to provide emergency treatment for life-threatening illnesses. Studies have shown a trend towards decreasing child mortality rates with ETAT use. Besides ETAT, there are few WHO guidelines on how to address critical illness in resource-limited and non-western countries.

Botswana has been exemplary in implementing the primary healthcare model, but progress has been paralyzed by the lack of recommendations in tertiary healthcare delivery. Efforts to curb child mortality from diseases targeted by public health measures have yielded minimal results in the last decade. I strongly believe this is the result of addressing healthcare from a singular focus on primary healthcare while neglecting tertiary care. Diseases such as pneumonia and diarrhea can and must be addressed from a primary healthcare and preventative medicine standpoint. However, we must also recognize that if primary healthcare measures fail, these diseases become critical and often fatal conditions, and in Botswana, they account for 36% of child mortality of children between 1-59 months.


In order to minimize child morbidity and mortality, and maximize positive outcomes, we must both prevent disease occurrence and have effective treatment strategies, inclusive of critical care interventions in the non-western world. 50% of deaths in children occur within the first 24 hours of arrival to the healthcare facility, possibly due to delay in attendance or inadequate, untimely care. The majority of these deaths are from reversible causes, and developing effective emergency and critical care services could substantially reduce mortality.

Many reasons are cited for the paucity of critical care in resource limited settings, including limitations in the existing infrastructure, lack of disposables, and low numbers of trained healthcare workers. Cost constraints have traditionally caused critical care to be considered low priority. But because over half of deaths are often due to acute, reversible conditions (such as diarrhea and pneumonia), it is imperative that we prioritize timely, reliable, evidence-based critical care interventions for acutely ill patients before disease progression to organ failure and death. Measures such as fluid resuscitation, oxygen administration and empiric antibiotic use can be deeply impactful in improving outcomes.
I believe every life matters. If every life matters, then every death matters; therefore preventable death should be minimized if not eradicated. This is not solely a matter of primary healthcare systems, but tertiary healthcare systems that address every illness in every child. To succeed, tertiary healthcare systems must be developed alongside primary healthcare systems, for balanced prevention and treatment strategies that target all diseases.