An Evaluation of Capacity and Gaps in Critical Care Services in Rwanda: A Mixed Methods Approach

Abstract

Background Low- and middle-income countries (LMICs) shoulder a disproportionately high burden of critical illness with limited healthcare infrastructure. However, despite increased attention on critical care capacity due to Covid-19, LMIC intensive care unit (ICU) capacity remains largely undescribed-especially in East Africa. We sought to characterize barriers to critical care capacity and delivery in Rwanda, hypothesizing that gaps in specialized personnel, training, and supervision ('human resources') would be perceived as more important limitations to high-quality ICU care compared to gaps in beds, medications, and diagnostics ('facilities, materials, equipment'). Methods We performed a cross-sectional survey of all hospitals with dedicated ICUs in Rwanda using a mixed-methods approach, adapting conceptual frameworks for health services evaluation in global disaster response and emergency medicine. Using World Health Organization (WHO)-developed benchmarks for facility-level surgery and trauma evaluations, we created a set of tools for ICU assessment. Questionnaires for physicians, nurses, trainee physicians, and hospital leadership were developed and pilot tested using REDCap software. Inventories of ICU and hospital capacity using an adapted WHO tool were undertaken at each site. Descriptive statistics including percentages, means, and standard deviations were performed. IRB approval was obtained though Columbia University Medical Center and the University of Rwanda. Results Four hospitals in Rwanda were identified with dedicated ICUs. Total ICU beds were 27 (5- 8), total annual ICU admissions were 1128. The majority (96%) of invited ICU medical staff completed the survey, including nurses (N=60), trainee physicians (N=29), and attending physicians (N=10). Complete inventories were obtained from all 4 hospitals. Respondents identified insufficient staffing (63%), equipment/bed shortages (40%), lack of training opportunities (36%), and inadequate supervision (23%) as key obstacles to providing high quality critical care. Both human resources (39%) and material resources (28%) were identified as key gaps. Inability to treat common critical illnesses was frequently reported. Inventories at the hospital level clearly identified resource constraints. Conclusions In this study, gaps in both material and human resources were perceived as limiting ICU care, in line with provider perceptions of inadequate care quality. Obstacles to change include material gaps, lack of training, and institutional barriers. Notably, health system leadership in Rwanda on multiple levels is aware of these gaps and challenges with specific plans to improve training, support, and availability of equipment and supplies. This study emphasizes the complex nature of LMIC critical care limitations, providing insight into addressing them institutionally.