title: Critical care in resource-poor settings: lessons learned and future directions.
abstract: BACKGROUND
  Critical care faces the same challenges as other aspects of healthcare in the developing world. However, critical care faces an additional challenge in that it has often been deemed too costly or complicated for resource-poor settings. This lack of prioritization is not justified. Hospital care for the sickest patients affects overall mortality, and public health interventions depend on community confidence in healthcare to ensure participation and adherence. Some of the most effective critical care interventions, including rapid fluid resuscitation, early antibiotics, and patient monitoring, are relatively inexpensive. Although cost-effectiveness studies on critical care in resource-poor settings have not been done, evidence from the surgical literature suggests that even resource-intensive interventions can be cost effective in comparison to immunizations and human immunodeficiency virus care. In the developing world, where many critically ill patients are younger and have fewer comorbidities, critical care presents a remarkable opportunity to provide significant incremental benefit, arguably much more so than in the developed world.
  Key areas of consideration in developing critical care in resource-poor settings include: Personnel and training, equipment and support services, ethics, and research. Strategies for training and retaining skilled labor include tying education to service commitment and developing protocols for even complex processes. Equipment and support services need to focus on technologies that are affordable and sustainable. Ethical decision making must be based on data when possible and on transparent articulated policies always. Research should be performed in resource-poor settings and focus on needs assessment, prognostication, and cost effectiveness.
  
  
  CONCLUSIONS
  The development of critical care in resource-poor settings will rely on the stepwise introduction of service improvements, leveraging human resources through training, a focus on sustainable technology, ongoing analysis of cost effectiveness, and the sharing of context-specific best practices. Although prevention, public health, and disease-specific agendas dominate many current conversations in global health, this is nonetheless a time ripe for the development of critical care. Leaders in global health funding hope to improve quality and length of life. Critical care is an integral part of the continuum of care necessary to make that possible.
authors.affiliation: Brigham and Women's Hospital, Department of Internal Medicine, Boston, MA, USA. beth_riviello@post.harvard.edu
authors.forename: Elisabeth D
authors.initials: ED
authors.lastname: Riviello
authors.forename: Stephen
authors.initials: S
authors.lastname: Letchford
authors.forename: Loice
authors.initials: L
authors.lastname: Achieng
authors.forename: Mark W
authors.initials: MW
authors.lastname: Newton
mesh_terms: D035843:Biomedical Research / Q000941:ethics; D020811:Biomedical Technology; D003362:Cost-Benefit Analysis; D003422:Critical Care / Q000941:ethics / Q000458:organization & administration / Q000592:standards / Q000639:trends; D003906:Developing Countries; D004501:Education, Medical; D005544:Forecasting; D006292:Health Priorities; D006295:Health Resources; D006801:Humans; D007630:Kenya; D012121:Respiration, Artificial; D000078329:Workforce