A Research Agenda for Acute Care Services ... - Wiley Online Library

BREAKOUT SESSION

A Research Agenda for Acute Care Services Delivery in Low- and Middle-income Countries Rachel T. Moresky, MD, MPH, Mark Bisanzo, MD, Beth L. Rubenstein, MPH, MBA, Stephanie J. Hubbard, MPH, MA, Hillary Cohen, MD, MPH, Helen Ouyang, MD, MPH, Herbert C. Duber, MD, MPH, and Regan H. Marsh, MD, MPH

Abstract Delivery of acute care services at every level of the health system is essential to ensure appropriate evaluation and management of emergent illness and injury in low- and middle-income countries (LMICs). The health services breakout group at the 2013 Academic Emergency Medicine consensus conference developed recommendations for a research agenda along the following themes: infrastructure, implementation, and sustainable provision of acute care services. Based on these recommendations, a set of priorities was created to promote and guide future research on acute care services. ACADEMIC EMERGENCY MEDICINE 2013; 20:1264–1271 © 2013 by the Society for Academic Emergency Medicine

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ver the past 10 years, the World Health Organization (WHO) has passed two resolutions that challenge the global health community to broaden its vision of acute health care delivery in lowand middle-income countries (LMICs). World Health Assembly Resolution 58.33 states that all people should be able to access health services and not be subject to financial hardship in doing so.1 Resolution 60.22, “Health Systems: Emergency Care Systems,” further calls on both governments and the WHO to ensure universal access to emergency care services.2 Considered together, these resolutions mandate that all countries develop sustainable ways to implement emergency care services that are accessible to all members of the population. These resolutions codify the growing understanding that emergency care services are part of essential health

care and should be integrated into the “health for all” agenda, as stated in the Declaration of Alma-Ata, which has traditionally been limited to primary care.3,4 Adding to this broader understanding of health services, this year, Lancet published the most comprehensive analysis of the global burden of disease to date.5 The findings highlighted the epidemiologic shift taking place in LMICs and underlined the need for stronger horizontal health systems that can respond to a diverse mix of presentations, ranging from injuries to acute communicable and noncommunicable diseases, as well as chronic diseases.5 Health services in LMICs remain largely underfunded, underresourced, and understaffed, particularly in their acute care capacity. For example, in 2011, 19 of the 46 countries in the WHO Africa region spent less than

From the Columbia University Mailman School of Public Health, Department of Population and Family Health, sidHARTe Program (RTM, BLR, SJH), and the Department of Emergency Medicine, Columbia University College of Physicians & Surgeons (RTM, HO), New York, NY; the Department of Emergency Medicine, University of Massachusetts Memorial Medical Center (MB), Boston, MA; the Emergency Medicine Center, Maimonides Medical Center (HC), Brooklyn, NY; the Division of Emergency Medicine, University of Washington, and the Institute for Health Metrics and Evaluation (HCD), Seattle, WA; the Department of Emergency ^ pital Universitaire de Mirebalais, Partners In Health Medicine, Brigham and Women’s Hospital (RHM), Boston, MA; and the Ho (RHM), Mirebalais, Haiti. Received July 12, 2013; revision received August 15, 2013; accepted August 16, 2013. This article reports on a breakout session of the May 2013 Academic Emergency Medicine consensus conference in Atlanta, GA: ‘‘Global Health and Emergency Care: A Research Agenda.’’ Breakout session participants included Nanaefua Afoh-Manin, Anjoli Anand, Theodore Christopher, Joseph Becker, Bianca Green, Bhakti Hansoti, James Holliman, Gabrielle A. Jacquet, Nancy L. Kerr, Kajal Khanna, S.V. Mahadevan, Ernest Mavunga, Caitlin McCord, Mariah McNamara, John T. Meredith, Ramon Millan, Donna Moro-Sutherland, Ronald Ruffing, Megan Rybarczyk, Sangeeta Sakaria, David Scordino, Ryan J. Wubben, and Svetlana Zakharchenko. The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: Mark Hauswald, MD. Address for correspondence and reprints: Rachel T. Moresky, MD, MPH; e-mail: [email protected].

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© 2013 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12259

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U.S.$44 per capita on health, the minimum amount recommended by the WHO.6–8 Given these economic constraints, implementation of affordable and accessible acute care services as mandated by the World Health Assembly Resolutions 58.33 and 60.22 will require careful attention to infrastructure development, implementation, and long-term stability and sustainability. The overall aim of the health services working group was to set forth research priorities to inform the development of comprehensive acute care services in LMICs. Research priorities will focus on determining the essential elements for the following areas: 1) infrastructure for acute care services, 2) implementation of acute care services, and 3) sustainable provision of acute care services.

The WHO Emergency and Essential Surgical Care project aims to define a basic package of emergency and surgical care resources. The project has developed several tool kits, including the WHO Integrated Management for Emergency and Essential Surgical Care tool kit and the WHO Generic Essential Emergency list. Further, the WHO Violence and Injury Prevention group developed a series of tables for essential trauma care detailing the human and physical resources to assure optimal care of the injured patient across a range of health facilities.12 Nonetheless, there is more work to be done in developing tools that can define and assess appropriate infrastructure needs for acute care service delivery.

AIM 1: DEFINE THE ESSENTIAL ELEMENTS OF ACUTE CARE INFRASTRUCTURE IN LMICS

What Are the Infrastructure Needs at Different Levels of Care Within the Health System? Multiple approaches may be considered when determining the infrastructure priorities for acute care services at a health facility. These include focusing on the type of services offered, local burden of disease, cost-effectiveness, security and public health-preparedness, and feasibility. A strong private or nongovernmental health care structure may be able to work in concert with the public health system to provide some elements of acute care infrastructure.13 Ideally, a detailed understanding of the burden of acute diseases and injuries would guide health administrators when determining local infrastructure needs. While much progress has recently been made in calculating national burden of disease estimates, there are still relatively sparse national data from LMICs and almost no data on burden of disease patterns in the acute care setting.5 Furthermore, local variations in the burden of disease within a country may limit the benefit of uniform recommendations at the national and regional levels.14 Additionally, lack of access to primary care services in poor countries may increase emergency presentations disproportionately with respect to estimated burden of disease4 (see Table 2).

Acute care services at every level of the health system are essential to ensure appropriate evaluation and management of emergent illness and injury. Optimal distribution of infrastructure components across different levels of the system is critical to maximizing the effectiveness of a given facility and improving patient care. Acute care delivery is currently impeded by a clear infrastructure gap. While classically considered brickand-mortar structures, infrastructure incorporates a broad array of components (see Table 1). In Ethiopia, lack of transportation and diagnostic equipment were found to be significant barriers to the provision of quality emergency care services.9 In another study of emergency and surgical care capacity in five sub-Saharan African countries, fewer than 65% of hospitals had essential basic infrastructure (water and electricity), and fewer than half had the ability to provide 24-hour emergency care.10 This infrastructure gap also weakens local and national ability to respond to a pandemic or disaster.11

Table 1 Infrastructure Capacity for Acute Care Infrastructure Facilities

Utilities Clinical

Access Social/public health

Components Building and materials management Waste management Infection control Communications Supply chain Electricity/power Running, potable water Sanitation Outpatient services Inpatient services Surgical capacity Radiology Laboratory and blood bank Pharmacy Transportation Availability of services Fee structure Organization structure: public, nongovernmental organizations, private Sociopolitical context and patient population Financial capacity Surge and disaster preparedness

What Criteria and Framework Should Guide Resource Allocation for Acute Care Infrastructure Development? At times, there may be conflict between Table 2 Research Questions That Will Assist With Identifying Infrastructure Needs at Different Levels of Care Within The Health System 1. What is the burden of acute disease at the regional, national, and subnational levels? 2. What components of infrastructure for acute care services should be available at each level of care within the health system? 3. How do differences in infrastructure for acute care services affect outcomes? 4. How do burden of disease, cost-effectiveness, public health concerns, and feasibility relate to the types of emergency care services needed at each level of the health system? 5. What methods are appropriate to validate needs assessment tools for acute care infrastructure? 6. How can the emergency medicine community advocate for acute care infrastructure indicators to be included in routine national surveys like service provision assessment surveys?

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Table 3 Research Questions to Help Guide Allocation of Acute Care Infrastructure Development 1. What are the best methodologies to be used for determining priorities for investment in infrastructure when resources are limited and burden of disease, cost-effectiveness, and rights-based frameworks conflict? 2. How can private and nongovernmental organizations’ health care providers be leveraged to support infrastructure for acute care services? 3. Can guidelines for other lines of service delivery serve as proxies to guide priority-setting within acute care services? 4. What indicators and signal functions for acute care infrastructure can be developed given a specific population size and burden of disease? 5. How do the facility-based services provided and the distribution of these services affect the type of referral services needed?

the implications of burden of disease, cost-effectiveness, and other criteria that are commonly used to guide infrastructure investments. Quantifying infrastructure investments in terms of disability-adjusted life-years (DALYs) averted and cost-effectiveness may standardize measurement across a range of evidence-based outcomes; however, resource allocation will also need to be driven by ethical and rights-based considerations. A human rights framework may be used to justify investment in acute care infrastructure in accordance with the fundamental human right to the “highest attainable standard of health.”15 Demonstrating the linkage between acute care infrastructure, health care access, and reductions in morbidity and mortality would bolster this framework and establish acute care as a societal necessity. Population size and age distribution are other criteria that can be used to guide resource allocation for infrastructure development. For example, emergency obstetric care defines the components of basic and comprehensive emergency obstetric care facilities and then sets minimum standards for the number and type of facilities, based on population size.16 The acute care community can define similar population-based standards for general emergency care using age-specific burden of disease data. These types of estimates would help communicate infrastructure needs to Ministries of Health and other stakeholders17 (see Table 3). AIM 2: DEFINE THE PARAMETERS NECESSARY FOR THE IMPLEMENTATION OF ACUTE CARE SERVICES IN LMICS Identifying infrastructure needs is one step in building acute care services. However, to operationalize these components, it is necessary to consider implementation. As defined by the Annual National Institutes of Health Conference on Implementation and Dissemination, “Implementation is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings.”18 Research on implementation addresses the level to

Moresky et al. • RESEARCH AGENDA FOR ACUTE CARE SERVICES

which health interventions can fit within real-world public health and clinical service systems. What Are the Human Resource Requirements for Acute Care Service Delivery in LMICs? To effectively provide quality service provision, human resources are critical. Human resources include clinicians, managers, public health workers, and other ancillary staff. While nonclinical human resources also require investment in sophisticated training, this section focuses on the great paucity of clinical health care workers trained in acute care. There is a substantial shortage of health workers in LMICs, from community health workers to specialist physicians. In the 2006 Human Resources for Health report, WHO estimated a global shortage of 4.6 million doctors, nurses, midwives, and ancillary staff.19 Numerically, the shortage is greatest in Southeast Asia, but proportionally, sub-Saharan Africa bears the brunt of the crisis, with 25% of the world’s disease burden and only 3% of the world’s health care workforce.19 A PubMed search combining [acute care, emergency care, health outcomes] and [provider density, health worker density] revealed no research estimating the minimum provider density requirements for acute care. Several studies have supported a correlation of provider density to various outcomes including DALYs, vaccination coverage, and infant, under-five, and maternal mortality.20 Estimations of minimum provider density requirements for emergency obstetric care may help inform research for general emergency care.21 The optimal method for determining provider density standards for acute care remains undefined. The specific variables to consider include burden of disease, population density, provider scope of practice, geography, availability of needed supplies, and physical infrastructure.10,21,22 The interactions between these variables and the effect of each on acute care delivery are unclear. The literature on provider density estimates for other specialties has failed to properly consider some of these variables (i.e., geographic factors), indicating that assessment methods may need to be more nuanced.22 Areas of low population density or challenging geography may actually require a higher number of acute care providers per capita to ensure access to care. Last, health workers’ input regarding time to perform acute care tasks will need to be considered23 (see Table 4). Which Cadres Are Most Appropriately Positioned to Provide Acute Care at Each Level of the Health System? How Can We Safely Accomplish Task Shifting for Acute Care? Given the vast shortage and uneven distribution of physicians in LMICs,19 it is unlikely that the majority of patients in LMICs will have their acute medical problems managed by physicians, let alone emergency medicine specialists. It is estimated that in Africa, there is a need for 420,000 additional physicians by the year 2015,19 but some countries are not even graduating sufficient physicians annually to replace those lost through attrition, let alone increase their physician pool.24 Further, in addition to the “external brain drain,” an “internal brain drain” is drawing physicians


Table 4 Research Questions to Help Determine Human Resource Requirement for Acute Care Services in LMICs 1. What is the definition of acute care providers? 2. What is the clinical workload associated with emergency conditions in LMICs? 3. What are the human resources requirements, including clinical providers, ancillary staff, and management for a given population to safely provide acute care service delivery in LMICs? a. What is the optimal ratio of physician to nonphysician clinicians (also known as midlevel providers)? b. What are the community health worker, first responder, and ancillary support requirements? 4. What are the management and quality improvement requirements? 5. What are the policy and procedure requirements? 6. How do all of these requirements vary by each level of service? 7. What is the interplay between geography, transportation infrastructure, and optimal provider density?

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Table 5 Research Questions Pertaining to Scope of Practice and Task Shifting 1. What are the best research methods to study the safety and efficacy of task shifting? 2. How can task shifting for acute care be safely accomplished, with nonphysician clinicians reliably consulting physicians when they cannot manage the patient independently? 3. What is the appropriate comparator against which task shifting programs should be measured? 4. What factors will best delineate the scope of practice of each level of acute provider? 5. How can emergency medicine–trained physicians best coordinate with nonphysician clinicians to optimize patient outcomes in settings that cannot be staffed by physicians? 6. What role can mobile health technologies and telemedicine play in supporting task shifting?

LMICs = low- and middle-income countries. Table 6 Research Questions Surrounding Human Resource Training, Allocation, and Retention Priorities

from the public sector to nongovernmental organizations and the private sector, weakening care provided in public hospitals.25 A coexisting internal drain from rural to urban areas further affects this misdistribution of health care providers in LMICs.26 As a result, in many LMICs, patients in the acute setting are currently primarily assessed and managed by nonphysician clinicians.27,28 This reality reframes the question of “Can task shifting for acute care be safely accomplished?” to “How can we safely accomplish task shifting for acute care?” Various groups have examined task shifting to different levels of health workers29 and from “consultant” or specialist physicians to generalist physicians.27 Most studies in LMICs indicate that patients treated by nonphysician clinicians have outcomes comparable to those treated by physicians.28,30–32 However, the studies have focused on individual tasks and have not studied the evaluation and management of undifferentiated acute care on the whole. Furthermore, with the exception of one study describing outcomes related to procedural sedation, no studies have directly examined outcomes of patients managed by nonphysician clinicians within acute care.33 Technology and telemedicine offer other alternatives to increase access to acute care services in settings without emergency physicians. Telemedicine via cellular phone may allow nonphysician clinicians or generalist physicians to obtain emergency physician consultation when needed. In addition, mobile health technologies can be used to help guide management of many conditions.34 However, little systematic research has been done on implementation of mobile health and telemedicine in LMICs35 and many questions remain, including sustainable funding for these initiatives (Table 5). What Are the Human Resource Training, Allocation, and Retention Priorities for Developing Acute Care Systems in Countries Where Acute Care Is Limited?

1. What are effective ways of incentivizing each cadre to enroll in acute care training? 2. Which government policies and/or accreditation approaches are effective in training and retaining acute care staff? 3. What roles do government and training institutions play in emergency care development and how does that interact with community needs and wants? 4. What are effective ways of incentivizing acute care–trained providers to maintain countrywide distribution (as opposed to tertiary based alone)? 5. How do acute care training, allocation, and retention models differ in private and public sector institutions? 6. What is the success rate of “mandated rural placement” policies for public sector emergency medicine physicians?

Equitable distribution and long-term retention of acute care providers should be implementation priorities, not afterthoughts. There are many examples of initiatives to attract qualified health care workers to underserved rural areas, such as compulsory rural service in exchange for subsidized medical education.36,37 Discrete choice experiments looking at preferences among medical students in Ghana found that preference for rural posting was determined by salary, as well as other parameters such as improved equipment and supportive management.38 However, there is a scarcity of data on these topics that is specific to acute care (Table 6). AIM 3: RECOGNIZE OPERATIONAL CHARACTERISTICS THAT CONTRIBUTE TO SUSTAINABLE ACUTE CARE SERVICE DELIVERY Finally, we must be mindful of sustainability in all aspects of acute care services, from infrastructure (maintenance and repair plans) to developing human resources (proper training, accreditation, and incentives). In this context, we define sustainability as building upon the community’s strengths with local and regional buy-in through creation of a cost-effective,

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high-quality, longitudinal, and integrated program. Sustainable programs are cost-effective and have quality assurance measures that exist after the intervention is gone. This section focuses on the following components of sustainability for acute care services: 1) integration with other health services, 2) cost-effectiveness and financial sustainability, and 3) continuous quality improvement. How Can Acute Care Services Integrate With Other Health Services Such as Emergency Obstetric Care, Noncommunicable Disease Care, and Primary Care? Recently, health systems research has started to focus on how integration of vertical programs can have “diagonal” effects on larger health systems strengthening.39–41 For example, the inclusion of other health interventions in the prevention of mother-to-child transmission of HIV package of care, including malaria prophylaxis, nutritional supplementation, and family planning counseling for HIV-infected pregnant women, may enhance the utilization and effectiveness of these later service lines.42 Emergency obstetric care may also offer lessons for integration with acute care in a way that strengthens health systems, as much of the infrastructure and resource needs for emergency obstetric care are also integral to acute care (e.g., operating theaters, blood banks, skilled personnel, consumables, drugs, and a strong referral system). Recognizing acute care’s ability to also diagonally strengthen health systems and integrate within other programs, as with prevention of mother-to-child transmission of HIV and emergency obstetric care, may increase national and international support for service delivery. However, a systematic review on integration of health interventions found that integration does not always improve sustainability. For maximum effectiveness, integration of acute care services will require a thorough assessment of context, including burden of disease43 (Table 7). How Can Cost-effectiveness of Acute Care Services Be Maximized for Sustainability? There is a paucity of literature on cost-effectiveness in acute care services. However, there have been some documented attempts at applying clinical operations tools to improve institutional efficiency of acute care services, which may contribute to more cost-effective and financially sustainable Table 7 Research Questions to Improve Integration of Acute Care Services Within a Health System 1. What specific aspects of the health system are best suited to integration with acute care? 2. What stakeholders need to be involved in the implementation stage to increase sustainability of acute care services? 3. In what areas of the health system do we expect to see the diagonal effects of acute care manifested? 4. What approaches have been taken in other fields to demonstrate diagonal effects of vertical programming within weak health systems? How can we apply that methodology to measure the diagonal effects of acute care?


emergency care. For example, the application of lean manufacturing techniques at Komfo Anokye Teaching Hospital in Ghana was well received. Results indicated that the technique has positive potential for other LMICs and should be studied more extensively.44 Improvements to referral systems may also affect the cost-effectiveness of acute care services. Currently, many tertiary facilities receive large numbers of patients who could be adequately treated at lower levels of care, saving time and money for the patients and the health system.45 Cost-effectiveness considerations can also be used to guide recommendations for investment in infrastructure for acute care service delivery.4 Kobusingye and colleagues17 estimated that for a theoretical LMIC with an urban population of 1 million people, high-quality prehospital services would avert 700 deaths annually at a cost of only $94 per life-year gained. However, this modeling fails to account for essential nondirect costs (e.g., other infrastructure), which would increase costs per life-year gained. Research into the cost-effectiveness of acute care interventions is generally limited to date and is an important area for investigation (Table 8). How Do We Define Indicators and Collect Data to Ensure Continuous Quality Improvement of Acute Care Services? Performance indicators for acute care services in LMICs are essential for ensuring continuous quality improvement. Furthermore, quantifiable demonstrations of the effects of acute care, also known as “proof of concept,” are needed to gain traction with policy makers and funders and to establish the relevance of acute care within the public health realm. With regard to performance indicators within LMICs, several studies have proposed indicators for acute care, but most of these are in early development, are from high-income countries,46 or have not yet been validated or used for data collection. The scarcity of routinely collected data in LMICs leads to further challenges. In South Africa, 77 possible performance indicators for emergency medicine were selected through a consensus process, but feasibility of data collection remains unknown.47 There are several examples of successful implementation of data collection related to the WHO Integrated Management of Childhood Illness and Table 8 Research Questions Pertaining to Cost-effectiveness of Acute Care Interventions 1. What is the cost-effectiveness (cost per DALY) of different interventions within acute care, and how do these compare to other interventions within global health practice? 2. Do cost-effective interventions lead to increased sustainability and expansion of acute care services? 3. What research methods from other fields could be used or adapted to inform our approach to evaluating the costeffectiveness of emergency care interventions? 4. How can the emergency medicine community contribute more to primary and secondary prevention of acute disease and injury to increase cost-effectiveness? DALY = disability-adjusted life-year.


Table 9 Research Questions to Determine, Promote, and Utilize Useful Acute Care Service Indicators 1. What are some of the best practices to help define performance indicators for acute care? 2. How can these indicators for acute care services be implemented and validated? 3. What are some examples from other fields of introducing metrics into routinely collected regional and national health databases? 4. How have other fields successfully advocated for indicators to become part of an international agenda such as the Millennium Development Goals? 5. How is accountability for quality measures best implemented to ensure high quality of acute care services?

Emergency Triage Assessment and Treatment evaluation.48,49 However, these examples have not yet been scaled to capture the effects of all acute care services, including those for adults. Another important consideration will be to develop indicators to assess the health service coverage gap, with a focus on determinants of inequality such as geography, age, sex, ethnic minorities, and socioeconomic status. Reliable and valid indicators for this purpose have been established for evaluating various public health interventions in maternal and child health,50 and these existing indicators can be adapted to assess acute care equity. Once the acute care community agrees on key indicators, they should be incorporated into routine surveillance systems and health management information system databases. Improved data collection and utilization is essential to improving patient outcomes, as well as supporting the evolution of the acute care services to best fit the needs of a given health system (Table 9). CONCLUSIONS The objectives of the 2013 Academic Emergency Medicine consensus conference and this article were to review the present gaps in global acute care services and to develop a research agenda targeting those needs. Current research is not adequate to inform acute care infrastructure, service implementation, and sustainable provision of care. Cross-cutting research in acute care services is often eclipsed by more well-defined categories of research that focus on specific diseases or already-established health services. By articulating precise research questions in global acute care services, we intend to make this area of essential research more accessible to the global community of acute care providers with the overall aim of improving quality of service delivery. Research on acute care implementation will require diverse partnerships, including ministries of health and finance, clinical acute care specialists, public health researchers, nongovernmental organizations, and large bilateral donors and foundations. Research should not only look at best practices and evidence-based medicine, but also focus on determining the best research designs specific to acute care health services.

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The development of a broader and more robust evidence-based research agenda in global acute care services needs to be relevant to all levels of the health system. While prospective double-blind studies may not always be feasible in acute care health services research, implementation of evidence-based research must continue to be adaptive, context appropriate, and locally driven. Including acute care services within the global health research agenda is an important step toward upholding the principle of universal access to emergency care services codified by the WHO in the World Health Assembly Resolutions. References 1. World Health Assembly (WHA). Sustainable Health Financing, Universal Coverage and Social Health Insurance [WHA Resolution 58.33]. Available at: http://www.who.int/providingforhealth/topics/WHA58_ 33-en.pdf. Accessed Sep 28, 2013. 2. World Health Assembly (WHA). Health Systems: Emergency-Care Systems [WHA resolution 60.22]. Available at: http://www.wpro.who.int/mnh/A60_R22en.pdf. Accessed Sep 28, 2013. 3. World Health Organization. Declaration of AlmaAta: International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. Available at: http://www.who.int/publications/almaata_declaration_en.pdf. Accessed Sep 28, 2013. 4. Hsia R, Razzak J, Tsai AC, Hirshon JM. Placing emergency care on the global agenda. Ann Emerg Med. 2010; 56:142–9. 5. Murray CJ, Vos T, Lozano R, et al. Disabilityadjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012; 380:2197–223. 6. World Health Organization. Per Capita Total Expenditure on Health at Average Exchange Rate (US$). Situation and Trends as of March 2013. Available at: http://www.who.int/gho/health_financing/per_capita_ expenditure/en/. Accessed Sep 28, 2013. 7. Xu K, Saksena P, Jowett M, Indikadahena C, Kutzin J, Evans DB. Exploring the Thresholds of Health Expenditure for Protection Against Financial Risk. World Health Report (2010). Background Paper, 19. Available at: http://www.who.int/healthsystems/topics/ financing/healthreport/19THE-thresv2.pdf. Accessed Sep 28, 2013. 8. World Health Organization, The Taskforce on Innovative International Financing for Health Systems. Constraints to Scaling Up the Health Millennium Development Goals: Costing and Financial Gap Analysis. Geneva, Switzerland: World Health Organization, 2010. 9. Levine AC, Presser DZ, Rosborough S, Ghebreyesus TA, Davis MA. Understanding barriers to emergency care in low-income countries: view from the front line. Prehosp Disaster Med. 2007; 22:467–70. 10. Hsia RY, Mbembati NA, Macfarlane S, Kruk ME. Access to emergency and surgical care in sub-Saharan Africa: the infrastructure gap. Health Policy Plan. 2012; 27:234–44.

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