this article briefly reviews the need for emergency care in africa and barriers to its integration into health systems in the region .
we describe an example of an emergency care initiative at muhimbili national hospital ( mnh ) in dar es salaam that has integrated a multi - cadre training program with development of a dedicated emergency department in the largest public hospital in tanzania .
this article should be of interest to those concerned with prevention and treatment of acute illness in the sub - saharan region , and those with a particular interest in global emergency care and physician training initiatives in resource - limited settings .
low - income countries suffer the highest rates of every category of injury  from road traffic to drowning ; the highest rates of maternal death from acute complications of pregnancy ; and the highest rates of acute complications of communicable diseases including tuberculosis , malaria , and hiv .
the rapidly growing prevalence of cardiovascular and diabetic disease has only increased the burden of acute illness , as patients with chronic disease in low - income countries also have the highest rates of mortality from acute complications . 
 
the disease control priorities in developing countries project estimates that 45 per cent of deaths and 36 per cent of disability - adjusted life years ( dalys ) in low- and middle - income countries could be addressed by the implementation of emergency care systems .
while definitive specialty care will never be available at all times in all places , several studies suggest that emergency care is an effective and cost - effective means of secondary prevention : prioritizing an integrated approach to early resuscitation and stabilization of acutely ill patients greatly reduces the morbidity and mortality associated with a range of medical , surgical , pediatric , and obstetric conditions . 





 
in addition , many acute conditions can be mitigated by primary prevention ; disease surveillance at acute and emergency care facilities has been shown to increase preparedness and disease control capabilities . 
  in general , analysis of acute disease patterns and
the distribution of mortality across the acute care continuum is a crucial part of identifying the preventive and training initiatives most likely to improve outcomes . 



 
facility - based and pre - facility emergency care are essential components of a continuum ranging from prevention , through primary and chronic care , to inpatient critical care and surgery , and with resolution 60.22 the world health assembly has called for all its member states to consider  formal , integrated emergency care systems ' .
there are four foundational challenges to integrating emergency care into health systems in sub - saharan africa : 
 the burden of acute disease in sub - saharan africa is severely under - documented .
some data exist on the distribution of inpatient diagnoses in the region , but the actual range of acute presentations to health facilities is largely unknown .
studies that compare police , hospital , and insurance records with other sources in low - income countries , for example , suggest that as few as 1 in 10 injuries may be documented in official counts . 



health - care facilities often lack an integrated approach to triage , resuscitation , and stabilization of acutely ill patients . even at a single small district hospital , acutely ill patients
may be cared for by several different departments , depending on age , pregnancy status , and specific disease states .
this vertical approach means that there is rarely a dedicated acute intake area staffed with nonrotating personnel who can be trained in resuscitation and stabilization.essential components of acute and emergency care have not been determined , and there is no consensus on how to define success . to date , there has been no systematic analysis of the acute care delivery systems most appropriate to these varied contexts . while there are scattered examples of successful interventions , little
is known about what makes these programs effective or how others might replicate their success .
impact is often quantified by the number of providers trained , rather than by any measure that incorporates quality or performance assessment.there is no current advocacy plan for placing emergency care on the global health agenda . despite the essential role of early resuscitation and stabilization in averting morbidity and mortality ,
emergency care is conspicuously absent from discussions of global health priority initiatives ( such as the millennium development goals and un consensus statements ) and large - scale global health funding strategies .
the burden of acute disease in sub - saharan africa is severely under - documented .
some data exist on the distribution of inpatient diagnoses in the region , but the actual range of acute presentations to health facilities is largely unknown .
studies that compare police , hospital , and insurance records with other sources in low - income countries , for example , suggest that as few as 1 in 10 injuries may be documented in official counts . 


 
health - care facilities often lack an integrated approach to triage , resuscitation , and stabilization of acutely ill patients . even at a single small district hospital , acutely ill patients
may be cared for by several different departments , depending on age , pregnancy status , and specific disease states .
this vertical approach means that there is rarely a dedicated acute intake area staffed with nonrotating personnel who can be trained in resuscitation and stabilization .
essential components of acute and emergency care have not been determined , and there is no consensus on how to define success . to date , there has been no systematic analysis of the acute care delivery systems most appropriate to these varied contexts . while there are scattered examples of successful interventions , little is known about what makes these programs effective or how others might replicate their success .
impact is often quantified by the number of providers trained , rather than by any measure that incorporates quality or performance assessment .
there is no current advocacy plan for placing emergency care on the global health agenda . despite the essential role of early resuscitation and stabilization in averting morbidity and mortality ,
emergency care is conspicuously absent from discussions of global health priority initiatives ( such as the millennium development goals and un consensus statements ) and large - scale global health funding strategies . despite these challenges ,
interest in emergency care training is rapidly expanding in africa , and there are planned or established emergency training programs for specialists in botswana , ethiopia , ghana , kenya , liberia , rwanda , south africa , sudan , tanzania , and uganda ; and for other provider cadres in ghana , tanzania , south africa , and uganda .
we review one such initiative at mnh in dar es salaam , with a focus on the development of the emergency medicine residency program .
the united republic of tanzania is designated as a low - income country with an estimated population of 46 million , a per capita income of around us$500 , and an average life expectancy of 51 .
more than three quarters of the population lives in rural areas and a third lives below the poverty line .
the infant mortality rate is around 51 per 1000 population , and there are approximately 3 doctors and 39 nurses and midwives per 100  000 population . in january 2010 , mnh opened tanzania 's first dedicated public emergency department via a public  private partnership between tanzania 's ministry of health and social welfare ( mohsw ) , and abbott fund tanzania .
the mnh emd is fully staffed with physicians ( registrars have completed medical school and internship , whereas residents have worked as registrars and are now pursuing specialty training ) and nurses 24 hours per day and currently sees 100130 patients daily , or approximately 40  000 patients per year .
the department has full resuscitation capacity , and to add to the main hospital - operating suite a single - room operating theater dedicated to emergency cases has recently been opened within the emd . a business plan to ensure the department 's financial sustainability
has just been finalized through an agreement between the hospital , the ministry , and abbott fund tanzania .
nearly 40 per cent of mnh emd patients are female , 25 per cent are under 18 years of age , and 13 per cent are under 5 years of age ( table 1 ) .
approximately , one quarter of all patients and 20 per cent of pediatric patients present with injuries . in adults , intracranial injuries
are very common , and road traffic is a very common cause of injury in adults and children . other common diagnoses in adults and children include anemia and infections , particularly pneumonia in children .
mental illness is also a top diagnosis in adults , with the majority of these patients presenting with psychosis .
while the muhimbili emd project began as an infrastructure - development initiative , the necessity for a coordinated professional development strategy emerged early  at the time the emd opened , there were no emergency physicians in tanzania and no dedicated emergency care nurse training programs .
abbott fund tanzania initiated and supports an academic collaboration among united states ( us ) , south african , and canadian institutions to provide clinical training for nurses and physicians , with the goal of ensuring long - term sustainability of the muhimbili emd and training leaders to promote , disseminate , and sustain emergency care throughout tanzania . via this program , the emd providers are supported by international emergency nursing and emergency physician faculty year round .
visiting faculty serve minimum 1-month stints , and there is an emergency medicine residency program director from the university of california san francisco onsite for the majority of the year ( author tr ) .
the collaboration has developed site - specific training materials for a 10-module nursing curriculum , a 1-year registrar program , and a 3-year residency program .
ninety per cent of nursing staff have completed the program ; 15 registrars have filed to complete the 1-year emergency care credentialing process ; and the first class of eight residents and second class of six residents will be joined by a third class this fall .
the first residency cohort will graduate in july 2013 , and leadership of the program will transition to local faculty by the end of 2014 .
the program at muhimbili is the nation 's only emergency medicine residency and is fully integrated into the muhimbili university of health and allied sciences ( muhas ) master of medicine ( mmed ) track .
the initial curriculum was developed and implemented in a collaboration between the mnh head of department and the us emergency medicine faculty serving as abbott fund tanzania consultants .
the curriculum was subsequently revised as part of a university - wide initiative to introduce a competency - based format . at the time of the curriculum development
, the international federation for emergency medicine model curriculum had not been released , but we have since conducted a curricular review to ensure that our curriculum meets its guidelines .
residents currently spend approximately half their time in the emd itself , and half on outside rotations in other clinical departments relevant to the practice of emergency medicine , such as surgery , obstetrics  gynecology , cardiology , orthopedics , and pediatrics .
the competency - based curriculum guides evaluation and allows resident performance to be appraised with reference to context - oriented proficiency , rather than traditional , discipline - based evaluation .
this mode of targeted learning is particularly appropriate to the broad , setting specific practice of emergency medicine  especially as a newly established field  where the transmission of a culture of practice is as essential as the transmission of a body of scientific knowledge .
the program is monitored by a combination of resident examinations and other provider performance metrics .
each semester residents undergo a multidimensional evaluation including a written multiple - choice exam , a written essay exam , an oral case - based exam , and an observed clinical exam ( with case presentation ) on volunteer hospitalized patients .
exams are proctored by local faculty and international outside examiners approved by the university academic senate .
performance gaps are recorded and addressed in subsequent review sessions , and any gaps shared by multiple residents trigger review of the relevant component of the didactic and off - service curriculum .
in addition , all doctors , nurses , and health attendants undergo regular professional performance audits that evaluate on - time attendance , room - response times , and documentation quality .
the emd operations team is currently specifying metrics to evaluate throughput times , triage performance , and resuscitation process .
emergency residents have also agreed to participate in a 10-year tracking study , which currently surveys their experiences on off - service rotations , and will continue to track their practice sites and the disease burden they encounter over the next decade .
in general , medical trainees in tanzania face an extraordinary burden of disease and take on a degree of individual responsibility that rarely if ever falls on their us counterparts .
the ratio of patients to providers is daunting , and the ratio of faculty to residents in most specialties is simply not adequate to the supervision and training needs .
whereas this latter condition is mitigated to some extent by the visiting faculty in the muhimbili emergency program , other challenges result from the acuity of the specialty and its nascent status .
managing dynamically evolving , unstable patients is new to most trainees as their previous clinical training was often in settings with limited resources for intervening with critically ill patients ( who usually died ) . for now , emergency residents also face the challenge of being taught and supervised by faculty who have not been trained within the same system .
although they are guided by faculty in clinical decision making , ultimately the residents themselves are charged with developing the practice of regionally specific emergency care as they build their individual funds of knowledge .
they frequently serve as advisors and teachers for each other , and are often in the position of researching a condition as they treat it in a patient . on rotations in other departments , besides mastering the clinical content of that respective specialty , the emergency residents must serve as ambassadors and educate others as to the nature of their own specialty and their learning goals . as the first and only emergency physicians in the country ,
they are called into institutional and political service to a degree that only a handful of their international colleagues will experience much later in their careers . even in terms of the scientific advancement of the specialty ,
because the burden of acute disease is so poorly documented in the region , many of these dissertations will be the first , and for a time the definitive literature on the topic .
although the practice of emergency medicine has indeed  evolved during the past 40 years into a coherent global discipline with a unique set of cognitive , technical , and administrative skills for managing acute illness or injuries , ' there remain notable differences in the scope of practice required of providers in low - income countries .
simple translation of curricular content from other regions is unlikely to prepare trainees for what they will face during training and after graduation .
acute care facilities serve to fill many gaps in the health systems of low - income countries , and providers at facilities distant from referral centers may be required to perform tasks considered beyond the scope of emergency specialists in other countries , such as basic obstetric , abdominal , and orthopedic surgeries . in this context ,
off - service rotations serve a different role than they might in areas where consultants are expected to be accessible within minutes to hours . as much as possible , informed by interviews with local providers who have worked in district and sub - district facilities , we have adapted the content of our curriculum to accommodate this reality ( either by emd - based or off - service training ) .
in addition , to ensure that our curriculum is appropriate to the local disease burden , we are currently analyzing diagnostic and demographic data from the first 2 years of the mnh emd , and the 2013 curriculum will be adjusted based on these results and other emerging regional data .
eventually , we hope that the results of our physician tracking study will also serve to inform future emergency care curricula at muhimbili and elsewhere .
in an effort to advocate for the dissemination of high - quality emergency care in tanzania , muhimbili providers formed the emergency medicine association of tanzania ( emat ) , the first emergency medicine professional organization in the region .
emat was ratified by the ministry in may of 2011 with the mandate to : 
 promote and improve emergency care through teaching , research , and education.advocate for and provide emergency care across tanzania.collaborate with other emergency care research and educational organizations , regardless of location , to the benefit of emergency care in tanzania .
advocate for and provide emergency care across tanzania . collaborate with other emergency care research and educational organizations , regardless of location , to the benefit of emergency care in tanzania . with the approval of the mohsw , a research team including the authors ( tr , hs , jm ) and other emat members
has just completed site visits to every district hospital in tanzania to assess emergency care capacity .
the results will serve to guide future emergency care planning and development , as well as prevention initiatives .
other ongoing emat projects include expanding the registrar training program to accommodate visiting stints by district hospital providers ; onsite training of district hospital providers in regionally appropriate basic and advanced resuscitation and trauma management skills ; the development of a transport medicine skills course ; and a series of needs analysis studies that will facilitate the development of coordinated pre - hospital emergency services .
in addition , emat aims to expand collaboration with other emergency provider training efforts in arusha , bugando , moshi , and zanzibar and has begun an exchange of site visits and planned collaborative training projects . to amplify and support its national efforts ,
emat has affiliated with the african federation for emergency medicine and the international federation for emergency medicine , and plans are underway to establish an east african emergency medicine federation that will allow resource - sharing and coordination of research and training efforts . the first east african regional meeting on emergency care
sub - saharan africa faces a disproportionate burden of acute disease and many challenges to meeting the call of world health assembly resolution 60.22 for formal integrated emergency care systems . the abbott fund tanzania - supported program at mnh in dar es salaam represents one effort to integrate a multi - cadre professional development strategy with the establishment of a high - volume emergency care facility .
the muhas - based residency will soon enroll its third class and will produce its first graduates in 2013 . their and others ' future efforts will benefit from greater national and regional coordination to allow multi - site research and surveillance and sharing of educational resources .
emat has been formed to help expand regional and global advocacy efforts in collaboration with the african and international federations for emergency medicine .
 even though sub - saharan africa faces a disproportionate burden of acute injury and illness , few clinical facilities are configured to take an integrated approach to resuscitation and stabilization . 
 emergency care is a high - impact and cost - effective form of secondary prevention ; disease surveillance at facilities delivering acute and emergency care is essential to guide primary prevention . 
 barriers to emergency care implementation in the region include limited documentation of the acute disease burden , a lack of consensus on regionally appropriate metrics to facilitate impact evaluation , and the lack of coordinated advocacy for acute disease prevention and emergency care . despite these challenges , 
 interest in creating dedicated acute care facilities and emergency training programs is rapidly expanding in africa . 
 we describe one such initiative at muhimbili national hospital in dar es salaam , with a focus on the development of the emergency medicine residency program . 