The World Health Assembly resolution on integrated emergency, critical, and operative care for universal health coverage and protection from health emergencies: a golden opportunity to attenuate the global burden of acute and critical illness

Over the last three-and-a-half years, the coronavirus disease 2019 (COVID-19) pandemic has caused disruptions to global health, economies, and daily life. For the first time in nearly a century, a major global health catastrophe negatively impacted high-income countries (HICs) to at least a similar extent compared to low- and middle-income countries (LMICs). Most countries have yet to recover from the pandemic’s toll on their health systems and on other sectors. The pandemic revealed the pre-existing structural fragility of global acute critical care capacity, increasing the awareness of our limited ability to respond effectively to the expanding burden of both communicable and non-communicable critical illness. In LMICs, the acute crisis provoked by COVID-19 has amplified awareness of the burden of acute and critical illness and emphasized the need for global synergies to alleviate the chronic crisis of critical care resource scarcity.

At the 76th World Health Assembly in May 2023, a resolution was passed calling for timely additional global efforts to strengthen the planning and provision of high-quality emergency, critical, and operative care (ECO) services. The World Health Assembly resolution EB152(3), which advocates for “integrated ECO care for universal health care (UHC) and protection from health emergencies” constitutes a unique and momentous global health intervention. It represents an unprecedented and significant step to foster interventions to remove barriers to the expansion of ECO care system capacity, which includes both infrastructure strengthening and human resources development, to ensure high-quality holistic health care for all critically ill patients around the globe.

The longstanding challenges of acute illness burden to global and national health systems have largely been underappreciated for decades by governments, international organizations, and health care system stakeholders. Approaches based on specific diagnoses or specialties have been insufficient to effectively integrate ECO care systems and capacities to care for emergency, injured, and critically ill patients. The lack of integration of ECO care systems into primary health care and UHC, particularly in LMICs and other limited resource settings (LRS), has exacerbated global health inequities.

With rapidly degenerating climate stability, increasing socioeconomic disparities, expanding migrations, and increasing conflicts, our global community will inevitably confront numerous future pandemics, emergencies, disasters, and conflicts. Global ECO care systems must be integrated and strengthened to address both currently prevailing inequities and respond to future global or regional health emergencies. Global and national resolutions to build and strengthen ECO care capacities need to be effectively implemented.

To focus on the ‘critical’ component of ECO care, we start with the observation that critical illness occurs everywhere in our health systems, including intensive care units (ICUs), high care or dependency units, emergency departments, operating theaters, outpatient departments, general wards, ambulances, and the community. These diverse settings are commonly under-resourced and under-staffed, often with health providers who are insufficiently trained to manage such patients [1].

Critical care, therefore, does not equal technology-driven care in an ICU. Critical care is the identification, monitoring, and treatment of patients with critical illness through the initial and sustained support of vital organ functions [2]. It requires early recognition of the risk of or presence of organ dysfunction, clinical monitoring and surveillance, and a continuum of care to achieve a desirable clinical outcome. Unfortunately, many LMICs and other LRS currently struggle to provide quality critical care with meager human and material resources [3–5]. At least 30–45 million adults suffer critical illness every year [6], and an estimated 11 million people die annually from sepsis alone [7]. Without inclusion of critical care in UHC, which mandates free treatment at the point of care delivery, the financial burden faced by patients with critical illness and their families can be catastrophic.

Critical care includes a continuum of care that starts as a package of essential emergency and critical care [8] that might bridge to more complex ICU care provided by specifically trained providers. Consistent with the WHO fair choices framework, this package of essential emergency and critical care recommends prioritizing cost-effective clinical processes and hospital readiness structures, integrated into UHC systems and across the acute care journey for patients, focusing on early identification and essential treatment of critically ill patients [9]. While advanced ICU care should be expanded, essential critical care represents a foundation upon which all high-quality acute care can be delivered, regardless of environment or location. It is, therefore, necessary that an integrated ECO care system that provides high-quality foundational care be recognized as a human right under the auspices of UHC as an integrated care package. The COVID-19 pandemic reinforced the importance of this objective for every global health system.

We strongly support implementation of the recent World Health Assembly resolution across health systems globally and highlight the need to identify efficient, context-sensitive, patient-centered, community-friendly, and high-value pathways to build and sustain integrated ECO care systems.

As an international group of experts in acute care, and leveraging the lessons learned from the recent COVID-19 pandemic, we propose the following broad objectives to ensure effective resolution implementation across different health systems (Table 1).

Table 1.

Recommendations to ensure success of WHA resolution

Assessment of the burden of ECO-related acute illness, including needs assessments at national, facility, and pre-hospital levels in all countries and territories

Build strategies to develop and expand ECO human resources to scale up capacity at all levels of the health system, with focus on LMICs

Rapidly expand oxygen delivery capacities, as described in a related World Health Assembly resolution, in all health facilities, with the implementation of sustainable training of health care providers, biomedical engineers and other relevant staff in oxygen therapy

Identify and make available high-impact diagnostic and therapeutic resources in ECO care

Implement low-cost, high-yield ECO services for all patients to ensure equity and population impact; do this before scaling up more advanced services available only for a few

Develop programs to progressively improve the quality and standard of ECO care services, with due consideration to defining the optimal metrics for ECO systems

Establish data collection systems that capture essential health indicators for ECO care, including prevalence of pre-specified conditions and syndromes, interventions, outcomes, and resource utilization

ECO emergency, critical, and operative care.

We commend the World Health Assembly and the sponsoring countries of resolution EB152(3) for their courage demonstrated in the statements of this resolution. The clinical community looks forward to working together to ensure access to high-quality emergency, critical, and operative care as part of a high-quality integrated ECO care package for every patient globally.

Declarations

Conflicts of interest

There are no conflicts of interest to declare relevant to this work on behalf of the authors.