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Impact of the WHO emergency care toolkit on mortality in Zambia: an implementation-effectiveness hybrid study

Morgan C Broccoli,James Nonde,K. Mwanza,Julia Dixon,Jennifer Pigoga Hart,Lauren Lai King,Patricia Chibesakunda,Natasha Chenga,Winnie Kunda,Azmach Hadush,Godfrey Phiri,Alex Makupe,L. Wallis,Mwiche Chiluba

Published 2025 in BMJ Global Health

ABSTRACT

Introduction Low‐ and middle-income countries (LMICs) suffer the highest rates of death and disability due to emergency conditions. Strong emergency care systems reduce the morbidity, acquired disability and mortality associated with a variety of emergency conditions and have the potential to impact over half of the annual deaths in LMICs. The WHO emergency care toolkit (ECT) is an open access bundle of simple interventions to support care of the acutely ill and injured in LMICs. The aim of this study was to assess the impact of the WHO ECT on facility-based mortality at eight provincial-level hospitals in Zambia. Methods This study used an implementation-effectiveness hybrid design. Prospective data on mortality from a set of sentinel emergency conditions (paediatric diarrhoea, pneumonia, asthma, diabetic ketoacidosis (DKA), postpartum haemorrhage and injury) were collected for 8 months pre-implementation and post-implementation at eight provincial-level hospitals in Zambia. Case fatality ratios (CFRs) were calculated across intervention periods, and Z scores identified significant changes. Logistic regression analyses were conducted to identify associations between independent variables and mortality. Results A total of 7333 patients presented to the eight study sites with sentinel conditions: 4105 patients before and 3228 following implementation of the WHO ECT. Across all sentinel conditions, a significant decrease of 33.6% was seen in the crude CFR, and the odds of mortality were 35.7% lower after adjusting for confounders. Paediatric diarrhoea (−60.1%, p=0.048), DKA (−59.2%, p=0.001) and pneumonia (−48.1%, p<0.001) saw significant decreases in CFRs following WHO ECT implementation, and downward trends were seen for asthma and postpartum haemorrhage. Conclusion Implementation of the WHO ECT in eight Zambian hospitals showed a 35.7% reduction in adjusted odds of mortality from six sentinel conditions. The WHO ECT is an effective means of strengthening emergency care and improving patient outcomes in LMICs.

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