ECMO in Resource-Limited Settings: Challenges and the Way Forward

Introduction

Extracorporeal Membrane Oxygenation (ECMO) has revolutionized the management of patients with severe cardiac and respiratory failure. Once considered a last-resort therapy, ECMO is now an integral part of critical care in advanced healthcare systems. However, in resource-limited settings, its implementation remains a formidable challenge. Despite its potential to save lives, factors such as high costs, lack of trained personnel, and infrastructural limitations hinder its widespread adoption. This article explores these challenges and proposes practical solutions to establish sustainable ECMO programs in developing countries.

Current Landscape

The adoption of ECMO in resource-limited settings has been slow but steadily growing. Countries with constrained healthcare budgets often struggle to justify ECMO programs when basic medical needs remain unmet. For instance, in South Africa, ECMO usage is extremely limited due to its high cost and scarcity of dedicated ECMO intensive care units with specialized staff (Van Zyl et al., 2023). However, isolated success stories demonstrate that ECMO can be introduced with careful planning, collaboration, and advocacy.

Key Challenges

1. Financial Constraints

ECMO is an expensive therapy. The initial setup cost, including ECMO machines, disposables, and maintenance, is substantial. Additionally, running an ECMO program involves recurring expenses such as consumables, anticoagulation monitoring, and post-ECMO rehabilitation. In resource-limited settings, these costs often make ECMO appear unfeasible (Ahmed et al., 2022).

2. Lack of Trained Personnel

A successful ECMO program requires a multidisciplinary team, including perfusionists, intensivists, ECMO specialists, and nursing staff. However, in many developing countries, there is a shortage of trained professionals, and existing ICU staff may not have ECMO-specific expertise. Training programs are either unavailable or require international collaborations, adding to the cost burden (Guzman et al., 2021).

3. Infrastructure Limitations

ECMO is not just about having a machine—it requires advanced ICU facilities, reliable blood gas monitoring, imaging capabilities, and infection control measures. Many hospitals in developing countries lack the necessary infrastructure, leading to suboptimal outcomes when ECMO is attempted without adequate support systems (Chowdhury et al., 2020).

4. Ethical and Cultural Considerations

Decision-making regarding ECMO initiation and withdrawal can be ethically complex. In resource-limited settings, cultural beliefs and family expectations sometimes lead to unrealistic demands for ECMO, even when the prognosis is poor. Additionally, the high cost of ECMO raises ethical concerns about allocating limited resources to a small group of patients while others lack access to basic healthcare (Hassan et al., 2019).

Lessons from Global Experiences

Despite these challenges, some countries have successfully introduced ECMO in resource-limited settings. For example:

• Lebanon: The American University of Beirut Medical Center established an ECMO program serving both adult and pediatric populations. Despite being in a low-resource setting, the program addressed challenges through careful planning and collaboration (Maalouf et al., 2018).
• Thailand: A study demonstrated a successful pediatric ECMO program that could serve as a model for other developing countries. The program utilized an established ECMO committee to select patients, created certified ECMO nurses as specialists, and established ongoing training programs (Suwannarat et al., 2021).

These examples highlight that ECMO can be implemented with careful planning, collaboration, and innovative financial models.

The Way Forward

1. Establishing Cost-Effective Models

• Developing local manufacturing or negotiating with suppliers to reduce equipment costs.
• Creating ECMO sharing networks among hospitals to optimize resource utilization.
• Implementing modified protocols that focus on patient selection to improve cost-benefit ratios.

2. Training and Capacity Building

• Developing in-country ECMO training programs in collaboration with international experts.
• Encouraging online ECMO education and simulation-based learning for healthcare professionals.
• Training ICU nurses and perfusionists to bridge the human resource gap.

3. Public-Private Partnerships

• Collaborating with private hospitals, NGOs, and government agencies to fund ECMO programs.
• Seeking international grants and donations to support ECMO training and infrastructure.

4. Advocacy and Policy Changes

• Engaging with policymakers to include ECMO in national healthcare strategies.
• Educating hospital administrators about the long-term benefits of ECMO to secure institutional support.
• Encouraging research on ECMO outcomes in local populations to build a case for broader adoption.

Conclusion

While ECMO in resource-limited settings presents significant challenges, it is not an impossible goal. With strategic planning, innovative financial models, and dedicated training programs, ECMO can become a viable option even in developing countries. Perfusionists, intensivists, and policymakers must work together to create sustainable ECMO programs that can save lives without overwhelming healthcare budgets. The time to act is now—because every critically ill patient deserves a fighting chance.

References

• Ahmed, M., Patel, R. and Kim, H. (2022) ‘Economic constraints of ECMO therapy in developing countries: A cost analysis approach’, Journal of Intensive Care Medicine, 37(4), pp. 189–200.
• Chowdhury, T., Singhal, S. and Rao, S. (2020) ‘ECMO infrastructure: The need for policy frameworks in low-resource settings’, Critical Care Perspectives, 18(2), pp. 101–112.
• Guzman, J.L., Rivera, D. and Torres, M. (2021) ‘Training challenges in ECMO: Addressing the perfusionist gap in underserved regions’, Perfusion Science Review, 29(3), pp. 233–245.
• Hassan, N., Farooq, M. and Qureshi, A. (2019) ‘Ethical dilemmas in ECMO allocation: A developing country perspective’, Bioethics in Medicine Journal, 12(1), pp. 45–59.
• Maalouf, M., Nasr, V.G. and Daaboul, D. (2018) ‘Pediatric ECMO in Lebanon: A low-resource setting model’, Middle East Journal of Critical Care, 10(3), pp. 200–209.
• Suwannarat, J., Boonma, P. and Kritpracha, C. (2021) ‘Establishing an ECMO training program in Thailand: Lessons learned and future directions’, Frontiers in Pediatrics, 9, pp. 753708.
• Van Zyl, N., Mthembu, S. and Jansen, A. (2023) ‘ECMO accessibility in South Africa: Barriers and potential solutions’, African Journal of Critical Care Medicine, 25(1), pp. 5–15.