Until recently, efforts to reduce mortality globally have focused predominately on communicable diseases. However, injuries from multiple causes are becoming a significant contributor to overall mortality and morbidity. The World Health Organization (WHO) estimates that 5.8 million deaths annually are attributable to injuries, 90% of which occur in low-and middle-income countries (LMICs). Moreover, rates of one of the main causes of death, road traffic crashes, are increasing in most LMICs (1). Likewise, the burden due to non-communicable diseases, such as cardiac and vascular disease, is growing. Almost all injuries and a substantial proportion of non-communicable diseases present acutely and necessitate emergency care, both in hospital and in the prehospital setting. Similarly, a proportion of communicable diseases and many obstetrical conditions also demand emergency treatment (2).

Capabilities for emergency care in hospital are gradually being addressed (2). Capabilities for prehospital care must also be examined and improved. As regards injury, the preponderance of deaths occurs outside the hospital in countries at all economic levels. However, the proportion of deaths that occur outside the hospital is higher in most LMICs than in high-income countries (3). Thus any efforts to address injury related deaths globally must also include the prehospital setting.

Efforts to strengthen prehospital care in LMICs are hampered by many considerations, including lack of a clear path to follow in initiating new formal emergency medical services (EMS) where none currently exist, the lack of evidence as to what elements of such formal EMS are cost-effective and in which circumstances, and a paucity of studies on alternatives to formal EMS, such as widespread first aid training for first responders (4–5).

Despite increased awareness of the global impact of injury and the need for emergency services for many medical conditions, no broader assessment of prehospital care systems in the developing world has been published. Understanding the current status is essential in order to guide future efforts to strengthen prehospital care systems and ultimately reduce the burden of injury and other medical conditions needing emergency care. Thus, this study sought to better understand the methods of transport to the hospital, training and certification of EMS providers, organization and funding of EMS systems, public access to prehospital care, and barriers to further prehospital care development in a wide range of LMICs.

A standardized 32 question, five-page questionnaire was developed. This was derived from needs assessment forms originally created by WHO, based on the Prehospital Trauma Care Systems publication (5) and which had been pilot tested and refined in several countries previously (Mozambique, Ghana, Mexico, Vietnam). The form for the current study was further revised by the co-authors, many of whom also had prior experience using the preceding WHO needs assessment forms. The form was used provisionally in the first few countries to be surveyed, with minor alterations thereafter. This questionnaire focused on the methods of transport to the hospital, training and certification of EMS providers, organization and funding of EMS systems, public access to prehospital care, and barriers to further prehospital care development. Questions were primarily open ended, allowing for recording of information in the respondents’ own words. This allowed for later qualitative analysis.

This study sought to administer this questionnaire to EMS leaders in several countries in each of the main three developing regions (Africa, Asia, Latin America). We approached this research project as a qualitative research study. Given the available resources for the project, we realized that a representative sample of EMS programs in low and middle-income countries around the world would not be feasible. We therefore followed a qualitative research approach and did purposeful sampling to capture the range of approaches to EMS care in these countries. This type of sampling is appropriate when developing an understanding of general approaches to a problem (6–7).

Several of the co-authors led data collection efforts in their regions (MJ for Asia, AR for Latin America, and AZ for Africa). National leaders in EMS were identified in countries on each continent through personal contacts. When available, these were people who headed governmental agencies whose portfolio encompassed prehospital care. When such individuals or agencies did not exist, information was gathered from leading professionals in each country who have been at the forefront of EMS development or related research. This study sought to sample at least three countries from each major region.

Information was gathered via a combination of personal visits, phone interviews, email, and letters. Data were gathered during 2009–2010. Respondents were asked to give averages for the country overall to the best of their knowledge. As many important variables such as access to EMS would be expected to vary across nations and states, opinions were sought on many of these variables for rural vs urban differences.

Each country was classified into low-income, lower-middle-income, and upper-middle-income according to the World Bank Atlas Method (8). In general, the data were presented by country, with the exception of India. Given India’s high population and the significant variation among Indian states, data are presented by individual Indian state.

Data were analyzed qualitatively as to major findings and regional variations. A characteristic of qualitative research is that the approach relies less on numerical data than on synthesis of observations across the spectrum of models, in this case for EMS care. The data analysis was one of reducing the large amount of data collected to understand key themes of EMS care in these countries; it is not meant to be a quantitative data analysis of a random sample of programs (6–7). The tables reported in the results reflect this qualitative approach. The major emphasis in data analysis was to identify factors in prehospital care that could serve as solid foundations to build upon in future EMS development and to identify barriers and gaps that needed to be addressed. Responses were collated and themes across countries were identified.

For purposes of the questionnaire and the analysis, the following definitions were used: Emergency Medical Services (EMS) referred to formal prehospital services, within a defined organization and most often with ambulances. Prehospital care was a broader concept, encompassing EMS, but also first aid and prehospital transport provided by commercial drivers, private citizens, and other laypersons, whether as part of a formal system or not.

This study was deemed exempt from review by the University of Washington IRB.

Data were obtained from 13 countries (Figure 1). From one of these countries (India), separate responses were obtained from three states. These countries and states represented a wide geographic and economic spectrum. There were at least three countries from each major developing region (Africa, Asia, Latin America) and at least three from each economic stratum (Table 1). Respondents came from several backgrounds, as shown in Table 2. A national or state EMS director existed and provided data in 7 countries or Indian states. The most common respondents for the other sites were clinicians involved with EMS development. Three other countries (Rwanda, Togo, Venezuela) were approached for the study but did not participate.

This study sought to characterize prehospital care capabilities in a range of LMICs focusing on types of services available, access to those services, and the overall organization and funding of the services. By so doing, we sought to provide information that would be useful in planning of efforts to strengthen and expand prehospital care capabilities globally.

Although this is the most comprehensive study of this kind to date and did evaluate countries across a wide spectrum of geography and economic levels, there are several limitations. First, the study sought to obtain information from someone in charge of EMS either nationally or in a given state or jurisdiction. In many cases, there was no individual or agency designated as being in charge of EMS. In these cases, knowledgeable respondents were identified through personal contacts. It cannot be known if these were always the persons with the best information about a given location.

Second, although components of the data gathered were objective (such as ambulance standards, training of EMS providers, availability of uniform access numbers), much of the data were subjective and based on estimates rather than data obtained from existing databases (such as percent of persons with access to care under one hour).

Third, even when data did exist (such as for utilization rates per population served), it often existed only for specific areas. There were indeed some cases in which fairly reliable national data are available, such as for the National Ambulance Service in Ghana. For many locations however, it was not known how data from different locations could reliably be scaled up to reflect nationwide patterns of care. This was especially problematic as in most countries there were large discrepancies in the availability of prehospital care between urban and rural areas.

Fourth, this qualitative study utilized a purposeful sampling method that selected known leaders in prehospital care. This would tend to bias the findings towards locations with better developed systems, as less developed systems would tend to have less well known or externally visible leaders, if indeed anyone could even be considered a leader. This would in turn result in the findings showing prehospital capabilities to be better developed than for other LMICs that were not sampled. Thus, the problems and barriers identified in this paper are likely to be even more pronounced globally.

Despite these limitations, this study provides useful information about the current status of EMS development globally that will assist in future efforts to expand and strengthen prehospital care globally. Several major themes emerged from the data.

This survey could not provide direct estimates of unmet need for prehospital services, such as the percent of seriously ill or injured persons who would benefit from an ambulance but who do not receive it because of either geographic or financial accessibility. In part, however, unmet need can be inversely reflected in the utilization rates for EMS (9). There was a wide variation in utilization of EMS from 0.2 to 72 runs/year/thousand population. Differences in reporting likely account for part of this wide variation. Nonetheless, it is also likely that the lower end of the spectrum (e.g. utilization of less than 1 – 10 runs per year per 1000 population) represent considerable unmet need, with large proportions of severely ill or injured persons not yet able to receive formal EMS. By comparison, Seattle, USA (a city with a very highly utilized EMS) has approximately 100 runs/1000 population/year (10).

Although formal EMS appeared to have good coverage in middle-income countries and in some urban areas of low-income countries, its availability more generally in low-income countries remains low. Many severely ill and injured persons still come to hospital (when they do) by less formal means, such as commercial and private vehicles or non-motorized means, usually with considerable delays and with no first aid delivered. This supports the findings of other studies. In Mumbai, Roy et al found that only 35% of trauma patients were transported to the main trauma center via ambulance (11). In Kumasi, Ghana, half of trauma patients requiring admission were transported by commercial vehicles. Only 9% were transported by ambulance, almost all of whom were transferred from other hospitals, rather than directly from the field (12). Globally, it has been roughly estimated that 50–75% of the world’s people do not have access to a formal EMS system (13).

A wide variety of institutional arrangements were reported as to the level of government involved (national, state, local) in EMS administration and as to types of EMS providers (doctors, nurses, paramedics, etc) and their training requirements. The data presented do not allow conclusions to be drawn about whether or not one system might offer advantages compared to others. However, commonly cited barriers to improvement and expansion of EMS coverage were lack of integration of different services, lack of standards, and lack of leadership, which cut across the different systems and institutional arrangements. Other studies have cited similar considerations, including the fact that few doctors or other more highly trained professionals are interested in devoting significant portions of their career to EMS (13–16). There is thus a need, globally, to make EMS leadership a more desirable and valid career path.

The most commonly cited barrier to improvements and expansion of prehospital care cited in this study was inadequate funding. This is despite the fact that most countries had some mechanisms in place to provide funding for EMS, such as taxes or funds deriving from mandatory motor vehicle insurance. Clearly greater reliability of such funding mechanisms is needed (5).

The literature provides some useful ideas on potential solutions to the above-identified barriers to expansion of prehospital care to rural and other currently underserved areas. An approach that has not been given sufficient attention in many countries is greater usage of first responders, such as commercial drivers and other lay persons who are already providing a significant amount of the prehospital transport of severely ill and injured persons and who, in many areas, constitute a de facto EMS. Several programs and efforts in different countries have shown the potential benefit of such approaches. For example, a program that provided basic first aid training to taxi and bus drivers in Ghana resulted in 61% of drivers providing first aid to injured or severely ill persons in the following year, with a considerable increase in the provision of appropriate basic first aid measures to these persons (17). Jayaraman et al surveyed commercial drivers and community volunteers who often provided prehospital care in Kampala, Uganda and found that 48% had not received any first aid training. After a targeted one day training course, there was a significant improvement in fund of knowledge, both immediately after training and 6 months later (18).

In landmine infested areas of Cambodia and Iraq, one innovative program instituted widespread first aid training and provided basic supplies to a network of thousands of village volunteers. This resulted in a sustained decrease in mortality among victims of landmine injuries and other types of trauma, from 40% to 8% (19). Such methods to better train and involve first responders are a potential fruitful avenue to scale up globally. The current study did indeed demonstrate that most countries were making some effort in this regard. However, no consistent large scale efforts were reported. There are of course affordable and sustainable means to expand and strengthen existing formal EMS. For example, in Monterrey, Mexico increased number of sites of ambulance dispatch and improved training of paramedics through regular in-service training courses resulted in improve process of care and decreased mortality (from 10% to 7%) among injured persons cared for by the EMS in that city. This came at an increase of 16% in the EMS budget, which was affordable and which has been continued to be supported by the local government (14–15). In this regard, it should be noted that more costly advanced life support techniques have not been shown to be of significant benefit in the prehospital setting (14, 20–21). Rather, more widespread access to basic life support capabilities should be a greater priority, especially for areas that have currently limited access, such as many of the rural areas reported in this study.

One technical aspect of EMS to improve access is the establishment of a uniform emergency access telephone number. In the current study, most countries did report such a uniform emergency access number. However, WHO’s Global Status Report on Road Safety reported that 56 countries (31%) out of 178 surveyed did not have such numbers. Moreover, among those that did, 13 countries had up to three different national telephone numbers and a further 25 had regional or local numbers, making for confusion and delays if someone was not familiar with the access number in that area (22). It is interesting to note the corroboration between what was reported in this study and the Global Status Report on Road Safety. Most of the 13 countries in the current study were reported to have a universal access number in both studies. Mexico was reported to not have one in both studies. However, Colombia, Ecuador, Kenya, Ecuador, Panama, and Peru were all reported to have an access number in the current study but were either reported not to have such a number or did not have the information available for the Global Status Report. In these cases, it is likely the uniform access number, if it even does exist, is not well known or utilized.

Many of the above issues could be comprehensively addressed by legislation on prehospital care and EMS, the lack of which was cited as one of the most frequent barriers to EMS development. Legislation can encompass elements such as establishing a statutory lead agency if none exists. It also encompasses setting and promoting standards on training, communications, equipment and supplies, and financing of the system. Two countries that have enacted such EMS legislation in an exemplary fashion recently have been Colombia and Romania. In both cases the legislation resulted in documented improvements in the care received by victims of injury and other medical emergencies, such as decreases in prehospital times (9).

This global survey has shown that indeed much is being done well in many countries and that there are dedicated professionals and volunteers often working against considerable odds to provide and improve prehospital care in their areas. Their efforts could be aided by several measures, based on the findings of this study. These include: greater expansion of services to currently under- or un-served areas, especially in low-income countries and in rural areas everywhere. Such expansion could make better use of the already existing networks of first responders, such as commercial drivers and lay persons. Efforts to increase their effectiveness, such as more widespread first aid training, and better encompassing their efforts within formal EMS, in a tiered fashion, are warranted. In terms of existing formal EMS, there is a need for increased and more regular funding, integration and coordination among existing services, and improved organization and leadership, as could be accomplished by making EMS administration and leadership a more sought after career path and by national or statewide prehospital and EMS legislation that addresses many of the above elements in a comprehensive fashion.