U.S. Metropolitan Municipalities EMS Medical Directors Consortium ( The “Eagles” Coalition)
INTERNATIONAL RESEARCH PERSPEC TIVES
EMS systems in lower-middle income countries
face daunting challenges
By William J. Leggio, EdD, NRP; Peter Acker, MD, MPH; Jennifer A. Newberry, MD, JD & Benjamin Lindquist, MD
Suryanto M, Plummer V, Boyle M. EMS sys-
tems in lower-middle income countries:
A literature review. Prehosp Disaster Med.
2017; 32( 1):64–70.
Background: Prehospital care is an unmet
public health need in low- and middle-income countries (LMICs).
LMICs carry 90% of the entire global
burden of traumatic injuries, which
has a significant impact due to both
mortality and disability. EMS has
the potential to ameliorate a large
portion of this burden in LMICs,
however EMS development in many
LMICs is in its infancy and remains
underdeveloped compared to the significant existing need for prehospital
care and transport.
Researchers recently conducted a
literature review to define the current state of EMS establishment and
development as well as the barriers
to its growth in lower-middle income countries, a subset of LMICs.
Methods: The researchers used a previously published World Bank definition of
lower-middle income countries to target 48
countries for a thorough literature search performed using electronic medical databases
(CINAHL, Ovid Medline, EMBASE) and
Google Scholar for grey literature.
The search was performed with a list of
13 keywords including different versions of
“prehospital,” “emergency medical services
(EMS),” and “paramedic,” coupled with the
48 LMIC country names.
Articles were included if they reported on
the establishment of an EMS system, fund-
ing of the system, EMS human resources, case
load and incident types, prehospital transport
mode, availability of ambulances and obstacles
of implementing the EMS system. Exclu-
sion criteria included letters to editors, arti-
cles on disaster management, articles including
non-lower-middle income countries, articles
focused only on in-hospital care, and articles
not in English or Bahasa Indonesia.
Two thousand articles were identified using
the combination of keywords coupled with
country names. Of these, 57 articles met inclusion and were reviewed. The included articles
discussed only 16 of the 48 lower-middle
income countries ( 33.3%).
Results: The availability and progress of
EMS systems in lower-middle income countries varies and is generally hindered by financial constraints. Of the countries included in
the review, most lack an organized system
through which to deliver prehospital care.
As such, in many of the systems described,
patients depend largely on private vehi-
cles to provide emergency transport. When
ambulances are utilized, the scoop-and-run
approach is still generally practiced, as many
lack trained professionals to provide on-scene
and transport care.
Interestingly, Ukraine is one of the few
nations in the lower-middle income group
with a well-functioning, centrally coordinated prehospital care system, operating
well-equipped ambulances staffed by specially
trained nurses and physicians. Notably, it was
one of the first systems in the world to perform ECGs, prehospital thrombolysis and prehospital defibrillations.
Funding is a key obstacle in establishing an organized EMS system
in lower-middle income countries.
The cost burden is often placed on
Additionally, cultural and spiritual beliefs may lead citizens to seek
traditional healing methods prior to
utilizing costly transport to receive
more expensive care within the formal medical system.
High-income countries, such as
the United States and United Kingdom, have
supported the development of EMS in lower-middle income countries largely through
training and educational programs.
EMS systems in lower-middle income
countries utilize a range of provider types for
prehospital care, including physicians, nurses,
paramedics and unskilled drivers. Most lack
appropriate human resources.
Additionally, EMS staff are often inexpe-
rienced, overworked and have limited or no
medical training. However, some have tried to
Funding is a key
obstacle in establishing
an organized EMS
system in lower-middle