Administration and Leadership, Columns, International

EMS Systems in Lower-Middle Income Countries Face Development Challenges

Issue 8 and Volume 42.

Growth Barriers

Suryanto M, Plummer V, Boyle M. EMS systems 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, funding of the system, EMS human resources, case load and incident types, prehospital transport mode, availability of ambulances and obstacles of implementing the EMS system. Exclusion criteria included letters to editors, articles 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 vehicles 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 the citizens.

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 inexperienced, overworked and have limited or no medical training. However, some have tried to empower laypersons and military medics to provide care, particularly with hemorrhage control, and have positively influenced the outcomes of trauma patients.

EMS education and training varies for prehospital providers in lower-middle income countries. In some countries, EMS staff receive no formal training and rely only on on-the-job experience. Other countries train providers in very basic emergency care like CPR, oxygen therapy and first aid. As previously noted, some receive EMS education and training from high-income countries such as the U.S. and U.K.

Traumatic injury, most often from road traffic accidents, was identified as one of the most common patient categories requiring prehospital care in lower-middle income countries. Burn injuries are also common.

Patient transport vehicles in lower-middle income countries vary from pickup trucks to contemporary ambulances. Equipment also varies and appears to be influenced by prehospital provider level of training and system funding.

The lack of financial support for EMS was noted as one of the primary obstacles to creating and sustaining effective prehospital care services. This leads to reduced access to key equipment and medications, in some cases shifting a prohibitively large financial burden to patients.

Poor road conditions, high traffic volumes and inadequate road infrastructure present both obstacles for EMS delivery as well as contributing factors to the trauma case load in lower-middle income countries.

Lack of public awareness of the need for an EMS system and knowledge of emergencies negatively impacts the implementation and development of EMS in lower-middle income countries. Cultural beliefs about traditional medicine as well as religious beliefs also affect certain population’s perceptions of the value of prehospital care.

Discussion: The status of EMS development in lower-middle income countries varies but, from these limited reports, it generally remains underdeveloped and underfunded, with a scarcity of trained EMS providers.

Development of EMS systems in LMICs is challenging due to many factors, including: poor funding, lack of formal educational programs, lack of national guidelines, cultural values, infrastructure and community awareness. However, adequate prehospital services have the potential to improve public health in LMICs suffering from a large percentage of the world’s burden of traumatic injury, as well as emergencies related to both communicable and non-communicable disease.

Conclusion: There’s still much to be learned about EMS and prehospital care in lower-middle income countries. However, countries with well-developed prehospital care systems can influence EMS in these countries through training and education collaborations, support of local EMS leadership, and advocacy for awareness, funding and regulations. This study highlights the need for devoted international dialogues on delivery of prehospital care.