Emergency medical services infrastructure development and operations in low- and middle-income countries: Community first responder–driven (Tier-1) emergency medical services systems

Abstract

Low- and middle-income countries face unique challenges in delivering prehospital emergency care, often requiring context-appropriate emergency medical services development focused on community-driven solutions (tier 1 systems). Replicating high-income country tier 2 systems in low- and middle-income countries is not financially feasible in resource-limited settings. Instead, tier 1 systems composed of trained layperson first responders use locally available vehicles and involve local communities and stakeholders in their design and implementation to address specific local needs and emergencies. Community engagement is crucial for establishing sustainable and inclusive emergency medical services systems. This article focuses on the development and operation of tier 1 systems in low- and middle-income countries, covering technology integration, local appropriateness and co-operation, training curricula, trainee recruitment and selection, volunteer incentivization, monitoring and evaluation, and coordination with tier 2 systems. Layperson first responder programs are essential to address the global injury burden that disproportionately affects low- and middle-income countries and to evolve into, or coordinate with, tier 2 systems in resource-limited settings, but this requires community involvement to increase local ownership, drive sustainable solutions, and respect local values and cultures. Low- and middle-income countries face unique challenges in delivering prehospital emergency care, often requiring context-appropriate emergency medical services development focused on community-driven solutions (tier 1 systems). Replicating high-income country tier 2 systems in low- and middle-income countries is not financially feasible in resource-limited settings. Instead, tier 1 systems composed of trained layperson first responders use locally available vehicles and involve local communities and stakeholders in their design and implementation to address specific local needs and emergencies. Community engagement is crucial for establishing sustainable and inclusive emergency medical services systems. This article focuses on the development and operation of tier 1 systems in low- and middle-income countries, covering technology integration, local appropriateness and co-operation, training curricula, trainee recruitment and selection, volunteer incentivization, monitoring and evaluation, and coordination with tier 2 systems. Layperson first responder programs are essential to address the global injury burden that disproportionately affects low- and middle-income countries and to evolve into, or coordinate with, tier 2 systems in resource-limited settings, but this requires community involvement to increase local ownership, drive sustainable solutions, and respect local values and cultures. Low- and middle-income countries (LMICs) face challenges in delivering prehospital care that are different from those of high-income countries and require pragmatic solutions tailored to local needs. Replicating an emergency medical services (EMS) system designed for a high-income setting in an LMIC may not be financially feasible or contextually appropriate, creating additional barriers to care while diverting resources from other public health programs. With the 2023 World Health Assembly declaration that emergency, critical, and operative care services are an integral part of a comprehensive national primary health care approach and foundational for health systems to effectively address emergencies, it is essential that more viable solutions are sought, tailored to local needs. With the cost-prohibitive nature of professional ambulance-driven tier 2 systems in many resource-limited LMICs leading to a lack of formal prehospital services, there is often an informal network of providers delivering prehospital care and transportation, with police, fire services, bystanders, and commercial drivers frequently filling these roles (tier 1 systems). Finding these informal networks of providers, and allowing them to improve their effectiveness through providing training, equipment, and formal recognition and protection, can be an efficient way to fill gaps in basic prehospital care. Instituting and formalizing a simpler system that can evolve over time into a more complex and integrated service offering a broader range of care can be a first step toward formal EMS, and the World Health Organization recommended training layperson first responders (LFRs) in 2005.1World Health Organization Prehospital Trauma Care Systems. World Health Organization, Geneva, Switzerland2005Google Scholar Tier 1 systems train LFRs to provide basic prehospital care and transportation to the hospital using locally available vehicles. Tier 2 systems are increasingly complex and resource-intensive, involving organized networks of professional first responders within well-defined jurisdictions providing ambulance services, and may be integrated with a tier 1 system of providers. This is not meant to suggest tier 1 systems are an ultimate end-goal for all settings but to recognize that in settings where there is insufficient formal prehospital care, LFRs may address morbidity and mortality in areas that do not yet have the capacity to support or sustain tier 2 systems. Because of the diversity of settings in which they are implemented, different models of tier 1 systems have been developed to address varying challenges among urban, suburban, and rural environments. Programs may involve a network of mobile first responders, volunteers in fixed locations, or both. In developing tier 1 systems, refining infrastructure and operations are two sides of the same coin: the setting of the intervention dictates what types of operations are necessary and feasible, which will guide further infrastructure development. Similarly, the infrastructure and human resources available to support these operations help to determine the nature and scope of the intervention. The worldwide penetration of cell phone access and cellular network coverage has created new opportunities to connect patients with prehospital services. Basic technological initiatives including messaging systems to alert communities to natural disasters and accidents, GPS mapping to identify emergency hotspots, e-financing apps to support indigent patients, and video conferencing with medical professionals can be lifesaving in underserved communities. In addition, informal networks of providers often use messaging apps and social media to coordinate their activities. As with all technology integration initiatives, solutions should be co-created with the local communities to address specific problems and challenges within the context of a broader effort to improve provision of emergency services, rather than relying upon top-down imposition. Also, using simpler technologies (ie, prioritizing mobile phones over smart phones for volunteer dispatch) can create broader participation in these programs. Current challenges include cost, accessibility, mobile and internet connectivity, and server hosting.2Friesen J. Kharel R. Delaney P.G. Emergency medical dispatch technologies: addressing communication challenges and coordinating emergency response in low and middle-income countries.Surgery. 2024; 176: 223-225Google Scholar Early and broad community engagement should be heavily inclusive of socioeconomically underprivileged groups, as they are the most common volunteers and beneficiaries of tier 1 systems. These discussions can help identify from the outset the incentive structures, public communications messaging strategies, greatest-need demographics, and local political dynamics that must be considered in establishing a sustainable and inclusive EMS system. For example, in some communities, female patients may be uncomfortable being treated and transported by male LFRs, but at the same time women may not feel it is safe or culturally appropriate for them to volunteer as LFRs to transport unfamiliar patients over long distances to hospitals. Finding solutions that respect such cultural sensibilities requires both appreciation of community values and co-creation of solutions in partnership with the “end-users” of the service. Community engagement to co-create an incentive structure and financial model is also essential for sustainability. There is often a self-selecting group of local people who try to provide care to injured victims, such as small business owners at busy intersections or motorcycle taxi drivers. These grass roots efforts are sometimes further organized through messaging apps and social media to coordinate efforts with receiving hospitals. Finding these good Samaritans and giving them training, equipment, and a formal notification system creates an inexpensive but potent force for addressing time-sensitive traumatic injuries. A locally based network of community volunteers can rapidly provide basic care, especially bleeding control, primarily saving the lives of younger men who are family breadwinners. Most of the expenses for tier 1 programs are incurred in setting up the service, and ongoing maintenance costs are generally low, especially if there are active efforts to engage and retain trained volunteers. Creating an externally funded EMS program may discourage a sense of ownership that ultimately causes the program to fail if external funding ceases or is interrupted. EMS system financing arrangements to support tier 1 systems may range from public funding to public-private partnerships to exclusively private EMS services. Financial issues are the most common problems faced by LMICs.3Suryanto Plummer V. Boyle M. EMS systems in lower-middle income countries: a literature review.Prehosp Disaster Med. 2017; 32: 64-70Google Scholar Currently, early cost-effectiveness analyses with real-world data for tier 1 systems suggest cost-effectiveness, although no specific financing mechanism has yet been shown to be superior in resource-limited settings.4Delaney P.G. Eisner Z.J. Bustos A. et al.Cost-effectiveness of lay first responders addressing road traffic injury in Sub-Saharan Africa.J Surg Res. 2022; 270: 104-112Google Scholar Because LFRs generally do not have previous medical experience and may not be fully literate, training curricula are focused on a core set of relatively simple concepts such as bleeding control, fracture immobilization, and rapid transportation. Curricula should be contextually appropriate to address prevalent local emergencies (informed by needs assessments), emphasize hands-on training of practical skills, and have low student-to-teacher ratios. For example, the Emergency First Aid Responder program in South Africa has used stakeholder participation to tailor their training curricula to meet the needs of local communities.5Sun J.H. Shing R. Twomey M. Wallis L.A. A strategy to implement and support pre-hospital emergency medical systems in developing, resource-constrained areas of South Africa.Injury. 2014; 45: 31-38Google Scholar Tier 1 systems are especially effective in traumatic injuries (most commonly from road traffic injuries) with Basic Life Support interventions; LFRs providing Basic Life Support care have shown a mortality benefit for road traffic injury victims in Iraq.6Murad M.K. Issa D.B. Mustafa F.M. Hassan H.O. Husum H. Prehospital trauma system reduces mortality in severe trauma: a controlled study of road traffic casualties in Iraq.Prehosp Disaster Med. 2012; 27: 36-41Google Scholar The majority of trauma victims are young, otherwise healthy, and salvageable with simple interventions if provided promptly; therefore, networks of local LFRs able to quickly deliver care and transportation can reduce crash-related death and disability. Future training curricula should also consider inclusion of training on technological solutions, given their importance to future tier 1 systems. Tier 1 systems should seek to identify and recruit those volunteers best suited to deliver prehospital care in that particular setting. Outreach initiatives may involve, with stakeholder guidance, the targeted distribution of marketing materials such as flyers, advertisements in local newspapers and radio channels, as well as in-person engagement with schools, universities, community centers, and areas at which commercial drivers congregate. Actively bringing women into LFR programs should involve community outreach with religious and civic leaders, as well as individual family members, to address cultural and religious barriers discouraging women from volunteering as first responders. Collaborating with community leaders can help guide campaigns to reach potential LFRs, and final selection should focus on factors such as where they live and work, motivations for volunteering, personal experiences treating or transporting victims, and recommendations from other community members.7Ramsbottom A. O’Brien E. Ciotti L. Takacs J. Enablers and barriers to community engagement in public health emergency preparedness: a literature review.J Community Health. 2018; 43: 412-420Google Scholar In addition, recruitment of first responders must respect their cultural values and sensitivities, directed by local stakeholders and informed by local norms. In LMICs, only a small minority of patients with conditions requiring emergency care are transported to the hospital by ambulance. In most cases transportation, using locally available vehicles, is arranged by family or bystanders. Because LFRs often operate their own vehicles, rapid transport to definitive care may be achieved, reducing the burden on traditional ambulance infrastructure. Commercial drivers, motorcycle taxi drivers, and police are common participants in tier 1 systems, in part, because they so frequently encounter emergencies and can provide transportation. For LFR programs, Disease Control Priorities-3 recommends a volunteer pool comprising roughly 0.5–1% of the population to be trained as LFRs to achieve adequate emergency coverage.8Hsia R.Y. Thind A. Zakariah A. Hicks E.R. Mock C. Prehospital and emergency care: updates from the disease control priorities, version 3.World J Surg. 2015; 39: 2161-2167Google Scholar The costs associated with recruiting, training, and maintaining such a large service network can be prohibitive, especially in large urban areas. However, there is evidence that robust coverage can be achieved with smaller numbers of volunteers through selective placement favoring areas with high numbers of incidents. Along national Bangladeshi highways, TraumaLink deployed 4 volunteers/kilometer, achieving 100% response rates and responses in 5 minutes or less in 88% of emergencies.9Moussally J. Saha A.C. Madden S. TraumaLink: a community-based first-responder system for traffic injury victims in Bangladesh.Glob Health Sci Pract. 2022; 10e2100537Google Scholar In many LFR programs, a relatively small percentage of volunteers are responsible for the majority of emergency responses.10Eisner Z.J. Delaney P.G. Klapow M.C. Raghavendran K. Klapow J.C. Identifying a “super-responder” phenomenon in three African countries: implications for prehospital emergency care training.Injury. 2022; 53: 176-182Google Scholar This “super responder” phenomenon suggests that careful vetting of candidates may be a more resource-conscious approach to scale-up prehospital care in resource-limited settings. Maintaining a stable pool of experienced and engaged LFRs mitigates recruitment and training costs. In addition, experienced volunteers require less oversight, permitting less staff supervision. Volunteer retention can be improved by maintaining regular contact through social media and in-person visits, and with public recognition. First responders often enjoy an elevation in their social status, and small business owners and commercial drivers have reported an increase in customers, with trained motorcycle taxi drivers reporting earnings 30–40% greater than untrained counterparts.11Delaney P.G. Eisner Z.J. Blackwell T.S. et al.Exploring the factors motivating continued lay first responder participation in Uganda: a mixed-methods, 3-year follow-up.Emerg Med J. 2021; 38: 40-46Google Scholar Socioeconomic benefits promote sustainability of tier 1 systems in resource-limited settings that might otherwise not be able to afford EMS. Therefore, trainee selection is essential to ensure volunteers are recruited from careers that may derive benefits in order to promote continued involvement. Working as a volunteer may also lead to job opportunities within EMS as systems formalize or in other allied health care systems by enhancing professional experience and skill building. Although tier 1 systems require effective, sustainable, and feasible monitoring and evaluation, assessing the quality of care provided by LFRs can be challenging. It can be logistically difficult for program supervisors to observe and provide feedback on the performance of volunteers during emergency responses in less formal systems. These challenges can be addressed, in part, by providing direct feedback during training and by seeking input from staff in receiving facilities about the quality of prehospital care. One tool for assessing program efficacy is the Prehospital Emergency Trauma Care Assessment Tool, which independently assesses the frequency of provision of basic prehospital interventions, and has been used to assess LFR programs in Sierra Leone.12Delaney P.G. Eisner Z.J. Thullah A.H. et al.Evaluating a novel Prehospital Emergency Trauma Care Assessment Tool (PETCAT) for low- and middle-income countries in Sierra Leone.World J Surg. 2021; 45: 2370-2377Google Scholar Tier 1 systems usually develop in the absence of formal prehospital care, but tier 2 systems can also train and integrate tier 1 first responders. Most tier 1 systems remain as standalone systems that integrate to varying degrees with more formal EMS services and other community services but do not evolve into a tier 2 system. One of the promises of creating tier 1 services is that they can provide a platform for the addition of more advanced prehospital service offerings that makes it more likely for these efforts to be efficacious and sustainable. In conclusion, prehospital emergency care is an essential component of a robust health care system, but it must be delivered in a manner appropriate to the setting in which it takes place. Although the majority of the world lacks access to formal emergency medical services, there are almost always good Samaritans who take it upon themselves to provide basic care and transportation. There is much to gain by investing in LFR training as an independent prehospital system, or as a foundation upon which to build tier 2 services, although programs must actively involve local stakeholders to create ownership, political will, and sustainability while integrating with other community services. The authors received no funding for this work.

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