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Evaluation of Emergency Medical Systems in 3 Major Nigerian Cities

Background

A typical emergency medical system (EMS) serves 3 major roles: 1) Accident prevention and public health awareness; 2) Pre-Hospital transport and care; 3) In-Hospital stabilization and treatment.

A principal purpose of an EMS is to provide timely care to patients with the overall effect reducing morbidity and mortality.  In addition to management of individual levels emergencies (e.g. trauma, myocardial infarction (heart attack), stroke), an EMS is a core component of disaster preparedness, accident prevention and broad spectrum public health safety net.

Basic components of an EMS include a population’s ability to access the system, trained human personnel, appropriate dispatch and financing mechanisms.  While the design of EMS systems may vary by country and population density, the underlying aim is the same. 

Like many developing countries, Nigeria faces significant healthcare challenges. International attention has mainly been disease specific with appropriate attention to the scourges of malaria, HIV, tuberculosis and perennial high infant and peri-natal mortality.  Nigeria’s urban centers are some of the most densely populated in the world.  While there is anecdotal evidence that significant morbidity and mortality is attributable to lack of a functional EMS, the inherent gaps and EMS capacity needs in Nigeria’s evolving landscape remain poorly described.  We believe that establishing the context specific evidence base for investment in EMS systems will bolster arguments for policy changes and resource allocation. As a first step, we performed qualitative assessment of existing EMS delivery processes in 3 urban cities, Lagos, Abuja and Jos, each with a population in the multiples of millions. 

Methods

We evaluated EMS capacity in Lagos, Abuja, and Jos. Data was collected during site visits (public and private hospitals) and from interviews with healthcare workers and key stakeholders  

Results

The importance of developing EMS systems is recognized at the all levels of government (district, state and federal) and by the private sector in Nigeria.  This has permitted commissioning of some resources toward the problem.  However, uncoordinated activity of the various players leads to duplication of efforts and suboptimal resource utilization. For example, despite investment in ambulances, an overwhelming majority of patients arrive hospitals via private vehicles and have usually sought care at other (inappropriate) facilities prior to arriving at an appropriate treatment centers. 

Specific gaps by EMS component are summarized below.

  1. Accessing EMS System – Multiple telephone numbers and lack of public awareness on how to access the EMS system limit the utilization of EMS resources.  Lagos State had the most advanced EMS system with dedicated, albeit unreliable, emergency access numbers. Utility was further limited by low public awareness.
  2. Transport & Dispatch Systems – Lack of effective dispatch systems.  In all 3 cities, ambulances were either hospital based or along highways.  Local citizens and road safety personnel dispatched the majority of highway units to accidents scenes.  Once dispatched, units invariably take citizens to the “nearest hospital”.  Hospital based units are effectively grounded due to the lack of hospital based dispatch systems. A key gap in the existing process is a lack of classification of hospitals based on resource capacity, and linking this information to first-on-scene units/transporters to prevent delays.  Private citizens who currently provide majority of emergency transport might also benefit from this information (directly or dispensed by a trained dispatcher) to guide transport to appropriate facilities.
  3. Human Resources – All 3 cities staffed their EMS units and call centers with either nurses and or technicians.  Of all health care providers surveyed, none had formal training in triage techniques, Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), or Advanced Trauma Life Support (ATLS).  Quality assurance mechanisms, training, and management.
  4. Emergency Medicine Financing & Public Safety Policies – Pay before service policies are strictly enforced at a majority of hospitals including major government medical centers. Only Lagos had explicit policies to ensure treatment and stabilization at public hospitals however there were no enforcement mechanisms. In addition such policies do not apply to private hospitals.  Investments in EMS occur sporadically and no direct financing mechanisms exist to ensure long-term sustainability.

Conclusion

All 3 cities surveyed have seen significant investments in EMS systems. However resources remain underutilized due to poor public awareness, lack of intelligent dispatch processes, and lack of requisite investment in human resources.  A key information gap we identified was hospital classification by care delivery (resource) capacity to guide intelligent decision making by transporters.

Filling this information gap is a core focus of Obala.

If interested, please contact us for more details on our findings.