Hospital proximity does not guarantee access to emergency care
Authors: Heike Geduld, Emilie J Calvello Hynes, Lee A Wallis, Teri Reynolds
Journal: The Lancet Global Health (2018)

We applaud Paul Ouma and colleagues' work (March, 2018),1Ouma PO Maina J Thuranira P et al.Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis.Lancet Glob Health. 2018; 6: e342-e350Summary Full Text Full Text PDF PubMed Scopus (182) Google Scholar which highlights the importance of access to emergency care. The authors conclude that 71% of the population in sub-Saharan Africa lives within 2 h of hospital access. Although we appreciate the mapping efforts and data presented in this paper, we do not agree with Ouma and colleagues' central assumption that hospital proximity equals access to emergency services. In reality, most patients with an emergent condition who can access a hospital are likely to be met with limited, ineffective or non-existent emergency care. Actual access to emergency care is much lower than the authors' estimates. Most hospitals in sub-Saharan Africa are without well organised emergency care provision. Many national assessments in the region using the WHO Emergency Care System Assessment Tool have established that first-level hospitals serving most of the population have little capacity for recognition and management of emergency conditions. This situation results from gaps in service delivery organisation, human resources, essential medications and technology, and legislation and government. In terms of service delivery organisation, many first-level hospitals do not have designated emergency units and standardised processes, including triage, resuscitation pathways, condition-specific clinical guidelines and transfer criteria required to treat emergency conditions.2Reynolds T Sawe H Rubiano A Shin S Wallis L Mock C Strengthening health systems to provide emergency care.in: Disease control priorities: improving health and reducing poverty. 3rd edn. World Bank Group, Washington, DC2017Crossref Google Scholar From the perspective of human resources, only ten countries in sub-Saharan Africa have emergency care specialty training programmes. Most frontline providers treat emergency conditions without the benefit of dedicated emergency care training or certification pathways. Many first-level hospitals do not have basic equipment and medications. An essential emergency care package has recently been published2Reynolds T Sawe H Rubiano A Shin S Wallis L Mock C Strengthening health systems to provide emergency care.in: Disease control priorities: improving health and reducing poverty. 3rd edn. World Bank Group, Washington, DC2017Crossref Google Scholar to address this gap and aid in national planning. Finally, few countries in sub-Saharan Africa have the legislative and enforcement mechanisms needed to ensure that access to emergency care is available to those who need it most, regardless of ability to pay. WHO has tools to facilitate improvements in each of the areas above; we specifically encourage efforts that quantify the capacity for emergency care service provision via standardised tools, such as the African Federation for Emergency Medicine's Emergency Care Assessment Tool3Calvello EJ Tenner AG Broccoli MC et al.Operationalising emergency care systems in sub-Saharan Africa: consensus-based recommendations for healthcare facilities.Emerg Med J. 2016; 33: 573-580Crossref PubMed Scopus (21) Google Scholar or the emergency unit module of the WHO hospital assessment tool.4World Health OrganizationEmergency and trauma care.http://who.int/emergencycareDate accessed: May 30, 2018Google Scholar When combined with the mapping analysis provided by Ouma and colleagues,1Ouma PO Maina J Thuranira P et al.Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis.Lancet Glob Health. 2018; 6: e342-e350Summary Full Text Full Text PDF PubMed Scopus (182) Google Scholar these objective measures of facility emergency services would be powerful in establishing a more accurate estimate of sub-Saharan Africa's access to emergency care. We declare no competing interests. Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysisPhysical access to emergency hospital care provided by the public sector in Africa remains poor and varies substantially within and between countries. Innovative targeting of emergency care services is necessary to reduce these inequities. This study provides the first spatial census of public hospital services in Africa. Full-Text PDF Open Access