Gaps in physical access to emergency care in sub-Saharan Africa
Authors: Regan H Marsh, Shada A Rouhani
Journal: The Lancet Global Health (2018)

Emergency care encompasses the urgent stabilisation, diagnosis, and treatment of acute medical, surgical, and obstetrical conditions.1Reynolds TA Calvello EJB Broccoli MC et al.AFEM Consensus Conference 2013 summary. Emergency care in Africa: where are we now?.Afr J Emerg Med. 2014; 4: 158-163Crossref Scopus (26) Google Scholar In low-income and middle-income countries, where substantial barriers to care exist, emergency care is often the primary access point to the health system;2WHOEmergency care systems. Geneva: World Health Organization.http://www.who.int/emergencycare/systems/en/Google Scholar however, emergency care systems remain underdeveloped in these countries. The Disease Control Priorities Project estimates more than half of all deaths and about a third of all disability-adjusted life-years in low-income and middle-income countries could be addressed through prehospital and facility-based emergency care systems.3Reynolds TA Sawe H Rubiano AM Shin SD Wallis L Mock CN Strengthening health systems to provide emergency care.in: Disease control priorities: improving health and reducing poverty. 3rd edn. World Bank, Washington DC2017Crossref Google Scholar Strengthening of emergency care is an important step on the path to universal health coverage and is endorsed by WHO as "an essential part of integrated health-care delivery".4World Health AssemblyHealth systems: emergency-care systems.http://apps.who.int/gb/ebwha/pdf_files/WHASSA_WHA60-Rec1/E/reso-60-en.pdf?ua=1Date: 2007Google Scholar The African Federation for Emergency Medicine, WHO, and other stakeholders have worked to define emergency care, design training programmes, and assess quality of emergency care systems in low-income and middle-income countries for the improvement of emergency care access and service delivery.1Reynolds TA Calvello EJB Broccoli MC et al.AFEM Consensus Conference 2013 summary. Emergency care in Africa: where are we now?.Afr J Emerg Med. 2014; 4: 158-163Crossref Scopus (26) Google Scholar, 5WHOEmergency and trauma care: activities. Geneva: World Health Organization.http://www.who.int/emergencycare/activities/en/Google Scholar This improvement must be accompanied by measurement. Currently, efforts to measure emergency care across low-income and middle-income countries globally have been limited by the paucity of data on hospital accessibility and service availability. In The Lancet Global Health, Paul Ouma and colleagues6Ouma PO Maina J Thuranira PN 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; (published online Jan 24.)http://dx.doi.org/S2214-109X(17)30488-6Summary Full Text Full Text PDF PubMed Scopus (182) Google Scholar substantially expand the understanding of physical access to hospital-based emergency care in sub-Saharan Africa. They compiled data from 100 different sources to create, and make openly available, a novel geocoded database of 4908 public hospitals in 48 sub-Saharan African countries and islands, including Zanzibar. They analysed road network data and estimated travel speeds to calculate travel times to hospitals, incorporating both walking and motorised transport. Subsequently, using the WorldPop spatial demographic database for 2015, Ouma and colleagues determined the population proportion living within 2-h travel times of hospital services, a benchmark for access to emergency surgical and obstetric care.7WHOUN Population FundUNICEFAdverting Maternal Death and DisabilityMonitoring emergency obstetric care: a handbook. World Health Organization, Geneva2009http://apps.who.int/iris/bitstream/10665/44121/1/9789241547734_eng.pdfGoogle Scholar, 8Meara JG Leather AJM Hagander L et al.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1850) Google Scholar Ouma and colleagues estimate that a staggering 287 282 013 (29·0%) people and 64 495 526 (28·2%) women of child bearing age live more than 2-h travel time away from emergency hospital care. Substantial variation was seen between countries, ranging from an estimated 97·3% of the population in Zanzibar to only 22·8% in South Sudan living within a 2-h travel time of a hospital. Notably, 32 (67%) of the 48 countries did not meet the international target that 80% of the population should live within a 2-h travel time of a hospital,8Meara JG Leather AJM Hagander L et al.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1850) Google Scholar and in seven countries less than 50% of the population met this criteria.6Ouma PO Maina J Thuranira PN 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; (published online Jan 24.)http://dx.doi.org/S2214-109X(17)30488-6Summary Full Text Full Text PDF PubMed Scopus (182) Google Scholar These striking gaps stress the importance of expanding physical access to hospital emergency care services as part of a strategy of universal health coverage. Several limitations will need to be addressed in future work. First, Ouma and colleagues examine only the physical presence of hospitals, but not the actual availability of emergency care services. True access to emergency care requires affordable services by trained providers, available medications and supplies, and referral systems. If these measures were incorporated into the present analysis, the number of people in sub-Saharan Africa without emergency care access would probably be much higher than the estimates calculated by the authors. Recently developed emergency care assessment tools1Reynolds TA Calvello EJB Broccoli MC et al.AFEM Consensus Conference 2013 summary. Emergency care in Africa: where are we now?.Afr J Emerg Med. 2014; 4: 158-163Crossref Scopus (26) Google Scholar, 5WHOEmergency and trauma care: activities. Geneva: World Health Organization.http://www.who.int/emergencycare/activities/en/Google Scholar offer potential starting points to evaluate these issues, and could be combined with future geospatial analyses. Additionally, although this study might be the most comprehensive list of public hospitals in sub-Saharan Africa, the database needs refinement to maximise its use for implementers, researchers, and policy makers. Specifically, the database should be verified at national level for accuracy. Furthermore, private hospitals and specific hospital-level service availability—including capacity for emergency care, emergency obstetric care, operating theatres, and diagnostics—should be added. Ideally, the database will be managed as an open access resource with a specific schema, topology, and attributes of interest to allow ongoing inputs from diverse sources. Finally, the present analysis presumes availability of motorised transport. Refined measurements of transport times, availability, and costs will capture a more accurate picture of emergency care accessibility than the current findings. Despite these limitations, Ouma and colleagues considerably expand the understanding of emergency care access with the first comprehensive geocoded spatial analysis of public hospitals in sub-Saharan Africa. Future analyses incorporating service availability and quality are needed to improve the understanding of gaps in emergency care. However, given the importance of emergency care to health outcomes in low-income and middle-income countries, these analyses should not delay efforts to advance physical access. As a logical starting point for implementation, Ouma and colleagues identify population dense areas without emergency care access. A variety of strategies could be envisioned, including road infrastructure improvements, new hospital construction, enhanced referral systems from small clinics, and improved ambulance and prehospital networks. Although each country will have different needs, identification and implementation of different options as well as best practices should be discussed and shared among countries. Ouma and colleagues' Article serves as a call to action to improve access to hospital-based emergency care in sub-Saharan Africa. With nearly 30% of the population more than 2-h travel time from the nearest public hospital, improvement to service delivery capacity is urgently needed. Future efforts to expand physical access should be coordinated with ongoing work to expand emergency care training, service availability, and quality to achieve universal 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