EFAR: a sustainable way to increase access to emergency care

Low and middle-income countries not only suffer the highest rates of every category of injury, they also have the highest rates of acute complications for communicable disease, maternal death and under-5 mortality (Jamison et al., 2012). Sadly these countries are the least likely to have established and effective emergency care systems.

When developing emergency care systems, lower-income countries often strive to duplicate systems from higher income countries. Implementing what has worked in high-income countries is a problematic strategy for various reasons: high-income countries have enabling infrastructure in place.  This is external from healthcare and includes roads, technology, telecommunications, and developed micro-financing/other insurance schemes.  Legislation and government policy also influences the success of the healthcare system.  Higher income countries government expenditure on healthcare is typically much higher than the expenditure in lower-income countries.

A strategy that might be more appropriate in lower-resource settings is to involve the community.  Engaging communities through the EFAR concept is a low-cost, context-appropriate strategy.  It allows for the community to bridge the gap whilst infrastructure and formal health systems are advanced.

So you might be wondering how teaching people first aid could be considered a national strategy.  There are two main differences between EFAR and first aid.  The first is that EFAR’s are integrated with the coordinated response system.  Secondly EFAR programs are designed to be context-specific and are adapted to the needs within the specific location.  This is a very different from ‘formal’ first aid courses that are designed to be generic.  EFAR training is aimed at teaching participants to manage conditions that they are likely to see within their context.  As example in Ghana out-of-hospital systems are not yet adequate, and long-distance truck drivers are likely to be on scene first.  Thus Ghanaian truck drivers were taught the basic principles when treating motor vehicle accident patients and basic scene management.




EFAR was also implemented in the gangster-ridden areas of Manenberg and Lavender Hill in Cape Town.  Cape Town has a well-established ambulance service, however there is some difficulties responding into gangster-ridden areas and informal areas with unmarked roads etc. There have been some difficulties with sustaining EFAR in these areas and it’s been suggested that integrating the informal system into a well-developed system is trickier than when the system is not yet matured.  For example in Zambia, EFAR has been rolled out to some of the country’s most rural areas.  This project has been ongoing since 2013 and a recent site visit (formal report pending) suggests that it is functioning well.

In Cambodia and Iraq healthcare workers were trained to be ‘paramedics’.  They then trained 2 800 community members. In the first two years of the project the community members managed approximately 800 patients and the mortality rate from trauma dropped from 28.7% to 9.4%.

EFAR as a strategy to enhance the capacity of emergency care systems are a feasible solution in low-resource settings.  In fact is appears to be more feasible than copying ‘international practice’ from well-developed systems. However EFAR is a bridging strategy whilst the formal emergency system is maturing, it is not a replacement strategy.  It is a cost-effective and easily implemented method to establishing out-of-hospital capacity.


Jamison, D. et al (editors) (2006) Disease control priorities in developing countries.  NCBI bookshelf http://www.ncbi.nlm.gov/books/NBK11728/

EFAR website: http://www.efarsystem.com/

Husum H, Gilbert M, Wisborg T.  Training pre-hospital trauma care in low-income countries: the ‘Village University’ experience.  Med Teach 2003: 25: 142-148

Sun JH, et al.  A strategy to implement and support pre-hospital emergency medical systems in developing resource-constrained areas of South Africa.  Injury (2012) http://dx.doi.org/10.1016/j.injury.2012.08.015

Wisborg T, Murad M, Edvardsen O, Husum H.  Prehospital trauma system in a low-income country system maturation and adaption during 8 years.  J Trauma 2008: 64 (5)1324-1348

And it is limited to low resource settings anymore.  Scotland are rolling out a system http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-460



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