There is no question about the need to develop better emergency care systems in low and middle income countries (LMIC). However, the significant barriers to developing the systems may appear daunting and unattainable. This is partially because any emergency care system need to start within the community or wherever incidents may occur, continue with care during transportation of the patient and allow early appropriate treatment at a healthcare facility.
Developing a system across the above continuum is complicated in LMIC’s. It is expensive and requires the presence of enabling factors external to healthcare. Examples of the enabling factors include sufficient technology and infrastructure such as telecommunications and roads.
As mentioned in a previous blog, an alternative and/or parallel strategy is to enhance the ability of the community to respond during an emergency. This is feasible even in areas where healthcare facilities are scarce, roads non-existent and telecommunications lacking.
Developing community responder systems are based on a fundamental principle that developing a basic capacity to render emergency care can be simple, efficient and cost-effective. To ensure sustainability, the following should be considered:
The trained members need to either live or work within the community. This might sound obvious, but often it is not. Also, training economically active people may result in these people not being within the community most hours of the day. Design should thus involve training the employed, pensioners, people who work within the community (they might even travel from outside the community to work there) and the unemployed.
- Managing expectation
Training the unemployed and even the employed may lead to another problem: expectation. People might participate with the expectation of getting a job or advancing their career and receiving job opportunities. Expectations needs to be managed by being upfront about what the community responder program is about and what is required from trained community members.
Community members may experience a downer after the initial high of being equipped with life-saving skills, or they may be traumatised by exposure to critically ill and injured people. Early attention to ways to keep members motivated, engaged and supported emotionally is required.
- Integration of formal/informal system
If there is a formal ambulance system, the informal (community) and formal systems should be integrated. Community members may feel intimidated by formal emergency care practitioners, and the formal practitioners may not help the situation. This seems to be a major difficulty when implementing community systems.
- Equipment and innovation
The other barrier to sustaining community first aid responder programs is the availability of equipment and stock, including splints, bandages and gloves. In LMIC’s even in healthcare facilities these are scarce items. Yet if it was freely accessible, it may be impractical to carry stock around at all times. This makes a case for training the community members ways to improvise and innovate.
A deterrent to continued participation is the cost of phones and airtime for telecommunications with formal emergency services and/or hospitals.
Concerns from the community may include if and how good Samaritan legislation would protect them, the need for documentation and remaining current with training and skills.
Emergency care competes with an existing bias from foreign funders to fund vertical disease programs, with early and easy measurable outcomes. For policy makers there is competing budgetary priorities and poor economic growth.
So when advocating for the development of emergency care systems, we need to motivate for cost-effective, easy to implement systems whilst simultaneously developing the more expensive formal systems. Formal systems would include tertiary training, specialization of medical practitioners etc.
Training community volunteers to provide early emergency care and stabilisation can save lives and prevent disability. The training provided and subsequent informal system needs to be context-specific, defined by the community and their needs. The greatest challenge after obtaining funding is integrating the participatory community system within formal more bureaucratic systems.
Jayamaran S, Mabweijano J, Lipnick M, et al. First things first: effectiveness and scalability of a basic prehospital trauma care program for lay first-responders in Kampala, Uganda. PLoS One 2009; 4: e6955
Mould-Millman NK, et al. AFEM Consensus Conference, 2013. AFEM out-of-hospital emergency care workgroup consensus paper: advancing out-of-hospital emergency care in Africa – advocacy and development. African Journal of Emergency Medicine. 2014; 4:90-95
Sasser S, Varghese M, Kellerman A, Lormand JD. Prehospital trauma care systems. Geneva: World Health Organisation.
Tiska MA, et al. A model of prehospital trauma training for lay persons devised in Africa. Emergency Medicine Journal. 2004; 21:237 – 9