The end of the short course route to become a SA paramedic

For years there have been rumors about the end of short course training for paramedics in South Africa.  It became real on 27 January 2017 when the Department of Health published a regulation pertaining to the qualifications for registration of the short courses. 

A brief background to those unfamiliar with the system:  Until now there has been a dual system to become a paramedic.  Taking the short course route meant completing a 4-6 week course in order to qualify as a Basic Ambulance Assistant (BAA). The BAA can do the basics including (but not limited to) the administration of oxygen and splinting of fractures.  For a long time (possibly still?) BAA’s was the backbone of the Emergency Medical Services (EMS).  Especially in the urban areas where there is a high density of hospitals, the BAA is valuable because they can perform basic care, load the patient and rapidly proceed to the closest facility.  This implies fast access to definitive care.  Career-wise to advance the BAA had to complete working full-time for 6 months or 1000 hours as prerequisite to apply for the next course. If successful, the BAA could then do the Ambulance Emergency Assistant (AEA) course.  The AEA can perform skills including nebulization and commencing IV therapy.  Again after 1000 hours or 6 months of full-time working, they can apply to do the 9 month advanced life support paramedic course.  This course has limited space and the entry exams are tough; thus AEA’s often have to work for a number of years and gain experience prior to doing the course.  This pathway to become an Advanced Life Support Paramedic is now being scrapped in favor of a 4 year degree program at selected UT’s.

In many ways this agenda has been driven by a desire to professionalize and create the capacity for research within the field.  Still there is an eerie sense of dèjá vu; the impact on training is similar to what happened to nursing not so long ago.  During the late 90’s in an attempt to restructure nursing, various colleges were shut down, shorter nursing courses were suspended, the university curriculums were adapted and the intake of nursing students at these institutions reduced.  Shortly thereafter community service for new nursing graduates became compulsory and to become a nurse meant 5 years of studying.  Fast forward about 20 years, and South Africa has an estimated shortage of 45 000 nurses, with only 3 500 new nurses are trained per year.  According to Nursing Council statistics 48% of Professional Nurses are above the age of 50 with 25% of nurses under the age of 40; of these only 5% are under the age of 30.  The shortage of nurses is dire and will continue for the foreseeable future, especially when the 48% above 50 start retiring in the next decade. 

The shortage gave rise to contract nursing, also known as ‘moonlighting’ where nurses work overtime shifts or only work as agency nurses.  Moonlighting caused (well-described) drastic consequences on the quality of nursing care in South Africa.  Furthermore it attributes nurse burnout.  Sadly it also costs the hospitals more money to buy-in agency staff, it increases the load on the nurse managers to process hours, plan staffing, negotiate and book agency staff. 

There are a few lessons to learn from the above.  Sadly though, paramedicine seems to be on the same trajectory. Other concerns include

1)      University qualified paramedics = higher salary expectations = higher budgetary demand

Remunerating a workforce that consists of degree paramedics will be at a far higher cost than paying different levels of short-course practitioners.  In a country where the health system is struggling with budgetary constraints exists I’m not sure whether the provincial health services would be able to accommodate increased salary budget demands without compensating other vital aspects such as vehicle maintenance, equipment or stocks.

2)      Related to the above.  The cost to train a degree paramedic

The cost per student is higher at a university than with in-service training. The duration of the courses are longer, meaning that any investment will only yield results in 4-5 years.  How can this be seen as cost-effective in a country with budgetary constraints, a growing burden of disease and ever-increasing demand? 

3)      Brain drain

It is not a new problem that newly qualified paramedic graduate leave the country in hordes.  They earn better salaries in Qatar, the UK and as contractors for the oil and gas industry. Thus the back bone of the provincial services has remained short course paramedics.  In the Western Cape the vacancy rate for paramedics in the public sector is 7.5% (2015/16 DOH report).  This is the highest across all healthcare professionals in the public sector; it is even higher than the nursing vacancy.  Taking away the short courses, spending all the money to train graduates and then have them leave the country doesn’t seem to solve the pressing issue of high vacancy rates.  The vacancy rate might already imply a paramedic shortage. 

4)      Loss of tacit knowledge and experienced practitioners 

Over the past decade the career progression for paramedics that came through the ranks by doing the short-courses has become more and more limited. Often despite their years of experience, they cannot apply for management positions; they earn less that their newly qualified inexperienced colleagues.  Because they know the system they often end up carrying newer qualified degree paramedics.  Over the years with the constant threat of the end of short-course training, and the rise of more and more degree paramedics, these practitioners have become disgruntled and unhappy.  Now that their qualification is officially extinct, why should they stick around in the industry? And can South Africa really afford to lose their knowledge and experience?

5)      Increased barriers to access emergency care 

I’ve been part of the Hout Bay Volunteer Ambulance Service (HBVEMS) since 2004, a community-driven ambulance service that predominantly functions with short course practitioners.  With no more short courses, the growth and sustainability of services such as HBVEMS are stunted.  The volunteer pool will shrink until there is no service left.  This is true for volunteer services across the country and it creates a gap in service delivery and access to essential emergency care.

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6)      Impact on fire services 

In Hout Bay and other areas, the fire services fill an important gap as first responders.  Often patients are taken to fire stations where care is rendered whilst waiting for an ambulance.  This is done by fire fighters that have completed the short courses.  As rendering emergency care is not their primary duty is seems nonsensical for them to do a 4 year degree.  Again the impact of fire fighters no longer being qualified to render basic care will be felt by the community.

7)      Paramedicine = exclusivity

A degree program has higher entry requirements than skills based programs, helping the professionalization of the field.  I fail to see how the professionalization and more elite paramedical qualification contributes to better serving the need of our country’s growing population.  Would the same money to train degree paramedics, not be more useful if used to purchase more ambulances?   Is scrapping short-courses really in-line with the needs of the population of South Africa?  Not to mention that there’s been studies questioning whether having higher qualified paramedics on scene actually equals better care, as they are more likely to spend longer time on scene performing advanced interventions that is not always required.  In the end one of a paramedic’s core functions is to stabilize and transport to definitive care. 

The key arguments for discontinuing short courses are that short courses do not comply with the National Qualification Framework Act.  And in order to professionalize paramedicine a degree program is required.  It has also been stated that the Health Professionals Council of South Africa has to protect the public by ensuring the registration of appropriately qualified emergency care providers who has the skills to practice their profession safely. 

“We learn to do something by doing it. There is no other way.” – John Holt

I completely agree that there should be a degree program that helps advance the field, promote research and education.  However in the end, a good paramedic is someone that can apply their skills.  Paramedicine is a skills-based function and whether having a degree equals being more skilled to perform practical interventions are questionable.  I disagree that the ‘professionalization’ of paramedicine at the expense of short-course programs is the best way forward.  Especially in a country that has a growing population, quadruple burden of disease and inequality in accessing care.  In fact to solve some of the problems that we face in emergency care, maybe we should rather follow one of the ideals of the Gates foundation:  “The ideal is creating a skills-based credential that is well trusted and well understood enough that employers view it as a true alternative to a degree” (Bill Gates 2013)

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Emergency care in Africa: There is no free lunch…

Let hunger be ranked first because if you are hungry you cannot work! No, health is number one, because if you are ill you cannot work! – Discussion group ranking; Musanya Village, Zambia1

The basic economic premise states that our wants are unlimited but our resources to obtain our wants are limited. On an individual level this implies that we are constantly prioritising desires in order to afford the most important ones (I’m using the word desire as an umbrella term for needs and wants). Sometimes we prioritize in a conscious way through budgeting, negotiating with our partners, saving for large expenditures or investing. At other times it’s automatic and we are largely unaware of the process. These ‘automatic’ decisions are based on beliefs and values, rooted in our culture, community and environment.

Every so often the desires are mutually exclusive and choosing one option means giving up on another, thus we make trade-offs or sacrifices. Our willingness to make a trade-off depends on the perceived benefit of the chosen option. The trade-off is not always financial, convenience or time might be valued more than cost. If the benefit is unknown or uncertain, the trade-off is viewed as risky and not worth the effort or cost.

Economics 101

  • Humans have unlimited needs and limited resources
  • We can’t have everything that we need or want
  • What you are willing to give up depends on what you get out of it (the benefit)
  • The decision is not always easy

fsdfs

The relation between income, benefit and trade-off can be seen in the triangle. Income represents the ability to raise financial resources to pay for care and it includes savings, obtaining a loan, etc. Benefit refers to treatment outcome and adequacy of emergency care. The trade-off is the sacrifice made to afford the benefit.

For people living in Africa the benefit is murky and the cost high. Ambulance services are rudimentary limiting the ability to obtain care at the site of injury, transport to definitive care or care during transit. Upon arrival at the health facility, Africans are burdened with out-of-pocket payments prior to stabilisation, resuscitation or basic care. In addition, due to low government investment, healthcare facilities create alternative funding methods to afford supplies, staff etc. These methods generally involve requesting (demanding) supplementary payments, known as informal payments, bribes or gifts. Paying these allows the patient to skip the queue, get a bed and receive care. Other cost considerations are the ‘hidden’ or indirect costs including the travelling costs, transportation, carer accommodation, waiting time and lost income opportunities.

Sadly, these expenditures are incurred to obtain care in facilities where infrastructure is lacking. Running tap water, electricity, basic equipment or medication are not a given. Also healthcare providers are often not well-equipped with basic emergency care skills.

Trade-offs are made in order to afford the care and may include

  • Reducing the household’s food consumption and budget
  • Selling a girl child into underage marriage
  • Selling assets such as livestock or dwelling
  • Removing children from school
  • Child labour
  • Selling foodstuffs like maize
  • Taking out loans at a high interest rates
  • If there’s more than one patient, prioritising care for one member at the expense of another

Basically, accessing emergency care requires massive trade-offs for a very uncertain benefit. An alternative is to not access care and hope for the best. This becomes a reasonable option when one considers that each year approximately 25 million Africans are pushed into poverty due to healthcare expenditure. Catastrophic health expenditure is calculated in various ways; however most methods exclude informal, indirect costs and the depletive sacrifices. The entire household suffers the repercussions of financial ruin.

tradeoff-for-blog

Emergency care benefits only the patient. The household makes the sacrifice so that one person can potentially benefit. It’s further complicated due to the urgency, emergency care requires time-critical interventions and delaying care can be devastating. The decisions taken shortly after a traumatic incident are probably not well-thought through, rational or informed. Predicting the required sacrifices is confounded due to different types of cost, changing costing structures and a whole lot of unknowns. It’s a tough call.

When we are involved in developing and strengthening systems in other communities than our own, we need to be aware that as outsiders we don’t understand the daily reality of those we serve. We can’t assume the local needs, wants, trade-offs and norms. Our observations are clouded by our own bias. This can be overcome by establishing ways to enable community participation that allows the implementation of sustainable and locally owned interventions.

On another level, advocacy for the greater good of accessible care includes continued lobbying for universal access to healthcare. Emergency care, especially out-of-hospital systems can significantly reduce cost as a barrier to access care.

                        For me a good life is to be healthy1 – Old Man Ethiopia

This blog includes some aspects that I addressed at the BADem symposium regarding the trade-offs that people make in Africa to access healthcare.

  1. Dying for change, poor people’s experience of health and ill-health. World Bank Study 2000. www.worldbank.org/poverty/voices

 

 

 

BADEM2016

Yesterday I had the privilege to participate in the emergency medicine symposium held by BadEM in Cape Town.  Conferences, symposiums and workshops that attract big name-speakers are often expensive and definitely unaffordable to students.  This symposium not only attracted THE big names in Emergency Medicine in South Africa, it was also FREE allowing everyone to participate and it filled 400 seats.  

The BadEm team are great believers in the power of social media, especially free open access medical education (FOAMed) and the power of social media was once again demonstrated.  By mid-morning (if not earlier) #BADEM16 was trending on twitter.  Word about what is important in emergency care in Africa gained a global audience and tweets were flowing in from all over the world.  How brilliant!

The BADEM16 talks was thought –provoking and covered themes including to stop using first world solutions for the developing world; should we be training CPR in low resource settings; owning up and learning from mistakes, errors and omissions; how to have the difficult death conversation with the family and how to allow the patient to die with dignity.  And that we need new solutions for the same old problems. 

I found it refreshing that clinical expertise took a bit of backseat, allowing the conversation to be on things that I think really matters, such as how do we develop sustainable cost-effective systems that the patients can trust and where people actually want to and can effectively work in the system.

Emergency Medicine is leading the way to new frontiers.  By creating global awareness, the need for emergency care systems can become a priority, resulting in better resource allocation and investment into emergency care systems.

In conclusion, this is without doubt an exciting time in the development of emergency care in Africa.  I feel incredibly blessed to be part of the story that we are writing, the story of how emergency care in Africa was developed.  To the BADEM team, well done!

See some pics below

NS – a blog to follow shortly on my talk and the fact that there is no free lunch

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check out badem.co.za

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Prof Wallis talking about CPR

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Some of the speakers and the BADEM team

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One of the tweets during my talk

 

 

Gugu Zulu: Another story about the barriers to access emergency care in Africa

In Africa, surviving serious illness or injury is like participating in Survivor.  In order to survive, people need to outwit, outlast and outplay the health system.

The death of the fit, apparently healthy 38-year old Gugu Zulu made news headlines. The events leading to his death are tragic. Zulu, a well-known South African personality died during the Trek4Mandela Kilimanjaro expedition that raises awareness for the #keepingagirlchildinschool movement.

Details on the descent that were supposed to improve Zulu’s condition and allow for further care are sketchy. The timeline in the media reports differ, some saying that it took 4 hours to cover 32 km on a bicycle stretcher, others say 8 hours.  Still, how terrifying the experience must’ve been for his wife that remained at his side throughout the journey.  Despite discrepancies in timelines and the exact cause of death still pending autopsy results, it appears that the lack of timely access to further emergency care was a contributing factor leading to his death.

Photo%20of%20the%20Week%20(15.10.26)%20Kilimanjaro%202011%20porter%20w%20stretcher

Example of the bicycle stretchers used in Kilimanjaro

 

Gugu Zulu required urgent emergency care, and he died because he couldn’t get to care. Sadly, the story repeats itself in various African settings on a daily basis where people frequently die because of health system failures. They die because there is no available transport to the health facilities, which are too far apart and ill-equipped.  They die because care is unaffordable and healthcare staff are not trained to deal with emergencies.  And they die because there are no out-of-hospital care systems (see earlier blogs on access to care and EFAR).

In Zulu’s case (and depending on the route taken) the closest appropriate facility was about 50km away from the National Park. The Kilimanjaro Christian Medical Clinic (KCMC) is a 600 bed facility and it has an emergency care department that doubles as outpatient clinic. It serves the healthcare needs of 15 million people. Time, geographical accessibility and method of transport appears to have been bigger issues contributing to his death than only the availability of an appropriate facility.

The effectiveness of emergency care is dependent on time. The following definition for emergency care was agreed upon at the African Federation for Emergency Medicine (AFEM) consensus conference in April this year: ‘emergency health conditions are those requiring rapid intervention to avert death or disability, and those for which treatment delays of hours or less make interventions less effective.’

Obtaining care for emergency health conditions are a challenge in Tanzania.  The country has a doctor to patient ratio of 2 per 100 000 people. Another constraint as highlighted in this case is the lack of formal out-of-hospital services. Formal systems would facilitate the delivery of care at site of injury/illness and continued care during transportation.

That said, Tanzania is one of the very few African countries that has emergency medicine residency and emergency nursing programmes. Local emergency care practitioners have been supported by international faculty to share expertise.  In 2011 the Emergency Medicine Association of Tanzania (EMAT) was formed.  This organisation works closely with the government to prioritise emergency care and to development emergency care.  EMAT and AFEM works closely together to advocate for the unrestricted access to emergency health care.

Ensuring unrestricted access to emergency care by developing sustainable systems requires awareness and funding.  Sadly, emergency care does not yet share a similar status to that of high-profile diseases like HIV, TB and Malaria.  People are aware of the high-profile diseases and thus they are well-funded and promoted.

The death of Gugu Zulu begs the important question, can global stakeholders in health care continue to ignore the importance of developing strong emergency care and out-of-hospital care systems?

As Olive Kobusingye says,

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In future, the stories told in Africa will depend on how well we advocate and continue building emergency healthcare systems.

P.S. I would like to share an idea that we’ve been talking about since the WHO Basic Emergency Course last year. The idea is to travel from clinic to clinic through some countries that has ties with AFEM by cycling and/or using the method of transport that the different communities would use to access care. The purpose is to raise the awareness of how hard it is to obtain emergency care.  I would welcome some ideas on how we could make such an undertaking work. 

Further reading

Gugu Zulu

https://www.ecr.co.za/news-sport/news/small-medical-facility-needed-mount-kilimanjaro-letshego-zulu/

http://www.msn.com/en-za/news/localnews/gugu-zulus-wife-pleads-for-mini-medical-facility-to-be-erected-on-mount-kilimanjaro/ar-BBuZ6G2?li=AAaxc0E&ocid=spartandhp

https://www.researchgate.net/profile/David_Irwin3/publication/267102897_A_Retrospective_Study_of_Acute_Mountain_Sickness_on_Mt._Kilimanjaro_Using_Trekking_Company_Data/links/54da49c70cf233119bc29c23.pdf

http://www.iol.co.za/motoring/industry-news/gugu-zulus-death-is-a-blight-on-tanzania-2049525

http://www.iol.co.za/motoring/industry-news/kilimanjaro-tragedy-the-inside-story-2047032

Emergency care

http://www.afem.info/

http://www.emat.or.tz/

http://www.kcmc.ac.tz/index.php?q=casuality

http://www.epijournal.com/articles/167/hendry-sawe-young-leaders-bring-fresh-energy-to-african-emergency-medicine

Access to care: time to reconsider the concept?

Imagine the uncertainty and level of decision-making required to visit a healthcare facility for a cholesterol test, blood pressure check or the renewal of a script versus requiring care and transport at the scene of an accident where there’s multiple injured patients, some requiring urgent care.

The pressure to make decisions, the emotional intensity involved (fear, anxiety, anger, remorse) and the perceptions about the possible barriers to obtain emergency care seem more complex than those required when visiting a primary healthcare clinic. Injury, accidents, sudden illness and complications from non-communicable disease all fall under the umbrella of emergency care.  Because emergency care is a frequent entry point into the healthcare system, one would assume that the barriers to access emergency care have been well-described and explored.

I reviewed more than 50 of the most cited papers that describe access to care and only three mention emergency care. Another interesting observation is that most authors do not clarify what they mean when using the term ‘access to care’. Most articles do however refer to either the behaviour model of access to care or the 5A model.

Models in brief:

The behavioural model of access to care (Aday and Andersen, 1974) highlights the relationship between utilisation and access.  It suggests utilisation as a proxy to measure access.  The flaw of using utilisation as a proxy is that patients that died prior to reaching care are not captured in the measurement.  In emergency care those that could not access care and the reasons why they couldn’t or chose not to access care are incredibly important.

In the 5A model (Pechansky and Thomas, 1981) access to care is described as a best-fit between the characteristics of the health service, the provider and the patient.  (5A’s=Availability, accessibility, affordability, acceptability, accommodation).

In recent years, the approaches became more ‘holistic’ considering variables including culture, society and gender. Access to care has clearly become more than arriving at a healthcare facility.  But again, the ability to seek care during an emergency, at the site of injury/ out-of-hospital or during transit is not mentioned.

Most countries in Africa do not yet have emergency care systems or the infrastructure to support the development of emergency care. Functional and accessible emergency care systems would enable these countries to address the burden of disease, reduce the impact of road traffic accidents and under-5 mortality to name just a few.

In these countries, when a household member requires emergency care the household needs to make harsh decisions and weigh the risk of financial ruin against a family member’s life.  This can cause irrational decision-making or a delay to make the decision. How can this not be a consideration when describing access to care?

Why including emergency care in access to care discussions matter?

The terms emergency care and out-of-hospital care are relatively new and not included in discussions on access to care, especially not those building on the older, generic descriptions.  It makes it hard for policymakers and funders to actually understand what emergency care is, how it enables access to the rest of the healthcare system and why it matters.

If key stakeholders do not understand the terminology used, they are unlikely to prioritize it, promote it or fund it. Measurement and evaluation are important to stakeholders.  Emergency care does not lend itself to quick, affordable projects with measurable outcomes.  For instance to a politician or funder arriving in a village and vaccinating 500 children is measurable and can be promoted.  To develop emergency care takes time and is harder to define and measure and thus less likely to be funded. If we can clarify the concepts around access to emergency care better, we might be able to create measurable outcomes and thus obtain funding and prioritization.

Not including emergency care as a core aspect when defining access to care in general complicates the development and advocacy of emergency care.  Maybe it’s time to design a model similar to the 3D model used for maternal mortality to define the determinants of access to emergency care.

I would love to hear your thoughts:  how would you describe access to care and if you agree that emergency care deserve more mention (or am I just biased?).

Please note that due to space I’m not including all the article. I can send a spreadsheet if anyone would like to see it.  Some of the authors include Donabedian, Aday and Andersen, Frenk, Pechansky and Thomas, McCintyre et al., Ensor and Cooper, Dutton, Gulliford, Goddard and Smith, Hadid and Mohindra, Mooney, Culyer, van Doorslaer and Wagstaff, Peters, O’Donnel and others.

Making EFAR stick

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:

  • Mismatching

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.

  • Other

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.

one tier system

The two tier system.  Mould-Millan et al. 2014

Further discussion

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.

Read more

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

http://www.who.int/bulletin/volumes/84/7/editorial20706html/en/

 

 

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

THE EFAR CONCEPT

 

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.

References

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