Emergency Medical Services in Nigeria - First Response No Longer a Last Resort
INTRODUCTION
Injuries and other time-sensitive illnesses such as pregnancy, childbirth-related incidents, stroke, cardiac arrest, sepsis and road traffic accidents are major contributors to premature deaths in low and middle income countries. The majority of these deaths occur before patients even get to the hospital and studies have shown that the existence of pre-hospital emergency care systems decreases the risk of premature death by up to 25%.
Nigeria is no exception to these trends. Over 11,800 road traffic accidents were reported in Nigeria between October and December of 2021 - of those, ~10,200 were injuries and ~1,700 were registered deaths. There have been numerous studies highlighting the impact of poor pre-hospital care on patient outcomes at emergency departments in hospitals across the country. Some have shown that up to ~75% of patients were either dead on arrival or within 6 hours of arrival at the emergency department of a major urban hospital in Nigeria, largely driven by poor pre-hospital emergency healthcare infrastructure on the ground as well as inadequate transportation to hospital. Other studies of pediatric emergency departments have shown that the majority of deaths occured when patients reported late to the hospital with limited pre-hospital care. According to a 2019 Emergency Response Africa (ERA) survey, 3 out of 4 Nigerians had experienced at least 1 medical emergency in the last 5 years, with over a quarter of Nigerians having more than 4 emergencies. Medical conditions (acute and chronic) and road traffic accidents contributed significantly to the number of emergencies.
Emergency incidents present a huge medical burden on the healthcare system in the country; as a result, existing emergency medical services (EMS) are struggling under the weight of this burden. Challenges exist at the pre-hospital and hospital care delivery level that undermine both the public’s willingness to use EMS as well as the EMS and hospital’s ability to receive and treat patients. Emergency medical services in Nigeria are plagued by poor infrastructure; limited availability of functioning ambulances; lack of robust paramedic and prehospital care training; and hospital emergency departments that are not adequately equipped or staffed to handle the volume of patients, and broken communications.
So how exactly is Nigeria coping with this burden? Exploring the current state, limitations and solutions for the EMS system in Nigeria could provide some much needed context, with a particular focus on the communication barriers that hinder effective care during medical emergencies.
CURRENT FRAMEWORK OF EMS IN NIGERIA & AFRICA
As one of the most populated cities in Africa, the Lagos state government has recognized the need to provide emergency medical care to the growing population and has invested more funding in their EMS than any other state in Nigeria.
In 1998, the Lagos government established the Lagos State Emergency Medical Services (LASEMS), the first state-run EMS in Nigeria. The LASEMS initially comprised of two trauma centers (located at emergency departments of the Lagos State University Teaching Hospital and Ikeja General Hospital, Lagos) and the attached ambulance services. In 2001, the ambulance services were separated from the trauma centers, forming the autonomous Lagos State Ambulance Services (LASAMBUS) which had six ambulance stations along major highways and spread evenly across the state. As of today, there are 25 ambulance points in the state as well as a Marine Rescue Unit. In an attempt to standardize and streamline the process of calling an ambulance, a radio-communication network was established to link the public and the various state-run EMS providers, including a dedicated phone hotline; however, several toll-free numbers (e.g., 112, 123, etc.) are advertised which makes emergency communications more difficult.
Even with successful communication between the public and EMS, limitations with emergency response still exist in the state. For instance, between December 2017 and May 2018, LASAMBUS received 1352 road traffic accident calls; while they successfully addressed 37% of these calls, up to 50% of the remaining accidents were false calls or had already been addressed either by self-evacuation, police response, or other miscellaneous reasons. An additional study also revealed that less than 3% of the road traffic accident incidents received by the Lagos State University Teaching Hospital (LASUTH) were brought in by LASAMBUS. These statistics raise some important questions about the state of emergency response in one of Africa’s most populous cities.
Unsurprisingly, the situation in Nigeria mirrors the rest of Sub-Saharan African (SSA) countries; a study published by the World Bank showed that few SSA countries have developed a systematic and financially sustainable approach to delivering EMS services at scale. For example, in Zambia, the MoH aims to ensure that every household is within 5km of a public health facility and can receive emergency medical care, yet the country has not designated a lead national agency responsible and accountable for comprehensive EMS system management. Whereas in Uganda, first responder care includes community health workers, community leaders, taxi drivers, volunteers and the police. However, the coverage is still low in the country, mainly in Kampala city and, partially, in the Masaka region. Lastly, Liberia reports few standard operating procedures for EMS dispatch available at the national level.
On the demand side, patients are often not able to receive sufficient health insurance coverage to cover the costs of emergency treatment. The National Health Insurance Scheme (NHIS) does not provide adequate allowance for EMS, with occupational industrial injuries and injuries resulting from natural disasters, conflicts, social unrest, riots, wars, and extreme sports excluded from the benefit package. Additionally, ambulance response times in Lagos range widely between 7 and 60 minutes, more than double the median urban response times in the USA.
These issues that undermine patient access to EMS have led to significant apathy and distrust for these services in the country. According to the 2019 ERA survey, only 3% of respondents reported calling an emergency number for ambulance service as the first step taken to get help during an emergency, with a whopping 78% of respondents calling family/friends nearby or driving, borrowing or hiring a vehicle. Once they got to a hospital, 44% of respondents indicated that they were either rejected, had their treatment delayed or were referred to another facility without any treatment - resulting in 64% of respondents indicating significant dissatisfaction with how medical emergencies are treated.
Recent policy changes have been implemented to address the ongoing issues with patient access to EMS across the country. In February 2022, the Ministry of Health signed a memorandum of understanding with the private sector and other stakeholders for the operationalisation of the National Emergency Service and Ambulance System (NEMSAS).
The goal of the NEMSAS policy is to operationalize the 5% of the Basic Health Care Provision Fund (BHCPF) allocated for the federal MoH to respond to health emergencies and epidemics. The BHCPF aims to deliver free minimum basic healthcare services to the poorest and most vulnerable Nigerians through the strengthening of accredited primary healthcare centers in each of Nigeria’s 36 states. The policy also involves rural ambulance services to meet the needs of rural community emergencies, particularly regarding access to maternal and child health.
Additionally, in May 2022, President Buhari signed the National Health Insurance Authority (NHIA) Act into law. This new law makes health insurance coverage mandatory for every citizen and legal resident of Nigeria; the required health insurance covers the basic minimum package of services defined by the NHIA. These policies mark a remarkable shift in the federal government’s prioritization of emergency care services that has not happened since the country’s inception.
COMMUNICATION AS A KEY BARRIER FOR EMS
While several attempts have been made to improve the volume and quality of EMS resources across Nigeria and other African countries, one of the key challenges that undermines EMS systems is the poor communication in the EMS space, both between EMS personnel (i.e., paramedics, ambulance operators) and the receiving hospitals, as well as between care seekers and EMS systems.
Various studies across Malawi, Rwanda, Tanzania, Ethiopia and other African countries have identified that limited communication between first responders/ambulance operators and receiving hospitals as one of the key barriers that undermines emergency care. While only part of the EMS treatment pathway, the lack of communication between EMS teams and receiving hospitals plays a substantial role in the quality of care and the likelihood of survival of patients during medical emergencies.
Poor communication between emergency responders and receiving hospitals results in the latter not being adequately prepared to treat incoming patients and the misallocation of hospital resources. When hospital emergency department staff do not have enough information on patients before they arrive, they are unable to prepare the necessary hospital resources to treat patients (e.g., prepping operating theaters, gathering medicines and tools for treatment, etc.). Anecdotal accounts in Nigeria often indicate that hospitals do not have essential resources such as oxygen and stable electricity to effectively treat patients in emergency situations, resulting in avoidable death. As such, in time-sensitive emergencies, even if the volume of ambulances/ambulance points is increased and ambulance response times are improved to meet international standards, the risk of death remains significantly high if receiving hospitals are not adequately prepared.
Additionally, patient/general public awareness of EMS services as a gateway to accessing healthcare in emergencies is worryingly low on the continent. Only 4 out of the 25 SSA countries sampled in the World Bank report had a single emergency number in place despite 21 of these countries having some form of formal or informal EMS system in place. Care seekers having limited and fragmented means of communicating with EMS services also presents a formidable challenge with coordinating effective and timely care in emergencies.
SOLUTIONS TO COMMUNICATION BARRIERS
While solutions to improve the limited and fragmented EMS systems, poor training of emergency responders and low quality and supply of ambulances/ambulance points are crucial to developing a functioning EMS system in these countries, solutions to communication barriers are equally as critical. But what should these solutions look like to have the most impact?
As all emergency response begins with patients seeking emergency care, communication systems should enable easy access. The means of communication should be memorable - this involves the consistent advertisement of a single, easy to remember toll-free emergency number to the general public. Nationwide campaigns should be developed to raise awareness of the number, but also to educate care seekers on the importance of pre-hospital ambulatory care and the positive impact on survival outcomes. Leveraging public-private partnerships could potentially be a highly effective way to launch awareness campaigns and engage with the general public. For example, a collaboration with Nigeria’s booming entertainment industry presents a unique opportunity for a cultural shift in how the public responds to emergency situations.
Second, emergency communication systems should be location-driven, but not internet-dependent. During natural disasters, damage to power lines could significantly disrupt communication pathways and road traffic accidents could lead to heavy congestion, lane closure and impassable roads, causing emergency response delays that could result in death. GPS tracking can help dispatchers identify the location of an emergency call and deploy the closest emergency response team to the site, significantly improving response times. However, in a country like Nigeria where only 46.6% of the population have access to the internet, it is crucial that location-driven communication systems are not exclusively reliant on internet availability.
Once a team of emergency responders are dispatched to the patient and are en-route to receiving hospitals, communication between both care teams is absolutely crucial. As such, solutions should enable real-time communication among all stakeholders, seamless data transfer, and access to patient history, particularly for those with chronic conditions/comorbidities that could impact the care they receive. Cloud-based and predictive analysis solutions can improve the efficiency of communication between first responder staff and the receiving hospitals and support better overall emergency medicine practices by predicting clinical outcomes in resource-constraint settings and optimizing resource management decisions. Prediction models can also aid in the identification of patients suitable for high- and low-risk priority dispatch and divert patients to the appropriate receiving healthcare facilities based on variables such as age, sex, medical history and symptomology.
As the Federal Ministry of Health and State Governments look to implement emergency medical services nationwide, special attention must be paid to the role of end-to-end communication from the scene of an emergency to the hospital emergency department in EMS success. A single break in communication at any stage has the potential to invalidate the work of other stakeholders in the emergency response process, potentially costing the patient’s life.
Key Takeaways from TC Health: As governments and key stakeholders embark on the implementation of effective EMS systems in Nigeria, communication should be a key consideration in the process. Leveraging partnerships with the private sector and Nigeria’s budding technology sector is key to accomplishing seamless care delivery for both first responders and receiving hospitals.
About Emergency Response Africa (ERA)
Emergency Response Africa is a health tech company that is building the largest network of first responders, emergency response vehicles, and verified emergency-ready hospitals across Nigeria who are connected to emergency victims using their technology application. The Signal by ERA app provides ongoing monitoring by ERA’s medical experts and first responder network for registered users with chronic illnesses, ensuring that receiving hospitals have all the information required to effectively treat patients (e.g., allergies, chronic conditions, comorbidities, etc.) and minimize medical errors in emergency situations.
