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Emergency Care in Low and Middle Income Countries
Rockefeller Foundation Search
Narrative
1. Background
Over 8 years ago, the World Health Assembly adopted a resolution on emergency care systems,placing
emphasis on the need to strengthen emergency care and trauma services worldwide and urging member
states to develop formal, integrated emergency care systems. It is only recently though that the Ebola
virus disease in West Africa, natural disasters, and the escalation of violence globally, have shed light on
the inadequacies of health systems to provide emergency care not only at the time of a crisis but even in
day-to-day, non-crisis situations. Experts have posed the question that if health systems across low and
middle income countries are not set up to provide care for citizens who face a road traffic accident or an
emergency pregnancy or a heart attack,can they really be equipped to provide care in the event of a large-
scale emergency such as an epidemic? Driven by this momentum in the global health sector,the Search
was initiated to assess the impact of limited accessibility to emergency care services for poor and
vulnerable populations in developing countries.
The Search focused on the emergency care systems in low and middle income countries globally across
both urban and rural areas,while also learning from solutions and innovations in developed countries.
Additionally, as evidenced by the external factors that have increased the relevance of emergency care,
the provision of care to individuals at the time of an emergency is tightly related to the provision of
services in the event of large scale disaster or crisis. Thus, although the Search focused on day-to-day or
“chronic” emergencies,it did take into account learnings from the humanitarian aid sector and proposed
opportunities that engage the humanitarian response community.
Another issue related to the definition of the scope of emergency care is the inclusion and exclusion of
services that may be considered emergency care since emergency care is a broad and horizontal field that
addresses a range of conditions across different patient types. While some experts in the field define
emergency care as treatment of individuals with acute conditions that are often “serious” in nature and
require complex interventions such as surgery, there are others who take a more broad definition of the
field. It has been widely commented that a standardized definition of emergency care is needed. For the
purpose of this Search though, we have included both complex (e.g. surgery) as well as simpler
interventions (e.g. antibiotics for infection control) in our study and have defined Emergency Care to
include the provision of effective curative health actions in response to extreme risk under intense time
pressures.
2. The Problem
Emergency conditions are at the top of the list of causes of death and disability globally and it is
estimated that 8 of the top 10 causes of death can be addressed by improving access to emergency care.
Though prevention can help address many conditions, not all emergencies can be avoided. Emergencies
occur consistently, affecting individuals across all income levels—and are often managed and treated
regularly. Nevertheless,the manner in which emergency care is executed is inconsistent and inefficient,
leading to higher levels of deaths and disabilities that could otherwise have been prevented via improved
access to emergency services.
Emergency care,if properly implemented, has the ability to save over 50% of all deaths and one-third of
disabilities globally. 24.3M deaths and 1,023 DALYs (Disability Adjusted Life Years) could be averted
by improving access to emergency services; and this number will only increase in the future. With the

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growing burden of non-communicable diseases and the rise in road traffic injuries, deaths from conditions
that could be addressed by improved emergency care are projected to grow by 24%. Multiple
international treaties and national constitutions have endorsed the right to health, but access to high
quality emergency services during a patient’s greatest time of need remains frequently overlooked and
most poor and vulnerable populations in low and middle income countries do not have access to
emergency services—especially when they most need it.
Beyond just health outcomes, limited access to emergency care also has detrimental effects on household
economies and national and global economies. The risk for, and the occurrence of,financial catastrophe
in the event of an emergency falls primarily on poor individuals and their families who face limited
financial protection against emergency care and/or loss of income due to death or disability. As opposed
to high income countries where emergency rooms often treat elderly patients with multiple chronic
conditions, in LMICs,emergencies disproportionately affect young individuals who are the prime
breadwinners and thus reduce economic productivity and inclusion.
While the problem of limited access to emergency care in developing countries and its detrimental effects
on global health outcomes and economies is irrefutable, healthcare access itself is a complex concept
driven by a range of issues across multiple sectors and players that contribute to the problem. Availability
of healthcare products and services,affordability, behavioral patterns, and health system architecture
together contribute to access. In the case of emergency care,challenges exist across each of these
dimensions. From the perspective of the patient, issues such as limited awareness of emergency services,
cultural barriers, geographic and transportation limitations, inadequate healthcare personnel or facilities,
limited financial coverage, and the inability to pay, all create delays in accessing care. Due to the time-
sensitive nature of emergency care and the strong relationship between timely response and health
outcomes in the event of an emergency, such delays can have a detrimental effect on patient health. In
looking at emergency care from the perspective of providers, lack of adequate training, shortages of
equipment and supplies, and skewed incentives reduce the quality and efficiency of emergency care.
These challenges that individuals faces in relation to emergency care,aggregated at the population level,
show how the problems related to emergency care access are manifested. Nevertheless,these challenges
arise because of systemic issues across the health system. Inadequate public funding for healthcare and
weak national health systems contribute to shortages in the human and material resources required to
deliver emergency care. Limited coordination and standardization across healthcare sector players—and
limited incentives for it—prevent even available resources from being used efficiently.
These failures are underpinned by one major issue—the low prioritization of emergency care. Road traffic
injuries alone for instance kill more individuals than HIV/AIDS,TB,and malaria combined but funding
mainly goes towards those priority programs. The global health community has historically focused on
developing vertical programs to address priority health problems; focus on horizontal programs such as
emergency care or primary care that address the needs of a broad range of populations is just beginning.
Thus, improvements to emergency systems are often sidelined in the face of other priorities,
misconceptions related to emergency care continue to exist, and gaps in emergency care access grow.
Current approaches to improve emergency care have primarily focused on point solutions to address
logistics and capacity-related challenges. Major areas of focus include: new approaches to emergency
transportation that take into account geographic and financial barriers to care; development of
communication systems to help facilitate delivery of services; prehospital care capacity development that
involves community members and paramedical personnel; and development of standardized protocols and
trainings for health workers.
Emergency transportation and communication systems have been implemented globally with varying
levels of functionality. In middle income countries, systems tend to be more advanced, typically with
universal call in numbers, call and dispatch centers,and trained personnel. However,lower income
countries, particularly in rural areas,continue to have limited access to reliable and affordable

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communication and transportation systems. Innovative solutions to transportation challenges (e.g.
motorbike ambulances) are being developed to address these challenges but remain limited in scale.
However,growing investments in infrastructure development may serve to enhance access to care over
the long-term. It is also important to note that in some severely resource-deprived settings, poor and
vulnerable populations remain disconnected from health systems altogether.
In the absence of formal prehospital systems, lower income countries are implementing basic first aid
trainings for community members to enable them to serve as first responders. Formal paramedical
systems development is typically limited to middle income countries, although personnel shortages and
inadequate training remain barriers to service delivery. Beyond prehospital care,formal emergency care
training programs are emerging in lower income settings aimed to address the training, knowledge, and
resource gaps. The full impact of such programs has yet to be realized given their nascent stage. A review
of emergency medicine training programs found that there is typically only one program per country, with
programs ranging in size from 3 to 30 trainees per year and total graduates varying greatly from 8 to 250.
Triage and referralprotocols have also been implemented to varying degrees in LMICs in an effort to
standardize processes and improve quality and coordination of care. Morbidity and in-hospital mortality
have been reduced through implementation of standardized trauma protocols in advanced trauma systems,
yet most LMIC hospitals have not implemented such protocols due to financial and logistical challenges.
Many of these approaches seem to have potential for impact; however, their success rates are largely
unknown due to limited data on cost-effectiveness. Lack of recognition of the role of emergency care in
improving health outcomes and inadequate resources also limit the scale and scope of successful
programs. Solutions that are holistic, evidence-based,and integrated are still needed.
3. New Possibilities
While the field of emergency care has historically been slow to develop globally, there are many areas of
change at the moment that have the potential to influence the problem and reduce gaps in emergency care.
Currently, international actors in global healthcare are reframing their approach to more efficient health
systems. Agencies are highlighting the need for a fundamental shift towards more integrated health
services. Additionally, growing national commitments to UHC are driving focus on improving
comprehensive health coverage,while the launch of new SDGs and targets for 2030 have generated focus
on NCDs,road traffic deaths,and urban resilience. When combined with the growing awareness of fragile
health systems in light of recent disasters and the Ebola crisis, this trend presents a timely opportunity to
frame emergency care as an essential component of integrated health systems, which could bridge the gap
in achieving already established development goals.
There is also increasing demand from local actors for improved health services. Recent disasters have
revealed underlying problems and weaknesses of many health systems. Communities are mobilizing from
the ground-up to provide better health services,as well as to demand improved services from
governments. Humanitarian agencies are also re-strategizing their approach and investing in local
initiatives and groups as an alternative way to provide humanitarian aid. Additionally, citizens and
regional organizations are advocating for strengthened emergency care and for the right to comprehensive
health services. This trend is evidence of the growing demand for more resilient health systems in the
face of major shocks, which in turn may support greater investment and focus on emergency systems
development.
Furthermore, there is a global move towards reforming healthcare delivery that considers value and cost-
effectiveness. This has led both policymakers and large-scale donors to more significantly consider health
outcomes as a measure for effective policies and successfulhealth programs. Thus, there is the potential
to create a stronger evidence base illustrating the cost-effectiveness of emergency systems development.

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In addition to the dynamism in the space,the global health innovation system is very active, particularly
around maternal, newborn and child health (MNCH) and expanding access to basic healthcare services
for the poorest and most vulnerable populations. However,innovations in emergency care are being
stalled by limited evidence around the burden and cost-effectiveness,health systems fragmentation, and
competing priorities. Grassroots movements have begun tackling these challenges and applying
innovations to address barriers to emergency care in LMICs,indicating that there is strong potential to
catalyze latent innovation in this space if innovators were provided the necessary support, linkages, and
resources.
Many innovations that are already being applied or that have the potential to be applied are specifically
designed for resource-constrained settings. Examples include local manufacturing of devices,
development of equipment by emergency care providers in low-resource settings, and international
partnerships to provide high-quality, local-context emergency care training to new providers. Examples of
simple, low-cost innovations in emergency care that have a major impact also exist. For instance, Noora
Health is training family members of high-risk patients how to care for their loved ones at home and how
to recognize the warning signs of emergencies. Other innovations rely on collaboration between multiple
sectors,such as public-private partnerships that are linking facilities with ambulance companies and
mapping software to ensure that trauma patients receive care during the “golden hour.”
Additionally, the growth in cell phone coverage and ownership across LMICs,as well as the increased
penetration of smart phones, is enabling a vigorous innovation system in which applications and
modifications of such tools are being rapidly tested and scaled. Healthcare delivery and triage can be done
remotely through telehealth applications; providers in more remote settings can easily conference with
specialists anywhere in the world for support and advice on a case. More established applications of
technology are also leading to more efficiency for emergency care. Mobile financing and payment
applications are enabling patients without a bank account to pay for services,which is commonly required
before treatment is rendered. Data collection applications on mobile devices are allowing for real-time
data analysis, and patient identification and longitudinal health record tracking, both of which have the
potential to advance the field of emergency care in LMICs.
There are also innovative applications of lessons learned from work in vertical disease programs that are
being applied to advance emergency care in LMICs. For example, breakthroughs and innovations that
have had a major impact on saving maternal lives, such as stabilization of hemorrhaging women during
transport to a higher-level facility, can be used to save lives in the broader context of emergency care
delivery. The MNCH space has been able to develop, test, and scale many such innovations because of
exponential growth in funding in the field from successfulinternational support campaigns. The
innovation system around emergency care in LMICs could similarly be catalyzed if framed in the context
of global priorities.
4. Looking forward
Entering the emergency care space would be a greenfield investment. Not only is there is a significant
unmet need in this space,but also the potential for impact given the strong links between emergency care
systems and health outcomes and the available range of entry points for RF. Based on the evidence in this
space though, there are severalkey considerations for development.
Firstly, while the emergency care field itself is nascent with few players, the overall global health field is
a crowded space and emergency care could become one issue that is vying for attention amongst a host of
other existing or rising development challenges. This risk can be assuaged though if RF ensured that
emergency care was presented in the context of existing goals and presented as an innovative strategy for

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achieving predefined health goals. Using emergency care systems development as a new approach to
achieve shared goals would set RF apart from the rest as this would be a novel strategy at scale.
Secondly, for the key opportunities to be successful, there needs to be showcased evidence that investing
in integrated emergency systems care can cost-effectively improve health outcomes and strengthen
resilience in the face of acute emergencies. To date, limited global data exists on the burden of
emergencies and the impact of intervening in this space. Therefore,building and presenting the evidence
base would be needed to gain buy-in from various stakeholders and to make the case for emergency care
systems development.
Lastly, dynamism is a critical element of the recommended opportunities. Thus, waiting too long to move
in conjunction with dynamism in this space may introduce risk. SDGs are likely to remain on the global
health agenda; however, dynamism around Ebola may be short-lived.
In comparing the two main recommendations, it should be noted that it may be more feasible to generate
evidence for reframing emergency care within the healthcare continuum given the strong M&E systems
already in place. Generating evidence for repositioning emergency care within the context of disaster risk
reduction could be more challenging given the many moving parts and shifting priorities during major
disasters. Similarly, it may be easier to bring together actors in health systems and emergency care,than
to forge partnerships in the humanitarian space as humanitarian aid has traditionally operated independent
of longer term health systems efforts.
Overall, the risks around reframing emergency care within the continuum of care seem fewer and more
easily managed than the risks around reframing within disaster risk reduction. The former opportunity
leaves considerable room to accelerate progress towards clearly defined and internationally accepted
development goals; whereas success in the latter opportunity is less clearly defined. There may be more
room to fail during major disasters given the unknowns that accompany acute emergencies and such a
failure may deter future investment in emergency care.
5. Conclusion
An effective emergency medical system is one that provides high quality, timely emergency services to
all who need them, regardless of one’s ability to pay. However,the global state of emergency care has
historically been ineffective in achieving this goal, particularly in low and middle-income countries,
where the provision of timely treatment during life-threatening emergencies is not a priority. This is made
evident by the high burden of deaths caused by time-sensitive illnesses and injuries that are prevalent in
many resource-limited settings. The lack of recognition for emergency care’s place within national health
systems has subsequently led to limited access and delivery of emergency care services. Current trends,
including the Ebola crisis in West Africa, the establishment of new development goals and metrics, and
the proliferation of mobile technology, are all global changes that allow for the timely opportunity to
refocus efforts to strengthen global emergency care systems. There are a number of innovations in
emergency care and adjacent fields, including integrated delivery models in maternal health that have the
potential to improve the delivery and accessibility of emergency medical services globally when applied
directly and brought to scale.
As an inventive actor in the field of global health, the Rockefeller Foundation has the timely opportunity
to make a transformative impact in the field by reframing global perspectives on emergency care, leading
to more systematic health systems strengthening, in which emergency care constitutes an integral
element. The evidence from this Search suggests that there may be sufficient interest from international
agencies, like the WHO,as well as some national governments that have already begun to focus on
development of emergency systems, which would allow for this reframing to take hold and be brought to
a global scale. While the approach and defined opportunities are not risk-free, emergency care is a high

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need area where RF has the opportunity to make a catalytic impact.