CE Gilbert Bonsu

BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH
DEPARTMENT OF INTERNATIONAL HEALTH
CULMINATING EXPERIENCE COVER PAGE
Name: Gilbert Bonsu
CE Advisor: Dr. Kojo Yeboah-Antwi
Strengthen Emergency Medical Services (EMS) in Ghana to reduce disabilities and
mortality due to disease with implications for EMS.
Abstract
This policy brief examines the three components of emergency medical services (EMS)
in Ghana by taking a look at the top causes of admission and death in Ghana hospitals
for all ages, with implications for EMS. Data for analysis were collected from published
reports, journal articles, email interviews, and Ghana’s Ministry of Health’s website. By
examining these three components, areas of improvements were identified and
recommendations were made on how Ghana’s Ministry of Health can strengthen
emergency medical services in Ghana. The recommendations included: 1) training first
responders and bystanders; 2) decentralization of the National Ambulance Services
(NAS) ; 3) embarking on a mass media campaign to promote NAS; 4) establishing a
national triage scale for all healthcare facilities. Strengthening of these areas of Ghana’s
emergency medical system will aid in reducing maternal mortality due to obstetric
emergency and disabilities and mortality due to road crashes.
Key Words: Emergency Medical Services, EMS, Ghana, Triage
CE Advisor: Date:

2 Culminating Experience
Table of Contents
INTRODUCTION...................................................................................................................................................3
COMPONENTS OF EMS......................................................................................................................................3
GHANA.....................................................................................................................................................................4
GHANA’S EMERGENCY MEDICAL SERVICES:...........................................................................................5
RECOMMENDATIONS........................................................................................................................................7
CONCLUSION.........................................................................................................................................................8
BIBLIOGRAPHY: .....................................................................................................................................................11

MEMORANDIUM
Date: December 19, 2012
To: Ghana Ministry of Health
From: Gilbert Bonsu
RE: Strengthen Emergency Medical Services in Ghana
INTRODUCTION
The Ghanaian government, after events such as the May 9th
Accra Sports Stadium disaster, in
which 126 lives were lost, took a step to form the National Ambulatory Service (NAS) to provide
emergency medical service.
The purpose of emergency medical services (EMS) is to stabilize patients who have a life-
threatening medical condition whether through injury, infection, obstetric complication, or
chemical imbalance in a timely manner by the best possible means to control morbidity, prevent
disability, and enhance survival (1–3).
Although having a medical-transport system is a crucial component in providing emergency
medical services, EMS functionality consists of three interdependent components. These three
components are; 1) pre-hospital care at the site of injury/medical emergency, 2) care during
transportation, and 3) health facilities care (1,2). It is critical that each component works together
to control morbidity, prevent disability, and enhance survival.
This policy memo will begin with reviews of the three components of EMS and it will take a look
at the top causes of admission and death in Ghana hospitals for all ages, especially those with
implication for EMS. Next, an analyzes of Ghana’s emergency medical services would be
provided with specific attention to efficiencies of healthcare facilities, pre-hospital and hospital
triage guidelines, and ambulance services. Based on the above mentioned analysis,
recommendations will be made in areas where Ghana’s Ministry of Health can strengthen its
emergency medical services system. Strengthening of Ghana’s EMS system will help the country
reach its MDG goals for 2015 due to the number of diseases and mortality that has implication for
EMS.
COMPONENTS OF EMS
In an ideal emergency medical system, all three components of emergency medical services are
present and work hand-in-hand. Pre-hospital care encompasses the care at the scene of
injury/medical emergency (home, school, work, recreation area, or other location) until the
patient arrives at a formal health care facility capable of providing the needed care (1,4).
Pre-hospital care involves site management, alerting the appropriate personnel for medical
transport, and preparing the patient for transport. This level of care can be performed by providers
with varying levels of training and skills. The three common levels of pre-hospital providers are
first responders (trained lay responders), Emergency Medical Technician (EMT), and paramedics.
First responders and EMT provide Basic Life Support (BLS) whereas care delivered by
paramedics is known as Advance Life Support (ALS) (1,5,6).
Care during transportation is a critical part of pre-hospital care (1,4). Emergency transportation
should be accessible in a short period of time and economical (4). In areas with formal EMS

system, transportation is provided by dedicated ambulances with basic and advanced life support,
whereas in a location with the informal EMS system, commercial vehicles, private cars,
motorcycle, or the police brings the patients to the health facilities (1).
Care in healthcare facilities is the third component of an emergency medical service where
appropriate definitive care is delivered upon arrival (1,4). The capability of health facilities varies
with respect to equipment, type of staff, and resources. Nevertheless, every health facility should
be available to provide some degree of emergency care (2,4).
GHANA
Ghana, a country of 23.8 million in population, is divided into 10 political regions with 138
decentralized districts. The population density in the country varies depending on the region. It is
sparse in the northern half of the country, which also happens to be the poorest economically, and
dense in the southern part of the country. Life expectancy from birth in Ghana is 60 years (7,8).
The maternal mortality rate in Ghana is 350 deaths per 100,000 live births (7). The delay in
reaching health facilities for obstetric emergency situations are key contributors to the high
maternal mortality (9). Obstetric emergencies are unique as care on-site, during transportation,
and in health facilities must be provided for two people, the mother and the fetus. Obstetric
emergencies can result from preterm labor and delivery, premature rupture of membranes, severe
preeclampsia, and prolapsed umbilical cord (10).
Changes in demographics and lifestyle have been accompanied by a change in the epidemiology
of morbidity and mortality in Ghana. Reckless driving is also a major contributor to the change in
morbidity and mortality in Ghana (11). Road traffic accidents continue to increase as the
population and urbanization grows. The number of registered vehicles in Ghana rises annually.
Table 1 provides summary statistics on road crashes in 2006 and 2007. The number of road
crashes increased by 3.2% from 2006 to 2007. Both fatalities and serious injuries increased from
2006 to 2007, 10.1% and 6.9%, respectively. Many survivors of road accidents eventually die due
to late emergency response and improper care at the injury site (12).
Table 1: Summary statistics of road crashes in 2006 and 2007.
Data Category 2006 2007 % Increase/ (Decrease)
# of registered vehicles 841,314 932,540 10.8
Total # of crashes 11,668 12,038 3.2
Fatalities 1,856 2,043 10.1
Serious Injuries 5,882 6,287 6.9
Fatalities per 100 crashes 15.9 17 6.9
Rural/Urban Casualty ratio 9,284/7,074 8,802/7,611 (5.2)/7.6
Male/Female Fatality Ratio 1,348/492 1,554/489 15.3/(0.6)
Source: Ghana Road Safety
An effective emergency care system can mitigate morbidity and mortality and obstetric
emergencies in Ghana (1).

GHANA’S EMERGENCY MEDICAL SERVICES
Theoretically, the core components of Ghana’s EMS are care in the community/first responder
system, pre-hospital emergency care, and hospital emergency services. The objectives of Ghana’s
EMS are:
 Reduce delays in getting to a health facility
 Reduce delays in getting appropriate health care
 Make pre-hospital emergency services readily available to all those in need
 Provide a continuum of care for emergency cases from site of emergency to health
facility level
 Increase the number of institutions with trauma care systems that maximize survival and
functional outcomes of trauma patients and help prevent injuries
 Increase the number of districts that have implemented guidelines for pre-hospital and
hospital emergency care (9)
Pre-hospital Care:
Pre-hospital care is informal in Ghana. When injury occurs at home, family members or
neighbors are usually the first people on site. From personal communications with people in
Ghana, most of these first responders are not trained in injury site management; how to prepare
patients for transport; and some do not know what number to call for the ambulance. Most deaths
from injuries occur immediately after the injury (50%), 30% within four hours, and 20% after the
event that causes the injury. Frequently, these injuries are treatable condition and deaths occur as
a result of airway compromise, respiratory failure, or uncontrolled hemorrhage (5,13).
The critical task required of a bystander/layperson outlined by in the WHO’s pre-hospital trauma
systems during an event of injury or medical emergencies are: getting involved; calling for help;
assessing the safety of the scene; assessing the victim; providing immediate assistance; and
securing essential equipment and supplies (5).
Through email interview, it was realized that in Ghana when injury or medical emergencies
occur, bystanders usually decide to get involved. They also call for help, usually to the police, fire
department, and commercial or privately owned vehicles for transport to health facilities.
Bystanders’ knowledge and skill make their decision to get involved beneficial or detrimental to
the victim. Most bystanders in Ghana are not trained in how to manage the site of injury to
prevent additional injuries to the victim and themselves. They lack basic skill in assessment and
may not recognize medical conditions as emergency and provide immediate assistance to avoid
risk of death or disability. The lack of access to equipment such as bandages, gloves, masks, etc.
can pose as a potential risk in the case of infectious diseases.
A study in Ghana that trained 335 commercial drivers using a six-hour basic first-aid course
confirms that such reported that improvement in the process of pre-hospital trauma care can occur
through these personnel. Appendix B displays a table of the components of the six-hour basic
first-aid course and results (1).
Care during transportation:
Ambulance services in Ghana are fragmented and lack effective and efficient coordination. The
main ambulance services in Ghana are the newly structured National Ambulance Services (NAS),

Hospital Ambulance Services maintained by the Ghana Health Services, the Fire Service
Ambulance Service (FS), and Private/ Non-governmental Organizations (NGO) Ambulance
Services such as St. John Ambulance and First Intervention Ghana (14).
The NAS is an important part of the Ghana’s EMS. NAS was established in 2004 as an agency of
the MOH in collaboration between the Ghana National Fire Services of the Ministry of Interior.
The core mandate of NAS is to provide efficient and timely pre-hospital emergency medical care
to the sick and the injured and transport them safely to health facilities (15). NAS operates in
every region in Ghana with 51 stations and 2 control rooms (16). The NAS also provides stand by
emergency cover at mass public meetings and liaise with other emergency services in time of
disaster or mass casualty incidents. It assists in the formulation and implementation of programs
for first respondents and in the establishment and operation of makeshift hospitals during mass
casualty situations (16).
A 2007 audit report on road safety in Ghana that reviewed the NAS showed that the two major
problems facing the NAS were fuelling issues due to inadequate and the late arrival of fuelling
coupons and the absence of ambulance maintenance services in regions due to the centralization
of the maintenance services (12).
The national ambulance services are fees for service and available in all of Ghana’s ten regions
but it is relatively unknown to the masses. Most people knew the fire service ambulance and
hospital ambulances that transfer patient from one healthcare facility to another. Majority of them
preferred a taxi or private owned vehicle as a means of transport to the healthcare facilities in
case of emergencies and thought these means were swifter. The few who knew about NAS,
however reported that the EMT were professional and seemed well trained (interviews).
Care at Healthcare Facilities:
Triage, the process of screening patients to determine their relative priority for treatment and
transfer is an important procedure in emergency medical services (4). Triage is important as it
identifies patients at risk, especially people who do not look sick, for treatment in a timely
manner (triage lecture). A study that compared Ghana, Mexico, and the USA found that mortality
could be decreased if pre-hospital and emergency room care are improved. This study also
reported that scene time was longer in lower income areas thus contributing to the high mortality
in pre-hospital deaths compared to high income areas (13). Having a national triage system can
help reduce the high mortality from emergency room care such as the prolonged time (mean of 12
hours) to emergency surgery at a main hospital in Kumasi (17).
The World Health Organization (WHO) assessment of quality of care for children in selected
hospitals in Ghana concluded that emergency care system was not well established and there were
no triaging systems in these hospitals. The assessment also stated that there was a lack of
protocols and guideline for in-patient care of childhood conditions thus affecting the treatment
and monitoring of diseases (18).
A cross-sectional study by Norman et al. between March – June, 2010 that evaluated the basic
logistical assets preparedness of 22 Ghana hospitals for emergency intervention confirmed the
WHO assessment. The study found that hospitals lacked pre-emergency and emergency
preparedness, and coordination of hospitals response mechanisms was poor. The study indicated
that the triage standards in the Ghana Health Services (GHS) was flawed because it did not cover
on-site management and only covered minimal in-hospital ER operations (19).

RECOMMENDATIONS
Ghana’s emergency medical services are in its infantile stage for a formal system. Although
improvements are being made in transforming EMS in Ghana from an informal to a formal
system, efforts should be made to strengthen the informal system, knowledge, and skill
laypersons.
1. Care at site of injury
Training of bystanders/first-responders: The MoH, GHS, or NAS should train first-
responders/bystanders in the critical tasks required by these individuals when an emergency
event occurs. Volunteers for this training course can be sought from bus/taxi stationmasters
alongside selected drivers, marketplace queens, and teachers since they are likely the first at
an injury scene.
The training course should include scene management, airway management, bleeding control,
splint application, primary survey (using the ABCs method for evaluating life threatening
injuries), moving causalities, phone numbers to appropriate authorities to contact, and
universal precautions (1,20). The national ambulance services EMT training instructors can,
with help from the Red Cross, conduct this course. Gifts in-kind, such as transportation to the
course and lunch during the training can be offered. Volunteers should also be provided a
basic first aid kit to keep on-site.
2. Care during transportation
Fuelling & Maintenance of NAS vehicles: The Ministry of Health should decentralize the
national ambulance services to avoid issues such as vehicles not being available because they
are sent for repairs in the country’s capital and lack of fuelling coupons. The MoH should
equip each regional headquarters maintenance facilities with the capacity to service these and
give it the authority to generate and issue fuelling coupons to ensure that vehicles are always
in the region and in an operating state.
Knowledge of the National Ambulance Services: The MoH should embark on a mass media
campaign to inform people about the national ambulance services and the services they
provide. This media campaign and stakeholder meetings should also be used as a platform to
help people distinguish between NAS and the police/fire ambulances; explain why it is much
safer for injured persons to be transported by ambulance; and for all persons to respect and
yield way for ambulances when in transport.
3. Care at Healthcare facilities
Poor quality of care at health facilities can deter community members from seeking care even
in emergency situations. One way to strengthen health facilities handling of emergency care
in Ghana is establishing a national triage scale for all levels of healthcare facilities (both
private and government owned). The Emergency Triage Assessment and Treatment (ETAT)
by the WHO’s Integrated Management of Childhood Illness strategy can be used as a guide to
develop a standard triage in-and-out hospital regime for all hospitals.
Establishing a national triage scale can be relatively inexpensive but will need strong political
backing and resolve from the Ministry of Health and hospital management groups (19).

CONCLUSION
As Ghana makes the transition from informal emergency medical services to a formal system, it
should take a calculated approach that ensures that all citizens can receive services. The MoH and
its service arm, GHS, should seek to improve all the core components of EMS. If pre-hospital
care at the site of injury and transportation is poor, deaths that could have been prevented occur.
On the other hand, if quality of care at health facilities is poor and leads to death, it neglects the
efforts of the first two components of EMS and the community may be discouraged from taking
patients promptly to health facilities even when transportation is available (1,4).
Ambulance services may not be the best solution presently for all areas in Ghana. Trained lay
responders can provide cost efficient and effective care at the site of injury and during transport in
these areas. It is important for laypersons are trained to aid EMTs as some areas in Ghana are in
need of accurate maps, house numbers, street names, and road signs. These elements make it hard
for an ambulance to easily reach a patient and elongate response times (1).
It is also crucial that the Ghanaian populations are aware of services by NAS as the country seeks
to move from an informal EMS system.

APPENDIX A: Providers of Pre-Hospital Care
Basic Life Support includes interventions that are non-invasive such as CPR, oxygen
administration, full immobilization and puts emphasis on transport to healthcare facilities.
Advance Life Support consists of all BLS interventions as well as providing intravenous (IV)
therapy, needle-chest decompression, and admission of control medications(21).
First-Responders: First responders are community members such as taxi drivers who have been
taught basic first aid techniques and are able to recognize threatening conditions. Some first
responders, known as the “advanced first-aid providers” are taught the principles of rescue, limb
immobilization, and how to prepare patients for transport. First responders training programs
usually lasts for a few hours (5).
EMT: EMTs are a group of EMS providers who have been trained in trauma care and thus have
knowledge and skills beyond those of first responders. EMTs skills include airway management,
applying oxygen, CPR, control of shock and bleeding, and more patient assessment. There are
two categories of EMT personnel, EMT-Basic and EMT-Intermediate. EMT training is general
about 100 to 400 hours long (5).
Paramedics: Paramedics are trained in all of EMT skills as well as administering intravenous
medications, using advanced airway adjuncts, IV therapy, and other wide range of injury and
acute diseases management. Paramedics are trained for thousands of hours in the classroom and
on the field (1,5).

Appendix B: Improvement in the provision of the components of first aid in comparison to
what was reported before the course.
Table 2
Components of first aid Before (percent) After (percent)
Crash management 7 35
Airway Management 2 35
Bleeding control 4 42
Splint application 1 16
Triage 7 21
Source: Mock and others 2002
Table 3: Cost & Length of Study
Cost $ 3 per participant
Length of study 10.6 months
Source: Mock and others 2002

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