Improving Emergency Medical Services in Ethiopia

Emergency medicine – the branch that deals with undifferentiated, often severe, conditions requiring immediate care – can saves lives after trauma. Studies indicate that expedient medical care, especially in severe cases, can significantly reduce fatalities. These services, however, are lacking in Ethiopia, where patients may wait more than 24 hours to receive treatment in an emergency room. EBR’s adjunct staff writer Meseret Mamo spoke with health care practitioners and government officials to learn more about what’s being done to develop the country’s emergency care infrastructure.

During a medical emergency, well-managed and timely emergency services can save someone’s life and improve overall health outcomes after physical trauma. This is why emergency medicine is one of the largest and most important fields within the profession. Emergency medical services – and, by extension, the overall healthcare infrastructure – are also important factors for foreigners coming for business, political or diplomatic reasons.
In a country like Ethiopia, where emergency cases are becoming more prevalent due to blood, heart and birth related emergencies as well as traffic and fire accidents, having a well-organised emergency medical service system is crucial. In fact, data obtained from the World Health Organisation (WHO) reveals that these were among the top 20 causes of death in Ethiopia in 2014, constituting roughly 17Pct of the total registered deaths that year.
The data indicates that traffic accident deaths in Ethiopia reached 15,015, which is 2.5Pct of the total, while birth trauma deaths stood at 29,663, accounting for nearly 5Pct of the total. On the other hand, stroke-related deaths reached 28,320, constituting 4.71Pct of registered deaths in 2014, while 14,728 coronary heart disease deaths were reported. Most of these could have been prevented if the country had more efficient, accessible and robust medical emergency services.
First responders, especially those working in ambulances, like paramedics, have a significant impact in reducing trauma mortality. According to a study published in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, “paramedics and lay first responders reduce trauma mortality in major injuries. Delegating life-saving skills to paramedic and lay people [immediately after a trauma] is a key factor for efficient pre-hospital trauma systems in low-resource communities.” The study, which was conducted over ten years by observing the data of nearly 3,000 emergency patients, found that trauma mortality reduced from 17Pct to 4Pct, with “survival especially improving in major trauma victims.”
The study, which was conducted in Iraq’s under-resourced areas, also found that these services can be developed without sophisticated Western systems. In fact, it demonstrated that “patients injured by land mines, war and traffic accidents were managed by a chain-of-survival system where non-graduate paramedic were the key care providers,” not physicians or highly-specialised health care professionals. This means that critical care is a potential sector in which to create jobs for people without extensive or formal education in health sciences.
Despite this reality, emergency medical services in Ethiopia are lagging. Even government officials believe there are shortfalls regarding this element of the country’s healthcare infrastructure. “For a long time, emergency medical services have been denied proper attention,” says Fatuma Ibrahim, Assistant Director of Emergency and Critical Care and Pre-Hospital Case Team Coordinator at the Ministry of Health (MoH). “It was placed under a case team with up to three personnel under the Medical Service Directorate at the Ministry. The pre-hospital emergency and ambulance services were also no different.”
This missing element was an intriguing phenomenon for Kibret Abebe (MD), who worked at Tikur Anbessa Hospital for 17 years as an anaesthesiologist in the critical care unit. The lack of a proper emergency medical response unit influenced Kibret to establish Tebita Ambulance, the first and only private ambulance and pre-hospital emergency services company in Ethiopia.
“It was painful to see a lot of patients who came to the hospital dead even if they received medical attention,” he recalls of his time at Tikur Anbessa, one of the largest public hospitals in Ethiopia. “At that time I noticed that the time element is very crucial in many critical cases and I continuously asked myself ‘should we have to wait for the cases to come to us, or should we act?’”
However, during a visit to England in 2007, he witnessed their emergency medical service system and was encouraged to develop a similar one here. “I saw how their pre-hospital ambulance service worked and how other emergency medical units operated in a collaborative manner, and I came back with a clear vision to do what I can in my capacity.”
Kibret’s vision required him to sell his house to earn initial start-up capital. “I bought three used cars from Dubai and turned them into vehicles that can provide basic ambulance services and then I established Tebita Ambulance in 2009,” he says. “The name ‘Tebita’ (which means ‘a drop’ in Amharic), emphasises the message that no matter how small the contribution, it still saves lives.”
That year, the MoH and Tikur Anbessa Hospital established a new pre-hospital emergency service unit under the Addis Ababa Fire and Emergency Prevention and Rescue Agency. “I was one of the members of a working group committee that established the pre-hospital emergency and ambulance service standards,” Kibiret told EBR.
The pre-hospital emergency and ambulance service unit was established with five ambulances, but it now has 24 vehicles stationed at seven fire stations throughout Addis Ababa. Each is equipped with first-aid medical supplies as well as nurses and provides the service to the public for free. Its call centre – 9-3-9 –also provides free services. During the first nine months of the current fiscal year, the centre received 180 emergency calls on a daily basis, on average, according to data obtained from the MoH.
Another step towards improved pre-hospital emergency medical services in Addis Ababa is the establishment of a health command post in every public hospital. These command posts patrol the 11 public hospitals in the capital to check which hospitals have unoccupied beds and informs the emergency medical team the facility to which they should take the patient. This increases service efficiency, since it will ease the process of finding a hospital with available emergency services, which in the past was a cumbersome process.
This public programme isn’t the only one offering ambulance services. The number of ambulances in the country is currently 1,473, including the Red Cross’ 212 ambulances. “We are working hard to increase their numbers,” said Fatuma
But it’s not just ground medical services that are being developed to address the growing need for emergency care in the region. The East Africa Aviation Academy recently launched the Air Ambulance programme. “Ethiopia is a country that hosts a large diplomatic and business community. The need for overseas medication is also increasing,” says Mulat Lemlemayehu (Captain), founder of the Academy, who worked for Ethiopian Airlines for 37 years and is the owner of the Dreamliner Hotel. “There used to be huge capital outflow for air ambulance services that came from Kenya and South Africa.”
Despite such improvements, however, stakeholders stress that a lack of ambulances is not the only problem plaguing the nation’s emergency health services. Rather, filling the ambulances with enough medical supplies; developing a central call system with a specific number throughout the country; and an integrated system of ambulance service units between the government, the Red Cross and the private sector are also needed to strengthen the nation’s emergency care infrastructure.
Still, more needs to be done to create a culture in which people properly access medical services. Hadush Gebrezgiabher, Head of Pre-hospital Emergency and Ambulance Services at the Fire and Emergency Authority, told EBR that the ‘9-3-9’ call centre service is not being properly utilised by the public. Even though they give priority to calls from the public, and this was the reason for the establishment of the unit, he says health institutions utilise the service with greater frequency. Of the 31,514 ambulance dispatch calls received by the unit in the first nine months of the current fiscal year, only 8,661 calls came from the public. On the other hand, 22,853 dispatch calls were from health institutions that sought emergency medical services for patients.
Hadush says this is because of an awareness gap about the existence and function of the service among the public. “We give priorities to calls from the public instead of those from health institutions because the former are far from medical services and need an immediate response as opposed to those patients that are in health institutions,” he explains.
Besides the poor awareness among the public about the existence of the service, Hadush says that the free call centre is usually busy with inappropriate calls, which makes it difficult to address actual emergencies. “Since it is free, many call without any purpose and abuse the service by making it busy and sometimes even making false calls,” he says. “The other [telephone numbers] are ten-digits, which are difficult to remember.”
Kibret has a similar opinion, alluding to the fact that most people don’t understand the function of emergency telephone services. “We also encounter the same problem,” he says. “People need to understand that this is a serious matter that may jeopardise the lives of those who need emergency medical service.”
The other challenge mentioned by stakeholders is the lack of an integrated system, which is particularly important during a mass trauma, such as an accident involving multiple vehicles or a fire. Currently, there are only two ambulances that are referred to as mobile clinics at St. Paul Referral Hospital, which are dispatched during important international meetings.
Tebita Ambulance, for instance, has three ambulances that provide advanced medical care for critical cases, like providing life support during heart failure or when a person is unable to breathe. “Saving lives is our common goal and working together will serve the public better,” says Kibret. By “working together,” he means finding a way for reimbursement in time of mass accidents, which obliges everybody in the business to lend a hand. “Making money doesn’t come before saving lives,” he stresses.
Kibret’s company provided emergency medical services for the Ethiopian Football Federation during an international match three years ago when FIFA threaten not to hold matches in the country due to a lack of medical services. The Federation is now their official client. Tebita was also awarded ETB30,000 from the Canadian Embassy for the services it provided during the mass accident that occurred near the Embassy a few years ago.
On the government’s end, the MoH says it is planning to add ten more intensive care units in the country by next year. Currently, there are twenty intensive care units throughout the country, eight of which are in Addis Ababa, according to Fatuma. Furthermore, two trauma centres – one at Alert and the other under St. Paul Referral Hospital – opened in June 2015. There are also plans to establish trauma centres in three populous areas: Bahir Dar, Shashemene and Adama.
Additionally, since 2011 Addis Ababa University’s Tikur Anbessa School of Medicine has offered emergency medicine as a field of specialisation for physicians and nurses in order to train health practitioners in trauma care.
Still, there is a long way to go. Up to 16Pct of admitted emergency patients wait for more than 24 hours in emergency rooms, according to the Addis Ababa Health Bureau. As a result, Fatuma believes emergency medical care in Ethiopia is still in its infancy.
She says the necessity of such services isn’t lost on the government and that they’ve demonstrated political will and commitment to improve and standardise emergency medical services throughout the country. “There are ways to improve the situation and it is up to us in healthcare management to take it in to the next level.” EBR