Identifying barriers for out of hospital emergency care in low and low-middle income countries: A systematic review

3 June, 2018

Dear HIFA colleagues,

Those of us in high-income countries often take it for granted that if we are in a serious road traffic accident or are otherwise in need of urgent care, such care will soon be available thanks to an ubiquitous ambulance service staffed with trained paramedics. This is not the case in many low- and middle-income countries, especially in rural areas...

CITATION: Kironji AG, Hodkinson P, de Ramirez SS, Anest T, Wallis L, Razzak J, et al. Identifying barriers for out of hospital emergency care in low and low-middle income countries: A systematic review. BMC Health Services Research. 2018;18(1):291


Background: Out-of-hospital emergency care (OHEC), also known as prehospital care, has been shown to reduce morbidity and mortality from serious illness. We sought to summarize literature for low and low-middle income countries to identify barriers to and key interventions for OHEC delivery.

Methods: We performed a systematic review of the peer reviewed literature from January 2005 to March 2015 in PubMed, Embase, Cochrane, and Web of Science. All articles referencing research from low and low-middle income countries addressing OHEC, emergency medical services, or transport/transfer of patients were included. We identified themes in the literature to form six categories of OHEC barriers. Data were collected using an electronic form and results were aggregated to produce a descriptive summary.

Results: A total 1927 titles were identified, 31 of which met inclusion criteria. Barriers to OHEC were divided into six categories that included: culture/community, infrastructure, communication/coordination, transport, equipment and personnel. Lack of transportation was a common problem, with 55% (17/31) of articles reporting this as a hindrance to OHEC. Ambulances were the most commonly mentioned (71%, 22/31) mode of transporting patients. However, many patients still relied on alternative means of transportation such as hired cars, and animal drawn carts. Sixty-one percent (19/31) of articles identified a lack of skilled personnel as a key barrier, with 32% (10/31) of OHEC being delivered by laypersons without formal training. Forty percent (12/31) of the systems identified in the review described a uniform access phone number for emergency medical service activation.

Conclusions: Policy makers and researchers seeking to improve OHEC in low and low-middle income countries should focus on increasing the availability of transport and trained providers while improving patient access to the OHEC

system. The review yielded articles with a primary focus in Africa, highlighting a need for future research in diverse geographic areas.


The lack of emergency services in many LMICs makes it all the more important that ordinary citizens are empowered with first aid information - because they will often be the only 'healthcare providers' available.the mHIFA working group is campaigning for all (or most) mobile phones to be equipped with essential first aid information, such as is found on the Red Cross First Aid app.

Best wishes, Neil

Coordinator, mHIFA Project (Mobile Healthcare Information For All)

Let's build a future where people are no longer dying for lack of healthcare information - Join HIFA:

HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 18,000 members in 177 countries, interacting on five global forums in three languages. He also currently chairs the Dgroups Foundation (, which supports 800 communities of practice on international development, health and social justice. Twitter: @hifa_org FB: