Overall, there were 52 individual interviews, and 3 focus group discussions completed representing 68 total participants. Males were 45, and 36 individuals were from the community. Respondent’s occupations (roles) were Community leaders, Members of community (merchants, teachers and police officers), Officials and Healthcare workers; Table 1 presents the community roles/occupations of the study participants. Findings are presented below and organized into three main thematic areas, each with sub-themes including awareness and personal experience of participants with prehospital care, barriers to access, and perceived solutions to overcome the barriers.
1. Awareness and personal experience with prehospital care
1.1. Prehospital care awareness
Respondents were asked about prehospital care and its role in saving lives. Most respondents knew about the concept of first-aid being provided at a scene, while health professionals often added that prehospital transportation and care were important components. Respondents agreed that it was important to give care in the prehospital setting to preserve life and prevent complications; most stated that helping someone in an emergency is a moral obligation.
“Patients may need instant care at the scene and during transportation […], need professional ongoing and follow-up care until arriving at the health facility […].” (A Health professional)
1.2. Personal utilization experience
Respondents were asked about personal experiences with ambulance needed prehospital services. Most of the respondents had neither utilized the service nor knew the phone number to call for an ambulance at the time of their interview. However, a few respondents did have experience of using an ambulance service. Of those, most had used their personal phone to call for an ambulance.
"I had experience (of using an ambulance), while I was in labor […]. Often, I also call for others, but it is less available during night time." (A community administration officer)
2. Barriers to access
Several barriers to accessing prehospital care were often identified by respondents. These include limited public awareness, infrastructure and organizational issues, and a lack of trained providers.
2.1. Limited public awareness
Respondents felt that there was uncertainty among community members related to when and how to initiate a call to the EMS system and what type of care to expect in the prehospital settings. Interviewed officials knew that there were toll-based landline phone numbers to reach ambulance services. However, only a few respondents knew of those phone numbers and none of them could recall those numbers having been publicly advertised. Overall, they felt that the ambulance operator’s phone number was not commonly known and this was true even among healthcare professionals. In spite of this, ambulance drivers reported frequent requests for an ambulance through phone calls; although they also reported prank calls. Furthermore, respondents identified misconceptions in the community with regard to contacting ambulance services. Some believed that only members of the Red Cross Society (RCS) and those who personally knew healthcare professionals could use or have access to an ambulance. Others felt that ambulances were only meant for certain emergency conditions; maternal and pediatric emergencies being the most frequently cited. Difficulty in contacting services due to lack of a toll-free universal emergency number was the most commonly raised system-related barrier. Unfortunately, interviewed health professionals felt that improving public awareness of how to contact and the purpose of an ambulance system would be difficult in the absence of a formalized prehospital Emergency Medical Service (EMS) system.
“Majority (community members) do not have an ambulance phone number […], but it should have to be advertised publicly, through mass-medias, at different community events like meeting stages and ‘Idir [Idir is a form of indigenous community organization that gathers or connects people in times of grief and joy]”. (One of the community leaders)
2.2. Infrastructure and organizational issues
2.2.1. Inadequate system organization
Poorly organized prehospital care system resources (in terms of personnel, logistics, communication, and transportation) and poor integration with facility-based emergency care was another major barrier to access. Respondents felt there was no uniform structure for prehospital care, upon which the many providers and resources could be organized. Both health care workers and community members commonly mentioned that ambulance scarcity relative to the needs in the community. Furthermore, there was often no back-up ambulance, should one need to be taken out of service for maintenance or repairable damage. Additionally, the available ambulances lacked essential emergency supplies and medications, and were not always staffed with a trained crew. Interviewed officials of ambulance owning organizations also mentioned limited budget allocation to ambulance services, which did not afford operational expenses for ambulances such as fuel and maintenance costs. For instance, an officer mentioned that, at the time of this interview each publicly operating ambulance receives about 50,000 Ethiopian Birr (at a time of this study this was equivalent to US$ 150 using the average exchange rate for the year) for one fiscal year.
“[…] there is only one ambulance, this cannot address needs in the community (…) most of the time this itself becomes out of service; in such an event, and we don’t have another option.” (A community leader)
Respondents mentioned that hospital-based ambulances lacked formally allocated phone numbers, whereas, public ambulances use regular landline phone numbers. However, they mentioned that those phone numbers are often not readily accessible for calls. Respondents revealed that phone operators either do not answer calls or challenge the callers as if he/she mistakenly called over a wrong number, particularly during a night-time when optional commercial transportation is not available. Nevertheless, regular phone numbers are not free of cell phone airtime charges and are not easily memorable in emergency situations.
“We call them so many times, sometimes they refuse to come… but often they do not answer the calls.” (One of the community leaders)
2.2.2. No standard regulation and protocol
According to interviewed officials and professionals, there are no statewide or local regulatory standards enforcing minimum standards of staffing and logistics for prehospital care. Apart from RCS owned ambulances, which were equipped with first-aid kits and trained volunteer first-aiders, there was felt to be a great deal of variability between crews and emergency supplies. Opinions from respondents revealed that a lack of protocols meant that care may be provided inconsistently or incorrectly, and patients’ access to safe and professional care was less ensured. In addition, there is no legislation that protects prehospital care providers.
‘’ There is no legislation for ambulance service. I am not aware of the existence of regional or national legislation.” (A Medical Doctor)
2.2.3. Delayed response to the scene
Another access barrier identified was delayed response times. According to community members, it could sometimes take up to 2 hours for an ambulance to arrive, and occasionally ambulances do not arrive at all. Drivers and officials attributed this to a high demand for ambulance services but a limited supply of ambulances. These long response times were a major cause for community dissatisfaction and preference for commercial transportation over the ambulance, according to the respondents.
“[…] usually, they did not come at all, even if they did, they would arrive after labor was already complicated.” (A midwife at a public health center)
2.2.4. Poor roads and transportation options
Commercial transportation such as taxis are the most commonly used as most of the respondents mentioned. Respondents mentioned difficult roads as another access barrier, compelling community members to prefer commercial taxis over ambulances despite the difficulty of affordability. Often drivers find it hard to navigate to reach the community due to absent or difficult roads within the township.
"There is high interest to use the ambulance in the community, but inner roads between blocks in the city are not suitable to allow ambulances. […] Often communities are forced to convey laboring women using homemade couches […] I remember there was a woman who gave birth on the way to the health center, while being carried on the homemade couch.” (Health professional at Public health center)
2.3. Provider related barriers
2.3.1. Lack of trained prehospital providers
Healthcare workers’ practices were also among the commonly reported barriers to access. Respondents felt that only RCS ambulances were routinely staffed with individuals who had been trained in first aid and could provide prehospital care. However, several respondents felt that the first aid training of RCS crews was insufficient to ensure safe and proper care during emergencies. According to respondents, the lack of trained ambulance crew was because of limited opportunities to train paramedics and emergency medical technicians (EMTs) locally. Hence, patients did not receive professionally provided initial and ongoing care either due to lack of providers or supplies in the ambulance, as mentioned by respondents. A few respondents also felt that the drivers also lacked proper ethical training and felt that most of the drivers were negligent, lacked compassion and commitment, and were disrespectful to clients. Police officers in particular stated that ambulance drivers were often cited for inappropriate use of sirens, driving recklessly, and hauling non-medical personal and items such as illegal drugs and alcohol in ambulances. However, interviewed ambulance drivers and other respondents did not agree with these allegations.
“I called him (the driver) as my sister was in labor; he responded that the ambulance was out of service due to maintenance, so we were compelled to use a commercial taxi. But, afterwards, I saw him while I was on the way to the hospital. He was transporting an administrative person in that same ambulance.” (A community health extension worker)
According to respondents, ambulances are commonly misused by administrative officials as regular service cars to haul medical and non-medical supplies for official purposes or domestic consumption. Respondents mentioned that ambulances are occasionally involved in transporting security personnel during civil unrest. Interviewed officers have confessed to the existence of the practice, often not on the behalf of their good wishes, but compulsions from administrative officials. They felt lack of: awareness, strong legislation, and administrative commitment to halt and, scarcity of optional transportation as major reasons for ambulance misuse.
“Using ambulances as office service has now become a habitual practice [...].” (A physician at the public hospital)
3. Perceived solutions to overcome the barriers
A wide range of solutions were suggested by respondents to improve access to prehospital care. This includes improved: system arrangement and resource allocation, human resource capacity, legislation, and public education.
“Much has to be done to make the ambulance service accessible to the community.” (A Nurse)
3.1. Improved coordination and system arrangement
Respondents called for improved resource organization and coordination for a better prehospital system and improved access. They felt that having multiple ambulance providers with varying levels of resources was inefficient. They suggested integrating these organizations under a common public access point and a single leading agency to improve coordination of these overstrained providers. They called for the establishment of a call center operated on a toll-free emergency number so that access would be improved. They felt that this was best done through new legislation that brought all providers onto a common platform and working system.
“I think all those independently operating service providers have to be integrated under one system. [...], but system integration is possible. This requires creating a common working platform; there should be legal enforcement, guidelines and politics and the provider's commitment.” (An official from ambulance organization)
3.2. Improved resource allocation and infrastructure
Improving resource allocation to prehospital care was another common solution. This included increasing the number of ambulances, care providers, and emergency resources. Officials also suggested increasing budget allocations to ambulance services, while community members felt investing in basic infrastructure such as proper road constructions would do more to improve access to emergency transportation.
“Everybody wants to use the ambulance during emergencies, due to the scarcity of ambulances. […] the infrastructure, especially, roads inside the city are not suitable and not adequate. There is no universal emergency number. I think all these should be improved; the government has to invest here.” (A community member)
3.3. Improved healthcare providers
Respondents felt improving EMS personnel would require investment in pre-service or in-service training to increase the quality and uniformity of prehospital emergency care. Although few respondents felt integration of prehospital care courses into existing pre-service training curriculum would improve the availability of professional providers. On the other hand, most of them feel that continuous on-service training would improve the quality of providers.
“I don’t know why such training (paramedics training) is still lacking in our country. [Don’t] Policymakers and planners believe in the necessity of prehospital care services to our community? […]. I think this is a time to move forward.” (A health professional)
3.4. Improved regulations
Respondents suggested standards for personnel, equipment, practice, and training to regulate prehospital care either at the state or local level. Interviewed officials and professionals also suggested prehospital care protocols to standardize care. Others also recommended legislation and administrative commitments to protect EMS resources from misuse.
“[…] and also, there should be guidelines for ambulance service and care at our facility level too. […] One day we will end this practice (ambulance misuse), but this may take time, and it needs strict regulations and commitment.” (A Nurse coordinating an ambulance)
3.5. Public education and capacity building
Most of the respondents supported public awareness campaigns to create a basic understanding of emergency conditions and when and how to access care. They also recommended community capacity building through first-aid training, so that community members can begin to initiate care even before an ambulance arrives.
“The public at large does not have awareness. I have not seen any attempt to (to create public awareness) [...] no interventions to engage the community [...], all these needs to be improved, the public at large should be aware of basic lifesaving skills, a first aid training program for the community.” (A Police officer)
3.6. Improved evidence generation
Interviewed professionals felt it was critical to collect and synthesize information to better understand the burden of disease and the status of existing services and systems. They believed that this would allow for the identification of gaps in the current system and lead to essential policy changes to strengthen the prehospital system.
“There should be improvements, but it have to be evidence based. Still, further research and investigations have to be done to establish bases and better solutions.” (A Health professional)