A summary of the EMS findings both at the national and sub-national levels is presented
in Table 1. Detailed discussion of the results by the two levels is presented below.
Leadership and governance: The Department of Emergency Medical Services at the Ministry of Health was a few
months old at the time of the study.
‘The Ministry is prioritizing this [EMS] now, as you can see with the creation of the
Department. But the major challenge is still that of resources. We have some development
partners who are helping.’ Key Informant, Ministry of Health.
Financing: Specifically, on funding:
‘There is no earmarking of funds. We get a block vote for salaries and some limited
operations here at headquarters. For the rest of the country, the districts have to
determine what to spend on it [EMS]. There is no ear marking there.’ Key informant interview respondent, Ministry of Health.
Coordination: The MOH was acknowledged as the lead agency in this area; however, there was an overlap
of roles and ambiguity in mandates and operations, between the MOH, Office of the
Prime Minister’s National Emergency Coordination and Operations Center, the Police,
and the armed forces. A universal toll-free telephone number was reported to be in
existence, but it was not functional. The Health Management Information System (HMIS)
office at the Ministry of Health did not have information specific to EMS.
Health workforce: Four courses addressing health facility-based emergency care were being taught at
certain tertiary institutions in the country (Table 2). One additional course (pre-hospital
emergency care) was under validation while another was under development.
Sub-national level findings
Governance: EMS delivery was plagued by poor coordination and communication. For instance, of
the 11 districts with more than one EMS provider, only 5 (45.5%) coordinated their
activities on regular basis. In addition, of the 52 pre-hospital care providers interviewed,
19 (36.5%) reported having dedicated emergency numbers for their ambulances and 25
(48.1%) had designated personnel to handle emergency calls. Twenty-three (44.2%) of
the 52 pre-hospital care providers reported use of a central dispatch point for their
ambulances. The rest had no specific dispatch mechanism.
Medical products: There was widespread lack of the most basic of equipment and medicines (e.g., blood
pressure machines, electrocardiogram, glucometer, defibrillator, and forceps) needed
to monitor and treat emergency conditions in ambulances and at emergency units (Tables
3-5). While triage stations were almost universally available, the capabilities in
emergency units to appropriately intervene in life threatening emergencies was limited.
Seventy-nine (71.2%) of the 111 sampled emergency units reported use of clinical protocols.
However, except for a few wall charts dealing with disease-specific conditions, there
was little evidence of protocol use. Private-owned health facilities and ambulances
were relatively better equipped and stocked than government-owned ones.
Health workforce: The Police, which was responsible for most (69%) transfers, had no trained medical
personnel on board. They also used pick-up trucks with no provision for patient space
beyond the bare floor of the truck. The rest of the providers had ambulances. Nine
of the sixteen (56.3%) non-Police pre-hospital providers with ambulances assessed
had a nurse on board, with some having an additional health worker (e.g., emergency
medical technician or doctor) when handling emergencies. Ninety-four percent (15/16)
of the non-Police pre-hospital providers had ambulance workers on a fixed salary,
in addition to a variety of other remuneration mechanisms (e.g., allowances and pay-per-rescue).
Only 27% (30/111) of the sampled health facilities had permanent (non-rotating) staff
in their emergency unit. This was evident even at the regional referral hospital level,
where only three of the seven regional referral hospitals had permanent emergency
room staff. Furthermore, 91% (101/111) of the emergency personnel in the sampled health
facilities (regardless of the level of care), had received no specific training in
the management of emergencies.
Service delivery: Nearly one in three(28.9%) of the sampled districts had more than one pre-hospital emergency services
provider. The same proportion had a medical director, with 66% of the pre-hospital
service providers having no medical director. Fifty (44.6%) of the 112 health facilities
and police stations assessed for ambulance services had an ambulance (42 standard
ambulances and 8 improvised ambulances).
Government (particularly the police) as well as private for-profit and not-for-profit
agencies provided pre-hospital care services. Thirty-three (63.5%) of the 52 pre-hospital
EMS providers were government-funded, with for-profit and not-for-profit agencies
funding the remainder. Of the 52 pre-hospital providers, 16 (30.8%) reported having
ambulance services with vehicles while the remaining 36 who were the Uganda Police
had no ambulances but improvised means of transportation (Police patrol trucks) in
emergency situations. The median cost for a long ambulance run was 114 US dollars
(400000 Uganda shillings) with a range between 9 US dollars (30000 Uganda shillings)
and 943 US dollars (3,300,000 Uganda shillings). This excludes government-owned pre-hospital
care providers (especially the Police) who generally provide free transportation to
health facilities. Forty-two (84%) of the 50 pre-hospital care providers that had
ambulance services were attached to a health facility. Only 8 (16%) of these providers
were stand-alone (i.e., not attached to a health facility).
While it was expected that lower levels of the healthcare system (i.e., HC III and
HC IV) might be closed for the night, we found 18.4% of hospitals, including regional
referral hospitals, where emergency services were not available 24 hours a day. Forty-two
(37.8%) of the 111 sampled health facilities did not have laboratory support for part
of the day. Moreover, there was little capacity to manage extra-ordinary events at
all levels of the healthcare system.
Information use and sharing: There was wide variation in the formats and types of data collected on EMS within
districts. Most information was neither shared with relevant agencies and offices,
nor was there much indication that it influenced planning. Even operations-specific
information such as the fact that critically ill patients were being transferred to
a certain health facility was not always shared. For instance, 26 (50%) of the 52
EMS providers interviewed reported that they never notified health facilities prior
to transferring emergencies there. Only 13 (34%) of the 38 sampled districts used
their EMS data for district-level system planning. Data for planning EMS came from
health facility records, police records, mortuary records, and community sources.
Thirty (57.7%) of the 52 pre-hospital care providers reported sharing their information
with authorities at the district level while 17 (32.7%) shared their data with the
MOH. Other stakeholders with whom data were shared included District Police Commanders,
the National Road Safety Council, and the media.