With the country's emergency services being understaffed, underesourced and overwhelmed, community-based ambulance services are the logical option for coping with these crises.
In a medical emergency, the time it takes emergency services to respond could be the difference between survival or death, writes Charmaine Cunningham, a lecturer in emergency medicine and global surgery at the University of Cape Town, for TimesLIVE.
Ambulance response time is a global benchmark of efficiency but it’s always possible that an ambulance might be sent from too far away to reach the patient in time, or have to struggle to negotiate difficult terrain; in South Africa, ambulance staff also frequently run the gauntlet of being targeted by criminals.
Community-based ambulance services could be one way to improve response times and to support established healthcare systems. We recently tested this idea using a volunteer community-based ambulance service in Hout Bay, Cape Town.
The Hout Bay Volunteer Emergency Medical Service (EMS) had an average response time within its own area that was 42.3% faster than the Western Cape Government’s emergency medical services. Its ambulances consistently beat the target time of 15 minutes for life-threatening calls in urban areas.
Because the service is based within the community – and not easy to reach from elsewhere in the city because of its mountainous topography – its ambulances are able to reach patients faster than those coming from elsewhere.
We believe the model can be expanded to other communities across the African continent. This is a key need: less than 9% of people across Africa are served by an emergency care system.
Developing effective emergency care systems could potentially save lives. The World Health Organisation estimates that more than 50% of deaths in low- and middle-income countries result from conditions that could be managed by emergency care. This is not the only reason for high mortality and morbidity rates. But it’s a contributing factor.
Collaboration and good working relationships are crucial for community-based ambulance services to work. Residents must work with each other, as well as with government departments and formal EMS providers.
Understanding Hout Bay
Hout Bay has been recorded as covering 32.3km². In the 2011 census, the official population was recorded as 33 000 people. The umbrella term “Hout Bay” describes three sections: Hout Bay, Hangberg and Imizamo Yethu. These sections differ in terms of socioeconomic conditions, ranging from abject poverty (no bulk water, sewerage or electricity) to adequate housing and healthcare, and to luxury.
The Hout Bay Volunteer EMS was started by a group of residents in 1994, concerned about how long it took ambulances to respond to medical emergencies in the area.
Part of the reason is that the area is physically isolated, enclosed on three sides by mountains, and by the coastline on the fourth side. Vehicles can only get in and out on three two-lane roads via the mountains. This causes delays in medical emergency response times, especially in peak traffic, tourist season or bad weather. Without traffic, it takes at least 25 minutes to drive into the suburb from the central business district of the city.
The Hout Bay Volunteer EMS operates with one sponsored ambulance staffed by at least two volunteers. The number of volunteers who regularly work shifts fluctuates depending on season, for example more volunteers are available over the festive season as they have leave from regular work. The average number of volunteers who contribute shifts in a year is 20.
We’ve identified various factors to consider when developing community-based response systems.
First, these should suit the setting: taking into account the specific community needs and the disease profile. This may include the distance to the closest appropriate facility, and the number/type of emergencies commonly seen in the setting. For example, it may be an area with a high number of road traffic accidents, requiring rescue equipment and capabilities. Or a high number of pregnancies.
It also helps if the community-based response system is embedded within existing community programmes or systems. For instance, the first Hout Bay Volunteer EMS emergency care responders were volunteer members of the National Sea Rescue Institute (NSRI) station 8 in Hout Bay. These volunteers organised a basic ambulance assistant course through the provincial ambulance college.
The institute was already well established, and initially most members were volunteers with both organisations. This helped to develop a co-ordinated response to emergencies.
The two organisations still have a close relationship. The Hout Bay emergency services is also embedded in other community-based partnerships. These include the community policing forum, neighbourhood watch and sponsors like local businesses.
Identifying, establishing and maintaining stakeholder relationships is probably the most vital component when developing a community-based response system. These relationships need to be nurtured and maintained, and Hout Bay Volunteer EMS has seen the benefit of appointing a dedicated liaison officer within the executive committee to build stakeholder relationships.
While the community, other community-based organisations and sponsors are important stakeholders, the Western Cape Department of Health and wellness EMS is the main enabler and a powerful stakeholder of the Hout Bay Volunteer EMS. An executive committee portfolio is dedicated to maintaining this key relationship and the service is permitted to function by a service level agreement between the two parties.
Trust is also key. Residents must know about and trust the service. This can partially be achieved simply by delivering a good, reliable service. The Hout Bay emergency service also interacts regularly with community leaders, offers community first aid training, facilitates fire prevention training, visits schools and provides medical support at community events.
Expand the idea
Emergency medical services remain underdeveloped in many African countries, resulting in underserviced communities. This isn’t the only volunteer emergency medical service on the continent. But the longevity of the Hout Bay emergency services suggests that the model has been sustainable and provides valuable lessons for other communities.
Meanwhile, reports The Citizen, in Gauteng, MEC for Health Nomantu Nkomo-Ralehoko has urged residents to protect EMS and paramedics to ensure better service delivery when they attend to emergencies.
Ralehoko said since the Gauteng Executive Council took a decision in 2009 to provincialise EMS, in line with the National Health Act, there had been a notable improvement in services in Johannesburg.
“The creation of one emergency number (112), as compared to many numbers that were used by the Local Authority. Gauteng EMS has no boundaries between metros and districts and resources can be activated from any metropolitan municipality or district.”
The City of Johannesburg EMS provincialisation was concluded in January 2020.
However, she added that despite all the gains, the provincialisation of EMS is not immune to challenges. “These range from service delivery protests which delay calls to emergencies, and damage to ambulances and response cars due to community attacks to paramedic attacks, which have an impact on the EMS operational strength because lengthy sick leave from injuries (mental and physical injuries).”
Attacks on EMS
She said the classification of certain areas in the City of Johannesburg as hot zones (from previous attacks and service delivery protests) means EMS officials must wait for SAPS escorts before attending to incidents. “We should not allow criminals to deny citizens their right to access emergency medical services,” she added.
The Citizen article – Protect paramedics to allow them to attend to emergencies, pleads MEC (Open access)
See more from MedicalBrief archives:
Community-based paramedics save lives – and need no SAPS escorts
MEC urged to intervene in ongoing Eastern Cape ambulance protests
Ambulance shortages and paramedic attacks cripple Gauteng emergency services
Western Cape ambulance crews to get live-streaming body cams for safety
Eastern Cape's Nelson Mandela Bay has only 2 ambulances for pandemic patients
56th robbery of Cape paramedics this year