
==== Front
Afr J Emerg Med
Afr J Emerg Med
African Journal of Emergency Medicine
2211-419X
2211-4203
African Federation for Emergency Medicine

S2211-419X(24)00026-0
10.1016/j.afjem.2024.06.008
Original article
The National Ambulance Service of Ghana: Changes in capacity and utilization over 20 years
Zakariah Ahmed N. a
Boateng Edmund a
Achena Christiana a
Ansong-Bridjan Foster a
Mock Charles cmock@uw.edu
b⁎
a National Ambulance Service, Ministry of Health, Accra, Ghana
b Department of Surgery, University of Washington, Seattle, WA, USA
⁎ Corresponding author. cmock@uw.edu
05 7 2024
9 2024
05 7 2024
14 3 172178
28 9 2023
24 6 2024
26 6 2024
© 2024 The Authors. Published by Elsevier B.V. on behalf of African Federation for Emergency Medicine.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Emergency medical services (EMS) are minimally developed in many African countries. We sought to document the achievements and challenges faced by the National Ambulance Service (NAS) of Ghana during its 20-year nationwide expansion, and to understand how well it is providing access to previously unserved, remoter areas.

Methods

Data routinely collected by NAS from 2004 to 2023 were analyzed, including structure and capacity (number of stations, ambulances, employees) and utilization and process of care (number of patients served, demographics, medical conditions, response site). Per population indicators of capacity and utilization were compared across Ghana's 16 regions.

Results

From 64 emergency medical technicians (EMTs) and nine ambulances in 2004, NAS has grown to 3,473 EMTs and 356 ambulances. From covering three cities in 2004, NAS now has at least one station in each of Ghana's 261 districts. From transporting 205 patients in 2004, NAS transported 38,393 patients in 2022. There have been interruptions due to financial restrictions, with numbers of patients transported per year in 2017–2019 decreasing by over 50% from the prior peak (n = 20,236 in 2014). In 2022, there were 1.13 ambulances per 100,000 people and 0.33 transports/100,000/day. Most (81.3%) transports are inter-facility transfers. Among Ghana's 16 regions, there is moderate variation in utilization from 0.16 to 0.50 transports/100,000/day. However, the three lowest-income, remoter regions currently have utilizations of 0.16, 0.30, and 0.37 transports/100,000/day, mostly near the National average of 0.33.

Conclusion

Despite periodic limitations due to finances, the NAS has expanded to cover all of Ghana's 261 districts and has largely achieved geographic equity. Sustainability has been aided by having a training school directly under NAS's control, assuring a steady supply of EMTs. Challenges include assuring financial stability and increasing utilization for emergencies at the scene, in addition to the current high utilization for inter-facility transfer.

Keywords

Prehospital
Emergency medical services
Ghana
Ambulance
==== Body
pmcAfrican relevance

• Prehospital emergency medical services (EMS) are at a low level of development in most African countries.

• Outcomes from most emergency medical conditions are better with earlier treatment, including in the prehospital setting.

• The current study demonstrates lessons learned in the development and nationwide expansion of a formal prehospital EMS in Ghana.

• The data presented and the lessons learned likely would be of interest to those developing prehospital EMS in other African countries.

Introduction

There is a high burden of death and disability from conditions requiring emergency care, such as trauma, cardiac and respiratory diseases, obstetrical emergencies, and stroke. The burden is especially high in low- and middle-income countries (LMICs) [1]. For example, 90% of trauma deaths occur in LMICs [2]. Prehospital care is essential to address these conditions [3]. Both first responder care and formal emergency medical services (EMS) are very cost-effective [4].

Despite the high need and strong cost-effectiveness, prehospital care is at a low level of development in many LMICs, especially Africa [5]. Mould-Millman et al. [6] estimated in 2017 that only 30% of African countries had EMS and that only 8.7% of Africa's population had access to EMS. Although the situation may have improved since then, EMS coverage remains low in most of Africa. Part of the problem is likely the long start-up time needed to initiate and expand formal EMS, including training and hiring personnel; purchasing and equipping vehicles; and developing infrastructure such as bases and communications systems.

Most examples of how to achieve an effective EMS system come from high-income countries, which are less applicable to LMICs. The National Ambulance Service (NAS) of Ghana has 20 years of experience. Prior studies reported on NAS's birth and early growth [7,8]. The current study sought to assess metrics of capacity and utilization over the past 20 years. By so doing, we sought to document the achievements and challenges faced by NAS, including lessons learned during nationwide expansion. Finally, we sought to understand how well NAS has been doing in providing access to the previously unserved, remoter areas. This information would likely be of interest to other LMICs in their EMS development.

Methods

Setting

Ghana is a lower-middle income country with 31.5 million people and an annual gross domestic product of US$2363 per capita [9,10]. Ghana has 261 districts, grouped into 16 regions. Most districts have first-level hospitals that are staffed by general doctors and that provide basic emergency care. There are generally gaps in resources for more advanced emergency care [[11], [12], [13], [14]] and a frequent need to transfer patients to one of the 16 regional or 5 tertiary hospitals.

Data collection

Data routinely collected by NAS were used for this study, including data on structure and capacity, utilization and process of care, and outcome. Structure and capacity include numbers of employees (by category) and numbers of dispatch centers, ambulance stations, and ambulances. Utilization and process of care include number of patients transported, demographic characteristics, type of condition (medical, trauma, obstetrical), and place of pick-up (health facility, residence, roadside). Collection of outcome variables started in 2022 and categorizes transported patients as deteriorated, unchanged, or improved. Process and outcome of care are recorded on each transported patient. Data are collected on paper forms, entered into a database daily, and reviewed for accuracy by station supervisors. Data are transmitted to NAS headquarters in Accra for monitoring and evaluation. For the current study, these data are supplemented by description of lessons learned and remaining challenges. These were based on prior reports [7,8,15] and on the experiences of the authors, who included senior leaders who collectively had 72 years of experience in the NAS and were well poised to know the lessons learned. The lessons learned were derived by consensus through discussions among the authors. Use of these routinely-gathered, anonymous data for this publication was approved by NAS's IRB. Data are housed by NAS using its internally-developed Enterprise Resource Planning software. Data were exported for analysis using Microsoft Excel (Version-2404). Transports/day/population were calculated using population data from the Ghana Census [10,16].

Results

Structure and capacity

Before 2004, prehospital care in Ghana was limited. Some hospitals had their own ambulances, used primarily for inter-hospital transfers. Otherwise, prehospital care was almost exclusively provided by relatives and bystanders. The National Ambulance Service (NAS) was founded in 2004. It started with two dispatch centers (one in each of the two biggest cities: Accra and Kumasi), seven ambulance stations, nine ambulances, and 69 emergency medical technicians (EMTs). NAS has grown to 16 dispatch centers, 297 stations, 356 ambulances, and 3473 EMTs (Table 1). There are 16 regional offices; each has its own dispatch center; and each is directed by a regional administrator (usually an EMT) with input from a physician (usually an emergency medicine specialist). Each of Ghana's 261 districts now has at least one station. Growth in infrastructure has reflected two major phases of increased governmental investment, in 2011–2012 and 2020. The latter reflected governmental commitment of having at least one ambulance per constituency (275 political divisions each having a member of parliament and consisting of a district or a portion of thereof). The number of ambulances doubled in 2012 and again in 2020, with the purchase of 301 new ambulances. However, the following year 144 were auctioned. These were vehicles that had outlived their usefulness of 5 years, with most being in disrepair.Table 1 Structure and capacity of the National Ambulance Service.

Table 1	2004	2005	2006	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022	2023	
National Population (millions)*	20.9	21.4	21.9	22.5	23.0	23.6	24.7	25.2	25.7	26.2	26.8	27.4	27.9	28.5	29.1	29.7	30.4	30.8	31.5	32.1	
Number of Dispatch Centers	2	2	2	2	2	2	10	10	10	10	10	10	10	10	10	10	16	16	16	16	
Number of Stations	7	7	19	24	24	24	24	24	121	122	128	130	132	132	132	132	133	278	297	297	
Number of Ambulances	9	9	37	37	37	37	38	38	199	199	199	199	199	199	199	199	500	356	356	356	
Number of EMTs	64	142	176	228	222	221	215	202	670	911	1375	1348	1618	1606	2154	2139	2112	3017	3449	3473	
Total Employees	69	147	184	239	233	233	233	232	700	956	1422	1395	1666	1650	2194	2175	2147	3055	3485	3509	
⁎ Population from Ghana census. Based on census for 2000, 2010, 2021, with growth rates between censuses as reported by Ghana census; and with growth rate of 2.1% per year used to calculate population for 2022 and 2023.

Ghana Statistical Service. Ghana 2021 Population and Housing Census. General Report. Volume 3A. Population of Regions and Districts. Accra, Ghana: Ghana Statistical Service; 2021.

Ghana Statistical Service. 2010 Population & Housing Census: National Analytic Report. Accra, Ghana: Ghana Statistical Service; 2013.

Abbreviations: EMT: emergency medical technician.

Regarding human resources, EMTs were initially trained by the National Fire Service. In 2013, NAS established its own Paramedic and Emergency Care Training School (PECTS). In collaboration with EMT instructors from the North Dakota National Guard, the curriculum was adapted from that of the Prehospital Trauma Life Support Course [17] and certification competencies required by the United States National Registry of Emergency Medical Technicians [18]. Periodic large increases in number of EMTs (e.g., 2014, 2018, 2021; Table 1) correspond to large numbers of EMTs trained at PECTS in those years. These also correspond to years in which government allotted additional funds. As training is subsidized by government, students are usually obligated to spend 2–5 years working with NAS after completion. EMT training lasts one year. Initially, all EMT training was at basic level. Since 2012, two-year Advanced-EMT (AEMT) training has been conducted. Thus far, paramedic training has only been conducted out-of-country at collaborating institutions in Florida and North Dakota, USA. As of 2023, out of the total 3473 EMTs employed by NAS, 3001 were basic, 469 were AEMT, and 3 were paramedics. AEMTs are assigned so that there is at least one at each of the 297 stations.

Another necessary component of structure is administrative mechanisms to monitor and assure quality [19]. An advantage of NAS's nationwide structure is the ability to monitor quality across all EMS units in the entire country. NAS's monitoring and evaluation include: (1) equipment standardization exercises; (2) standard operating procedures training; (3) senior leaders riding with ambulance teams; (4) audits (13% of cases); and (5) supervisory coaching as needed. In addition to case-by-case reviews, electronic data are collected on all cases and collated in the Prehospital Information Management System (PIMS), which allows nationwide monitoring. PIMS has been operational since 2020.

Utilization, process, and outcome

The number of patients transported by NAS has steadily increased over time (Table 2). The period 2017–2019 was difficult for NAS as finances were stretched thin and could not keep up with demand. Many vehicles were not available while awaiting repairs. This is reflected in substantial decreases in numbers of patients transported in those years. On the other hand, large investments in capabilities in 2010–2012 and 2020 led to substantial increases in patients transported.Table 2 Conditions of patients transported by the National Ambulance Service.

Table 2	2004	2005	2006	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022	
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	
Total patients	205	1498	4442	7995	8114	6368	5232	4760	7810	17,204	20,236	19,693	14,085	8518	7687	6039	38,255	41,903	38,393	
Condition	
Medical	205 (100)	887 (59)	1283 (29)	5234 (65)	4589 (57)	2989 (47)	3000 (57)	2870 (60)	3798 (49)	6345 (37)	8802 (43)	8821 (45)	6371 (45)	3631 (43)	3740 (49)	3495 (58)	18,789 (49)	21,382 (51)	20,568 (54)	
Trauma	0	611 (41)	1363 (31)	1332 (17)	1734 (21)	1564 (25)	573 (11)	1560 (33)	1320 (17)	4562 (27)	5639 (28)	5211 (26)	3572
(26)	2235 (26)	1761 (23)	1328 (22)	9247 (24)	8886 (21)	7785 (20)	
Obstetric	0	0	920 (21)	895 (11)	1000 (12)	1345 (21)	1028 (20)	200
(4)	1123 (14)	4577 (27)	4877 (24)	4912 (25)	3474
(25)	1907 (22)	1726 (22)	1167 (19)	9313 (24)	8538 (20)	6876 (18)	
Investigation1	0	0	876 (20)	534
(7)	791 (10)	470
(7)	631 (12)	130
(3)	1569 (20)	1720 (10)	918
(5)	725
(4)	662
(5)	745
(9)	385
(5)	49
(1)	906
(2)	2965 (7)	3164 (8)	
Other												24 (0.1)	6 (0.04)		75
(1)			132 (0.3)		
1 Investigation refers to referral from one health care facility to another for diagnostic tests that are not available at the first facility.

A slight majority (n=136,608; 52.9%) of all patients transported (n=258,447) have been female, with minimal changes year-to-year (data not tabled). Most patients transported by NAS have been in the older adolescent / younger adult category (Supplementry Appendix Table A1). Over time, the percentage of patients under one year old has grown, accounting for over 10% of patients since 2016. Similarly, the percentage of older adults (≥45 years) has increased, accounting for over 25% since 2020.

In terms of conditions for which patients were treated, there were notable variations among the categories in the early years (Table 2). Over the past 10 years, the patterns have remained consistent: medical conditions accounting for around half; trauma and obstetric emergencies each accounting for 20–25%; and transport for investigations not offered at the referring facility accounting for larger percentages in earlier years, but below 10% for the past 10 years.

In terms of place of pick-up, most transports (81.3%; n = 175,667 out of 216,009 for whom these data were available) have involved pick-ups from health care facilities (clinics or hospitals) for inter-facility transfer. Other places of pick-up have included: roadside (n = 18,927; 8.8%), residences (n = 14,302; 6.6%), and other (n = 7113; 3.3%). Inter-facility transfers have accounted for the majority of transports every year except for 2004, when they accounted for 43% of transports. Since then, inter-facility transfers have ranged from 54% to 87% of all transports. They have been above 80% for all years since 2018.

When looked at by population (Table 3), the number of ambulances per 100,000 population has grown steadily. There have been small variations, but the ratio has been steadily above one, since 2020. Aside from the first year, transports/ambulance/day have been steadily in the 0.1–0.3 range. This indicator has grown steadily, except for 2017–2019 when many of the ambulances had become inoperable, awaiting maintenance. Transports per 100,000/population/day has likewise grown, with dips during 2017–2019, but has been steadily above 0.3, since 2020.Table 3 Capacity and utilization per population.

Table 3	2004	2005	2006	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022	
Ambulances per 100,000 population	0.04	0.04	0.17	0.16	0.16	0.16	0.15	0.15	0.77	0.76	0.74	0.73	0.71	0.70	0.68	0.67	1.64	1.16	1.13	
Transports per ambulance per day	0.06	0.46	0.33	0.59	0.60	0.47	0.38	0.34	0.11	0.24	0.28	0.27	0.19	0.12	0.11	0.08	0.21	0.32	0.30	
Transports per 100,000 per day	0.003	0.02	0.06	0.10	0.10	0.07	0.06	0.05	0.08	0.18	0.21	0.20	0.14	0.08	0.07	0.06	0.34	0.37	0.33	

Vehicle availability is defined as percentage of time that a call is received and an ambulance is available to respond. This has been recorded since 2017. During the difficult years 2017–2019, this was very low at 26% (2017), 27% (2018), and 20% (2019), indicating that the majority of times that a call was received, no response was possible. With increased resources in 2020, this has now increased to 70% (2020), 78% (2021), and 77% (2022). Outcome data were added in 2022. Of all patients transported that year, 2.0% deteriorated, 2.3% improved, 90.7% were unchanged, and the information was not recorded for 4.9%.

Regional variation

Differences in capacity and transports by region are shown in Table 4. As a proxy for overall capabilities, EMTs per 100,000 people show a low of 5.5 (Northern) to a high of 17.7 (Savannah), with a National average of 8.9. NAS has been in operation the longest in the two regions with the biggest urban centers (Ashanti and Greater Accra). Their ratios of EMTs per population are approximately at the National average. The three regions with the lowest income in Ghana (i.e. highest unemployment rates) [20] and that had later implementation of the NAS (Northeast, Savannah, Upper East) have capabilities near the National average. Stations per population parallel EMTs per population. In general, there is one ambulance per station, so values for stations per population are equivalent to ambulances per population. In terms of utilization, transports per 100,000 per day show a range from 0.16 (Oti, Northeast) to 0.50 (Eastern), with a National average of 0.33. Ashanti and Greater Accra have utilizations only slightly higher than the National average. The lower-income regions have levels of utilization near the National average, other than Northeast (0.16). Vehicle availability ranged from 66.2% (Savanah) to 86.3% (Bono East), with a National average of 77.0%. Ashanti and Greater Accra have availabilities only slightly higher than the National average. The lower-income regions had availabilities that were below the National average.Table 4 Regional variation in capacity and transports in 2022.

Table 4Region	Population	Unemployment rate (%)	Stations	EMTs	Transports	Stations per 100,000 people	EMTs per 100,000 people	Transports per 100,000 people per day	Vehicle availability (%)	
AHAFO	572,573	11.9	6	80	613	1.05	14.0	0.29	81.69	
ASHANTI	5505,749	13.1	47	417	7799	0.86	7.6	0.39	81.38	
BONO	1238,865	13.8	13	187	1353	1.05	15.1	0.30	81.62	
BONO EAST	1235,892	11.2	12	132	939	0.97	10.7	0.21	86.30	
CENTRAL	2928,457	13.3	27	199	3636	0.92	6.8	0.34	85.28	
EASTERN	2954,910	11.8	33	349	5340	1.12	11.8	0.50	75.97	
GREATER ACCRA	5613,907	12.9	38	436	7076	0.68	7.8	0.35	78.49	
NORTHEAST	680,032	20.7	7	52	403	1.03	7.6	0.16	71.23	
NORTHERN	2396,444	14.3	18	133	2915	0.75	5.5	0.33	76.23	
OTI	758,457	6.7	9	73	435	1.19	9.8	0.16	69.68	
SAVANNAH	673,517	22.4	11	119	744	1.63	17.7	0.30	66.23	
UPPER EAST	1327,251	21.1	16	116	1788	1.21	8.7	0.37	69.30	
UPPER WEST	922,237	14.4	12	100	1119	1.30	10.8	0.33	73.38	
VOLTA	1677,289	13.8	19	159	1920	1.13	9.5	0.31	73.64	
WESTERN	2101,797	14.6	20	132	1793	0.95	6.3	0.23	67.74	
WESTERN NORTH	898,539	13.1	9	57	520	1.00	6.3	0.16	80.06	
TOTAL	31,485,915	13.4	297	2741	38,393	0.96	8.7	0.33	77.02	
EMTs (Emergency medical technicians): excludes EMTs based at headquarters, training school, and those who recently graduated and were yet to be posted to the various stations and who were not yet involved in daily responses.

Note: Population of regions based on data from Ghana National Census, using 2021 data with regional growth rates applied to derive 2022 estimates.

Reference: Ghana Statistical Service. Ghana 2021 Population and Housing Census. General Report. Volume 3A. Population of Regions and Districts. Accra, Ghana: Ghana Statistical Service; 2021.

Unemployment rate for people 15 years and older, based on data from Ghana National Census, Volume 3E. Economic Activity.

Finances

Financing for NAS includes several components. New ambulances are purchased periodically directly by government. Staff salaries are paid directly by government. A third component is NAS's operational budget. During the most recent three-year period (2020–2022), the three major sources of funding for the operational budget were: funds from the National Health Insurance Authority (which accounted for an average of 60% of fund in-flows; range 46–72% depending on the year); funds from government (averaging 19% of fund in-flows: range 8–40%); and funds internally generated by NAS (averaging 20% of funds in-flows: range 14–29%). Funds from government were primarily from general governmental revenues, but each year also included portions derived from donor funds. Internally generated funds included fees paid by trainees and fees paid by outside groups for standby ambulance coverage for activities such as sporting events.

Lessons learned

Table 5 presents lessons learned during the past 20 years, that have contributed to NAS's successful growth and sustainability. The table also presents the most important challenges remaining.Table 5 Lessons learned and existing challenges for the National Ambulance Service (NAS).

Table 5No.	Category	Description	
Lessons Learned	
1	Strong leadership	Effective leadership at all levels has been crucial in shaping the NAS, setting strategic goals, and ensuring accountability. A leader with an in-depth understanding of the mandate of the NAS, relevant experience, and commitment is crucial for its survival and growth.	
2	Human resource development	Given the scarce number of medical doctors in Ghana, it was decided early on to utilize the Anglo-American model relying on emergency medical technicians (EMTs), rather than the Franco-Germany model. Establishment of NAS's own EMT school has contributed to the self-sustainability of NAS in human resources.	
3	Infrastructure development	In order to be sustainable, infrastructure development has been approached cautiously. Expansion of NAS stations from 7 to 297 was accomplished gradually over twenty years. This ensured readiness to effectively handle increased demand. During expansion, NAS leveraged existing infrastructure belonging to the National Fire Service.	
4	Targeted publicity and limited marketing	During the period when NAS operated with a modest fleet of 9 to 24 to 128 ambulances, a key strategy was to minimize the influx of emergency requests. NAS adopted a deliberate strategy of targeted publicity and limited marketing aimed at preserving the public's confidence in the quality of service provided by NAS, within available resources.	
5	Community engagement and public awareness	Through targeted public awareness campaigns and partnerships with local stakeholders, NAS has educated the public about emergency services, promoted responsible ambulance usage, and encouraged timely reporting of emergencies. A notable benefit has been local communities’ support for establishment of NAS stations across different regions. This support has manifested in part through provision of space in local government buildings for NAS stations and staff accommodation. Community engagement has also fostered a sense of ownership, enabling the public to take an active role in emergency preparedness and response.	
6	Sustainability and funding	These remain a challenge. The sustainability NAS has achieved is due to:
Legal backing by an Act of Parliament to operate as a legal entity.
Strong diplomacy at all levels to facilitate obtaining needed resources.
Living within NAS means and expanding slowly.
Collaboration with other bigger agencies and institutions to run projects that benefit NAS growth.	
7	Information technology for monitoring	The Pre-hospital Information Management System (PIMS), developed on a NAS homegrown platform, provides invaluable data for monitoring and real-time, evidence-based decision making. It monitors crucial metrics, such as response times, vehicle availability, and service utilization, and identifies areas requiring improvement. It aids in human resources management, fleet management, quality assurance, clinical audit, patient records management, and continuous professional development certification, among others.	
Existing Challenges	
1	Funding and political influence	Government is the major source of funding for the NAS.
If the government of the day does not prioritize ambulance services, NAS will suffer for the period during which that government is in power.
So, at all material moments, the leadership of the NAS must lobby government for resources.
The only option for NAS to be free of this is to have a dedicated source of funding that is free from governmental influence.	
2	A well-equipped training school for trainings	NAS currently has an existing training school, known as the Paramedic and Emergency Care Training School (PECTS), which school still needs infrastructure improvement in meeting the internationals standard of a well-equipped training school.	
3	Infrastructure challenges for the stations	Some of the NAS ambulance stations are currently sharing offices with the Fire Service's stations and others are yet to get offices of their own. NAS still needs infrastructure support for some of the stations and to build additional ones for expansion.	

Discussion

We sought to document the experiences of the National Ambulance Service (NAS) of Ghana during its 20 year nationwide expansion, to assess metrics of capacity and utilization during this time, and to evaluate coverage of previously unserved, remoter areas. We found a steady growth in capacity and utilization, interrupted by difficult periods (e.g. 2017–2019) when financial restrictions interfered with vehicle maintenance and decreased availability to respond to emergencies. Nonetheless, by 2023, capacity and utilization were fairly evenly distributed across all of Ghana. The major challenge currently is assuring financial stability, as NAS is nearly totally dependent on government for funding and does not have an independent financing mechanism. Another challenge is to increase utilization for emergencies at roadside, residences, and elsewhere, as most utilization is currently for inter-facility transfer.

Similar issues are reported from other LMICs, although there do not appear to be any similar reports of a nationwide EMS organization. Quake et al. [5] reviewed the literature on EMS development in LMICs from 2010 to 2022, reporting on studies from 16 countries, most in sub-Saharan Africa. They identified the biggest obstacles to EMS development to be limitations of funding, workforce, and resources, which they reported as forming “a spiraling cycle of inadequacy with one another” [5]. NAS's development has been interrupted by periodic downturns of finances and resources. However, the nationwide structure has provided a foundation that assists with sustainability and allows economies of scale in purchases and resource development. The creation of a training school directly under NAS's control has provided stability in workforce, guarding against the cycle of inadequacy that Quake reports.

Quake et al. [5] also reported deficiencies in data for decision making, related to deficiencies in “a culture of documentation, auditing, and accountability”. NAS's emphasis on centralized data for monitoring, evaluation, and auditing is thus notable. This has been augmented since 2020 through the electronically-based PIMS (Prehospital Information Management System) database.

Geographic coverage of NAS has expanded from 7 stations in 2004 to having at least one station in each of Ghana's 261 districts [7,8,21]. The last areas to be covered were some of the remoter and lower-income areas of Ghana. Coverage is now fairly equitably distributed across all of Ghana's region with some differences in capabilities and utilization per population (Table 4). In general the remoter and lower-income areas are as well served as urban areas, but in these more remote areas, longer distance and hence longer response and transport times lead to greater periods of time when ambulances are unavailable.

A general benchmark on ambulance availability is 1 ambulance on duty per 50,000 population (or 2/100,000) [22,23]. This has been nearly achieved in Ghana in the past few years. However, the benchmark refers to ambulances on duty and some of the vehicles reported in Table 3 have periods of inoperability due to barriers in maintenance. Closely-related metrics include transports per ambulance and per population, both of which are in the 0.3 per day range in recent years. Utilization per ambulance appears low compared with other studies. Twenty responses per day are theoretically possible [22], but published reports tend to report 3–6 responses per day [24,25]. An evaluation of 70 EMS departments in the USA reported an average of 6.5 responses per ambulance per day [26]. Direct comparisons are difficult as the NAS data are for all ambulances, regardless of functionality and reports from the literature are functional ambulances on duty. Similarly, responses per 100,000 per day appear low compared to the literature, with approximately 30 responses/100,000/day reported from the USA [26,27]. The lower values in Ghana may relate to several factors, such as percent vehicle availability (ideally 100%) and the fact that inter-facility transfers are often long distances (e.g. to tertiary centers), whereas the reports in the literature are primarily transports from the scene to nearby hospitals. Likewise, data from the literature are for all responses, including those that do not result in patient transports, whereas the data from Ghana are for transports.

Most NAS transports are for inter-facility transfer and they accounted for over 80% of all transports each year since 2018, indicating that there is a large unmet need for responses to the scene, such as for traffic crashes. Nonetheless, inter-facility transfer is an important component of EMS. In LMICs in particular, strengthening inter-facility transfer is a key strategy for improving access to emergency obstetric capabilities and lowering maternal mortality [28,29].

Many of the lessons learned during the past 20 years (Table 5) parallel lessons reported by WHO in its summary of trauma and emergency care improvements globally [7]. These include: leadership and perseverance. WHO stated that it was important to endure “frustrations and short-term failures in order to make gradual but steady progress” [7]. There is a need for timely and accurate data to guide decision making, as is being provided to NAS by its PIMS. Finally, the importance of community involvement has materialized in Ghana, as local communities have been instrumental in providing stations.

Limitations

Lessons learned were derived by the authors. Although they have extensive experience within the NAS, a more formal process with engagement of a larger set of stakeholders might have yielded more robust findings. Second, we have reported the percentage of transports from the scene, which appear to show a high unmet need for direct responses. However, there are not data available to calculate the unmet need itself.

Conclusions

Despite periodic limitations of operations due to finances, the NAS has expanded to cover all of Ghana's 261 districts. Although there are some differences between areas in metrics of capacity and utilization, the NAS has largely achieved equity, with remoter, lower-income areas having similar metrics to higher-income urban areas. Sustainability has been aided by having a training school directly under NAS's control, which has assured a steady supply of EMTs. A solid foundation of data allows monitoring and evaluation. Remaining challenges include assuring financial stability and increasing utilization for emergencies at the scene, in addition to the current high utilization for inter-facility transfer.

Dissemination

Data about the changes in structure (capacity), utilization, and process of care have been shared with the 3000 employees of the National Ambulance Service through presentations during staff meetings and in-service training.

Authors’ contribution

Authors contributed as follows to the conception or design of the work; the acquisition, analysis, or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content: all authors contributed equally (20% each). All authors approved the version to be published and agreed to be accountable for all aspects of the work.

Declaration of competing interest

The authors declared no conflicts of interest.

Appendix Supplementary materials

XML, application 1

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.afjem.2024.06.008.
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