Improving emergency care vital

I. Rusike, E. Sharara, C. Chimhete and T. Munouya
In front of us in one of our rural districts is a road accident with injured passengers including children.They are distressed – the local public hospital has no ambulance and they are trying to find enough money to assure the private ambulance service that they will be able to pay the fee before they will send the ambulance.
The fee is more than they can afford, but if they don’t find someone to pay and get people to care quickly the injured people could have complications or suffer avoidable deaths.
This is not the only problem people who have emergencies face. Ambulances can take long to respond. Many ambulances do not have basic equipment or adequately trained staff to take care of patients during transit, also complicating their recovery or risking fatalities in transit.
Emergency departments are under resourced, without adequate equipment and staff to cope with the critically ill patients coming to them, including patients who have delayed seeking care until they have an acute emergency.
In some countries in our region, a critical shortage of doctors and other skilled health workers has affected the quality of the response to emergencies. Yet in others, like South Africa and Uganda, ambulances are better equipped and staffed, and people arriving at emergency facilities find doctors and nurses on stand-by and ready to receive patients and give them prompt care.
This situation is compounded by conditions that increase the risk of traumatic injury. For example, the state of our roads in Zimbabwe raises concern, especially when they are further damaged by heavy rains and other climate disasters.
Poor roads not only raise the risk of accidents, but also mean that ambulances cannot easily access patients in need. During the rainy season, rural roads become impassable, making access for emergency services even more difficult.
While communities assist with emergencies where they can, local transport operators sometimes take advantage of poor conditions to overcharge desperate patients in need of acute care, including pregnant women, carers of sick children and elderly people.
In the absence of adequate investment in roads and services, poor people pay the price. Allocating funds to improve road systems will prevent accidents and also make it easier for ambulances to reach emergencies.
Yet in 2017, of the $15 million that the Harare City Council said it needed to improve the road network, it received only US$1,2 million from the Zimbabwe National Road Administration (Zinara).
The situation may be worse when air rescue emergency services are needed, as a key component of an effective emergency care system. Air rescue emergency services are more scarce healthcare resource, and as in Zimbabwe, the only public service for this may be the Air Force.
There are private services for those who can afford the costs of private insurance or providers, but these are unaffordable for the majority, and thus only used by a minority of people.
In the common discussions on universal health coverage and emergency responses, it is important that we at minimum ensure availability, accessibility and affordability of effective and good quality emergency medical services for everyone in the public.
Good quality emergency medical services provide an immediate response to a variety of illnesses and injuries and the treatment and transportation of people in health situations that may be life threatening.
They should provide universal quality care to all those who need it at the time they need it to save their lives, prevent suffering or disability. Although the current situation varies from country to country in the region, for many this is not yet delivered.
The situation contradicts the fact that in Zimbabwe, as for seven other countries of the region, according to EQUINET policy brief 27, the constitution guarantees citizens the right to health care, including emergency medical services. Section 76 (3) of Zimbabwe’s Constitution states this as, “No person may be refused emergency medical treatment in any health care institution.”
Of course no service would refuse care, but a situation of inadequate investment in affordable, accessible and good quality emergency services, including ambulances can be understood to be a form of denial, or refusal.
The Zimbabwe Constitution makes this clear in stating that the state must take reasonable legislative and other measures, within the limits of the resources available to it, to achieve the progressive realisation of this right.
While public emergency services offered by state-owned health institutions, the Air Force, the police and Fire Brigade are weak and poorly resourced, people’s rights are violated and they are exposed to high payments for private services, or worse still disability or death.
It is evident that this is a core duty of the state and must be adequately funded. When public emergency care services are not adequately funded, staffed or provided, it leads to a growth of commercial and privatised services.
While this is a private sector response to demand, and can help to minimise morbidity and mortality if of good quality and properly regulated and monitored, it is not appropriate to rely on the private sector for this service, and leads to inequities in access to care. The driving force of private provision is maximising profits and not the needs of the most disadvantaged members of society.
A trend towards privatisation of emergency medical services thus has highest burdens for the poorest, adding to the stresses in often tough economic environments of accessing services and meeting medical bills.
A 2016 study by the Zimbabwe Coalition on Debt and Development on a public-private partnership in one major central hospital in Zimbabwe found that residents faced challenges in realising their right to health care, due to the high cost of services, unfair treatment of those who cannot pay, “ . . . deepening inequality between the haves and have-nots” and report of corruption in the demand by staff for differing levels of cash payments.
They attributed this violation of rights to health care to the “private vendor profit motive” and diminished public control.
Beyond improving public funding of emergency care services, we can
also take advantage of technology advances. For example, health facilities have used mobile phones to alert ambulance services and to support those attending to patients while waiting for an ambulance or medical personnel, improving the possibility of improved outcomes for patients.
A “Dial-a-Doc” initiative by one mobile operator in Zimbabwe works with enlisted services of medical practitioners at a call centre to respond to phone-in requests for information and help from the public. A similar service is available in South Africa, Zambia and Malawi. At the same time, we cannot keep relying on the health services to manage growing risks in the environments we live and work in.
Death and disability from traumatic injuries from road traffic accidents on poor roads, from climate disasters and other accidents, and acute health crises in pregnancy, for children and others, and due to unsafe working conditions are largely preventable and should not be filling our health services.
We need to have a commitment from all sectors that play a role to identify and reduce their role in traumatic injury and illness.
As economies improve they should show marked reductions in such trauma, but even under challenging economic conditions, adequate, affordable and accessible public emergency care