Identifying barriers for out of hospital emergency care in low and low-middle income countries: a systematic review

BMC Health Serv Res. 2018 Apr 19;18(1):291. doi: 10.1186/s12913-018-3091-0.


Background: Out-of-hospital emergency care (OHEC), also known as prehospital care, has been shown to reduce morbidity and mortality from serious illness. We sought to summarize literature for low and low-middle income countries to identify barriers to and key interventions for OHEC delivery.

Methods: We performed a systematic review of the peer reviewed literature from January 2005 to March 2015 in PubMed, Embase, Cochrane, and Web of Science. All articles referencing research from low and low-middle income countries addressing OHEC, emergency medical services, or transport/transfer of patients were included. We identified themes in the literature to form six categories of OHEC barriers. Data were collected using an electronic form and results were aggregated to produce a descriptive summary.

Results: A total 1927 titles were identified, 31 of which met inclusion criteria. Barriers to OHEC were divided into six categories that included: culture/community, infrastructure, communication/coordination, transport, equipment and personnel. Lack of transportation was a common problem, with 55% (17/31) of articles reporting this as a hindrance to OHEC. Ambulances were the most commonly mentioned (71%, 22/31) mode of transporting patients. However, many patients still relied on alternative means of transportation such as hired cars, and animal drawn carts. Sixty-one percent (19/31) of articles identified a lack of skilled personnel as a key barrier, with 32% (10/31) of OHEC being delivered by laypersons without formal training. Forty percent (12/31) of the systems identified in the review described a uniform access phone number for emergency medical service activation.

Conclusions: Policy makers and researchers seeking to improve OHEC in low and low-middle income countries should focus on increasing the availability of transport and trained providers while improving patient access to the OHEC system. The review yielded articles with a primary focus in Africa, highlighting a need for future research in diverse geographic areas.

Keywords: Barriers to prehospital care; Emergency medicine; Low income countries (LIC); Low-middle income countries (LMIC); Out of hospital emergency care; Prehospital care.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Africa
  • Developing Countries*
  • Emergency Medical Services* / organization & administration
  • Emergency Medical Services* / statistics & numerical data
  • Health Services Accessibility*
  • Humans
  • Poverty