The current state of emergency medical services in South Africa: A review

Emergency medical services (EMS) are a vital component of the health system and provide pre-hospital emergency care and specialised transport for patients requiring access to health facilities, thereby contributing to universal health coverage and improving health outcomes. Evidence regarding the current state of EMS within South Africa to fulfil this role is lacking and was the motivation for this review. Our objective was to describe the current state of EMS in South Africa. A literature search was conducted using keywords, BOOLEAN operating terms, and eligibility criteria on Sabinet, EBSCOhost, Google Scholar, ProQuest, Medline, PubMed, and ScienceDirect databases to find articles related to the components of the EMS system in South Africa. The articles were critically assessed, and six themes emerged: leadership and governance; resources; preparedness (knowledge, attitude, and practices) of the emergency care provider; health and safety; training; and communications. Challenges were found in all themes at a provincial EMS level despite improvements in legislation, leadership, and governance from the National Department of Health. These themes demonstrate that all components in the EMS system are not functioning optimally and may be affecting its contribution to improving universal health coverage and health outcomes. The current state of EMS appears to be constrained and requires greater leadership and governance from the Provincial Departments of Health to improve poorly functioning components of the EMS system. Significance:


Introduction
Inequalities in health infrastructure, inequitable access to services 1 and the burden of disease (identified through communicable and non-communicable diseases, injury, mental health, and maternal and child health) 2 remain healthcare challenges in South Africa.These challenges also exist globally, prompting the World Health Organization (WHO) to advocate for additional efforts to improve health care to "the most disadvantaged, marginalised and hardto-reach populations, to ensure that no one is left behind" 3 .The WHO recommended that emergency services, also known as emergency medical services (EMS), be integrated into the health system to improve patient access to the appropriate level of care. 3 South Africa, the Integrated Healthcare Delivery Platform (Figure 1) is the model used.4 This model promotes the relationship between Core Health Services, Support Services (linked to the WHO health system building blocks) 5 , and Linkage Services which is expected to yield improved health outcomes.Integrating EMS with other health services improves universal health coverage, keeping with the recommendation of the WHO. 3 The role of EMS within this model is to provide efficient emergency care and transport for patients requiring access to Core Health Services.4 While the EMS in South Africa is going through reform in emergency care education 6 and clinical practice 7 , complaints and challenges of service delivery have also been noted 8 . I trying to understand the effectiveness of EMS in the integrated healthcare delivery model, our research question was developed: What is the current state of EMS in South Africa?There is a paucity of information to answer this research question, therefore we explored the current state of EMS in South Africa and make recommendations.The review approach was used to identify, analyse and learn from existing published South African EMS studies and to provide a background and context for subsequent studies.

Method
We conducted a literature search of Sabinet, EBSCOhost, Google Scholar, Proquest, Medline, PubMed, and ScienceDirect databases using the following keywords: 'emergency medical service', 'EMS', 'paramedic', 'prehospital', 'pre-hospital' and 'South Africa'.These keywords were also used to search university repositories.The Boolean operating terms 'OR' and 'AND' were used to refine the database search.
The inclusion criteria were limited to the English language within the South African setting, and to the period 2010 to 2023.Sources of information included journal articles, dissertations/theses, official reports and government documents.
The Integrated Healthcare Delivery Platform, understood in the context of the WHO Health Systems Framework, provided key components (building blocks) of an EMS system.As the study was focused on the EMS system, articles were deemed eligible for inclusion if they related to the components of the EMS system.The state of EMS could therefore be described using these critical components, as proposed by Mehmood et al. 9 Anecdotal information and articles that did not contain information about the components of EMS were excluded.

results
The literature search process (Figure 2) returned 1548 records; of these, 1478 were excluded as they consisted of duplicate articles and those that did not meet the inclusion criteria.A further 33 articles were excluded after screening as they did not relate to the objective of the study, leaving a total of 37 articles that were analysed using a thematic coding approach.
Each article was read, and key findings were coded and tabulated on an electronic spreadsheet alongside the corresponding title, study location and reference.Codes with commonalities were grouped and developed into initial themes.Themes were selected based on their ability to provide information on the components of an EMS system, which was key to effectively addressing the research question.Finally, interrelated themes were grouped, titled and validated by all authors.The following themes emerged from the analysis of the articles:

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Leadership and governance

Background on emergency medical services
Prior to 1994, governance in South Africa comprised four 'white' provincial administrations (Cape of Good Hope, Orange Free State, Transvaal, and Natal) and four 'black' homelands (Transkei, Bophuthatswana, Venda, and Ciskei). 10,11During this apartheid era, the provision of EMS was the responsibility of the local authorities (municipalities), who also provided services such as firefighting and motor vehicle rescue in each town. 11After the 1994 democratic elections, there was a redress of governance in South Africa which resulted in the establishment of nine provinces: Western Cape, Northern Cape, Eastern Cape, North West, Free State, Gauteng, Mpumalanga, Limpopo and KwaZulu-Natal. 10 Redress also included removing the responsibility of EMS from the local authorities, leaving the latter to concentrate on fire and rescue services.EMS was deemed a provincial function (provincialised) and became governed by the Provincial Departments of Health (PDOH). 12rrently, EMS has been provincialised in all nine provinces.Table 1 illustrates the provincial geographical area in relation to the population size in South Africa 13 , thereby providing context for this review.

Governance
Leadership and governance are critical components of the Integrated Healthcare Delivery Platform and the pre-hospital EMS framework as they hold management accountable for the quality of health services rendered to the public. 4The EMS Regulations, promulgated under the National Health Act, 2003 14 , and regulating the operation of public and private EMS in South Africa, were published in 2017.This was a sign of improving governance as EMS providers were required to be accredited and licensed through the PDOH Inspectorate and Licensing Division. 14gulations relating to standards of operating EMS in South Africa were, however, lacking in governance.Assessing the quality of service delivery is possible through standard quality assessment tools guided by governance policies and systems; however, in 2020, Howard et   16 While these regulations were going through the stages of becoming gazetted, the NDOH implemented the Ideal EMS Framework, including its assessment tools designed to evaluate the progress made towards achieving the EMS standards (Table 2). 16This approach demonstrates NDOH's focus on improving issues of governance.
According to the Regulations relating to Standards for EMS 16 , leadership and governance are the responsibility and accountability of the PDOH, whose role is to oversee and support the EMS by ensuring a functional governance structure exists and that there is quality in service delivery.The outcomes of provincial assessments are not yet in any published records; therefore, the quality of provincial leadership and governance remains to be determined.

Leadership
The Campaign on Accelerated Reduction of Maternal (and Child) Mortality in Africa (CARMMA) was a strategic plan introduced by the NDOH, in 2009, to improve maternal and child health.This campaign required "allocating dedicated obstetric ambulances to every subdistrict to ensure prompt transfer of women in labour and women with obstetric emergencies to the appropriate level of care" 17 .Most provinces implemented obstetric ambulances and resolved that obstetric cases be triaged as a priority. 18In 2015, Yancy et al. investigated the implementation status of obstetric ambulances in KwaZulu-Natal and Mpumalanga and found that the number of operational ambulances and staff was inadequate. 19The operation of dedicated obstetric ambulances appears to be unstainable given the shortage of staff and operational ambulances.NDOH leadership appears to be providing strategic direction, while provincial leadership needs improvement in implementation, oversight, and reform.

Recommendation regarding leadership and governance:
• Assessments of all components of EMS need to be urgently conducted by independent quality assurance bodies and validation provided to PDOH.Review Article

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The PDOH should develop and implement a quality improvement plan in response to the assessments and report outcomes to the NDOH that provides oversight to provinces.

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The NDOH needs to establish a standardised and comprehensive national database of provincial EMS resources and assessments for purposes of monitoring, evaluation, strategic planning, and reporting.

Ambulance availability and equipment
South Africa has a population of approximately 60 million people. 13he standard provision of 1 ambulance for every 50 000 people is an international recommendation 20 ; however, in South Africa, the national 'norm' is 1 ambulance per 10 000 people, which is dependent on socio-economic and geographic distribution. 19None of the provinces has achieved this norm. 8,21Studies have found that the high case load outweighs the number of scheduled ambulances. 8,22This situation is worsened when scheduled ambulances are unavailable due to repairs, accident damage, and awaiting vehicle parts (import delays).The high breakdown rate is due to the fleet operating with mileages beyond 300 000 kilometres. 21study in KwaZulu-Natal found that response times for obstetric patients were delayed due to the unavailability of ambulances. 22[25] Ashokcoomar et al. 25 found problems such as a lack of essential equipment, malfunctioning equipment, and unsterile clinical procedures; and concluded that the emergency care providers in KwaZulu-Natal lacked preparedness to manage inter-facility neonatal transfers.Improving the number of fully equipped ambulances is vital for EMS to fulfil its role within the Integrated Healthcare Delivery Platform.
Recommendation regarding resources:

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The PDOH needs to prioritise and increase funding for EMS to assist with staffing and procurement of fully equipped ambulances to meet and maintain the norms and standards of the NDOH.

helicopter emergency medical services
The helicopter emergency medical services (HEMS) is a vital resource for the EMS and is beneficial in cases such as long-distance patient transfer, inaccessible terrain, and when advanced clinical skills are unavailable in the districts.Studies show HEMS operations in the Western Cape, Eastern Cape, KwaZulu-Natal, Gauteng, Free State, Mpumalanga and North West provinces; the status of HEMS in other provinces is unknown due to the lack of published records. 26,27Studies into the operation of the HEMS revealed mixed outcomes.While challenges such as underutilisation of this resource 28 , over-triage, and overuse 29 were noted, Pule et al. 30 reported on the usefulness and appropriateness of the HEMS in long-distance transfers of patients who had major trauma.Similarly, Vlok et al. 27 found that HEMS served as a vital critical care transport resource for inter-facility transfers.

Recommendation regarding HEMS:
• HEMS provides invaluable support to the EMS and should be included as an additional service operated nationally with clearer dispatch guidelines developed through future studies.

Theme 3: Emergency care provider preparedness
Three levels of emergency care providers exist in the EMS in South Africa: Basic Life Support, Intermediate Life Support, and Advanced Life Support. 92][33][34][35] For example: • Emergency care providers lacked knowledge of the Glasgow Coma Scale 31 , triage 32 , management of attempted suicide 34 and management of psychiatric emergencies 36 .
• Emergency care providers' attitude showed a lack of empathy 34 , fear, and apprehension towards mental health care users 37 .Mosca et al. found that emergency care providers expressed difficulty in managing paediatric emergencies due to the complexity of such cases, a lack of support such as protocols, and lack of specific equipment. 383][24][25] Vincent-Lambert et al. 39 found that 51% of trauma patients who arrived at an emergency department were hypothermic, with a core temperature of <36 °C. 38In KwaZulu-Natal, Royal and McKerrow 40 found a mean time delay of 9 hours for inter-facility transfer of critically ill paediatric patients and that emergency care providers (mainly Basic Life Support) failed to keep these patients stable in transit.
The lack of preparedness of emergency care providers could increase the risk of negligence, clinical mismanagement, harm to the patient (maleficence), and litigation for the provider and the EMS.

Recommendations regarding emergency care provider preparedness:
•

Theme 4: Health and safety
According to Section 6 of the Occupational Health and Safety Act 85 of 1993, "Every employer shall take all practicable steps to ensure the safety of employees while at work" 41 .The National Health Act No. 61 of 2003 also places responsibility on managers to ensure the safety of employees in the workplace. 13While legislation is in place, reports indicate that violence against emergency care providers is primarily initiated by patients and people known to the patient (family, community), which compromises health and safety. 42e South African EMS Safety Forum reported that an increase in assault, theft of personal belongings, theft of equipment and damage to ambulances has affected the morale of emergency care providers and caused a noticeable increase in resignations, transfer requests, and absenteeism.EMS personnel did not feel supported by executive management. 42iver safety, physical fitness and mental fitness have also emerged as health and safety issues:

• Physical fitness
The nature of EMS work requires a high level of physical fitness to perform strenuous tasks and emergency care providers who are not adequately prepared for this line of work increase their risk of injury.Mthombeni et al. 44 measured the physical fitness of emergency care providers in the North West Province and found that many participants were not physically fit to perform duties.The participants demonstrated a high body mass index and poor upper body and grip strength amongst other assessments.There was no evidence of physical fitness assessments or programmes in the other provinces.It may be generalised that emergency care providers in other provinces are also unfit to perform their duties.

• Mental fitness
Ntatamala and Adams 45 investigated the risk of Post-Traumatic Stress Disorder (PTSD) in emergency care providers in the Western Cape and found that this condition was prevalent in 30% of the respondents.PTSD and burnout were also found in a study in Limpopo 46 and paramedic trainees in Gauteng demonstrated high prevalence rates for PTSD (16%), depression (28%), alcohol abuse (24%) and alcohol dependence (8%) 47 .These studies show that dysfunctional coping mechanisms such as smoking, abusing prescription drugs, drinking alcohol and using illicit drugs were common to manage PTSD.In a similar study, Van Rooyen et al. 48ound a high prevalence of stimulant use amongst emergency care providers as a coping mechanism to overcome work-related stress, to stay awake and to improve physical and mental performance.
The impact of work-related stress, with or without substance abuse, compromises the health and safety of emergency care providers 44,45 and the performance of their duties 37,38,45,47 , which could affect the availability of ambulances and the quality of care afforded to patients.

Recommendations regarding health and safety:
• The PDOH Directorate for Employee Health and Wellness Programme needs to improve EMS participation in wellness programmes and ensure access to Employee Health and Wellness practitioners.

•
The PDOH, guided by the South African EMS Safety Forum, needs to urgently develop and implement strategies to reduce attacks on emergency care providers.

Theme 5: Training
In South Africa, emergency care providers hold qualifications from institutions that provide skills-based short-course training or from higher educational institutions that offer diplomas and degrees. 9'Short-course training' ended as it was not compliant with the National Qualifications Framework Act (NQF).The EMS colleges are now guided by the National Emergency Care Education and Training Policy, which aims to "align emergency care education and training with current education legislation, national education and training needs…" 6 .
The Higher Certificate in Emergency Medical Care (1-year programme) and the Diploma in Emergency Medical Care (3-year programme) are two new courses that have replaced short-course training.EMS colleges wanting to provide these NQF-accredited courses must be registered as higher education colleges, which requires accreditation with the Council on Higher Education, South African Qualifications Authority, and the HPCSA. 6,49The accreditation process has been slow, with only two of the nine provincial colleges receiving provisional accreditation. 49In the interim, some provincial and private colleges have partnered with public universities such as the University of Johannesburg and Cape Peninsula University of Technology which offer one or both of these new courses. 49he transformation in EMS training is a necessity to promote lifelong learning; however, many emergency care providers are struggling to meet the new course entry requirements. 49Emergency care providers' morale may therefore be low due to lost academic and career progression.
Programmes and discussions are ongoing in an effort for emergency care providers to meet the course entry requirements. 49ile the accreditation process in EMS training continues, emergency care providers are required to attend training to keep abreast of current evidence-based clinical practice 50 ; however, we found poor compliance amongst emergency care providers in attending clinical update training.These findings appear to be correlated with the poor knowledge of emergency care providers described earlier.In 2019, the HPCSA released the new clinical practice guidelines that significantly increased the scope of practice of emergency care providers. 6Emergency care providers were required to attend and complete the clinical practice guidelines training; however, compliance with this directive is unknown.

Recommendations regarding training:
• PDOH needs to develop and implement strategies to assist their provincial EMS colleges in achieving accreditation as higher educational institutions.This will enable emergency care providers to access new qualifications, thereby increasing their scope of practice and standard of care.

Theme 6: Communication systems
Access to emergency services such as the police, the EMS, the fire department, and sea rescue has been traditionally through contacting their respective telephone numbers.A short code number -112, the legislated emergency number for EMS -was launched in October 2019 and may now be used to access any of the emergency services in South Africa. 10The 'old' EMS emergency number (10177) will be phased out through a process of government notice.
The dispatching system used by EMS varies between provinces and ECCs, making integration impossible and information not directly accessible by the NDOH.The disparity also exists due to varying standard operating procedures, technology, infrastructure, and staffing. 10There are no nationally accepted criteria for ECC call handling and dispatch processes.
Studies have identified this component as one of the problems within EMS. 13,25,36,51 In a study by Lambert and Wade 51 , respondents described the ECC as ineffective, due to problems such as unanswered calls, call takers not understanding basic medical terminology, and poorly co-ordinated inter-facility transfers.
Stander et al. 37 noted that challenges with the ECC dispatching system were one of the barriers to managing behavioural emergencies.Similarly, a study by Alshehri et al. 52 53 The ECC appears to be plagued with various issues that contribute to its less-than-satisfactory role within EMS.
Recommendation regarding communication systems:

Limitations
Firstly, despite the operation of EMS and its colleges in all provinces, the research articles available did not represent every province.As a result, official reports and government records were used to provide evidence for those provinces.Secondly, most articles focused on provincial EMS, while some articles had a mix of private and public EMS participants.Based on the principle of generalisability, our findings may represent only provinces with similar EMS challenges and geographical settings.Thirdly, we did not explore planned patient transport, inter-facility transfers, the role of EMS in disasters, ground rapid response services, or medical rescue services.These are also core services provided by EMS and require further study.Lastly, this review focused only on South African EMS studies, as context was needed for the development of a subsequent study.

relevance of the study
In a study regarding the state of EMS in Africa, Mould-Millman et al. 54 , citing the WHO 55 and Lopez et al. 56 , stated: People in Africa bear a disproportionate burden of preventable and excess deaths before arrival at a health facility -the pre-hospital setting -even when compared to low-and middle-income countries on another continent. 54e study found that fewer than one in three African countries had an EMS system in place, and, where EMS systems existed, they were "inadequate to meet the demands of the population" 54 .The relevance of the current study is that it adds to the body of knowledge of an African EMS system and provides an opportunity for other African countries to mitigate their approach in developing or modifying their EMS systems, thereby contributing to universal health coverage and outcomes.

Conclusion
The WHO Health Systems Framework provides key components (building blocks) of a functional health system.This study found that all components applicable to the EMS system are not functioning optimally, thereby contributing to the apparent constrained state of EMS.The six themes that emerged from the articles were: leadership and governance; resources; emergency care provider preparedness; health and safety; training; and communication systems.Challenges were found in all themes at a provincial EMS level, despite improvements in legislation, leadership, and governance by the NDOH.The evidence suggests that the EMS system is not adequately fulfilling its role in the Integrated Healthcare Delivery Platform in South Africa -a finding which requires further study and urgent intervention by the NDOH.Greater leadership and governance, especially from the provincial and district health levels, are required to improve poorly functioning components of the EMS system to ensure that the state of EMS improves.

Association to other research
This study was designed to provide information on the current state of EMS, to provide background and context to a current doctoral study regarding the management of obstetric haemorrhage by emergency care providers in the KwaZulu-Natal Province.

Figure 1 :
Figure 1: Modified Integrated Healthcare Delivery Platform.Source: South African Department of Health 4 ; reproduced under a non-exclusive licence for educational and informational purposes

Figure 2 :
Figure 2: Flow diagram showing literature search, screening and search process.

table 2 :
16gulations relating to standards for emergency medical services (EMS)16 All emergency care providers need to be audited to determine compliance with the Health Professions Council of South Africa's (HPCSA) Continuing Professional Development policy.•Training plans ought to be developed and implemented through collaboration between the provincial EMS, College of Emergency Care, and Human Resource Development structures.EMS standards requirementsPatient rights • Dignity of patients, information for patients, stakeholder satisfaction surveys, complaints management Clinical governance and clinical care • Patient health records, clinical management of emergency care provision, dispatch of emergency vehicles, response management, clinical leadership and clinical risk, inter-facility transfers, planned patient transport services, patient safety incidents, prevention and control of infections, waste management https://doi.org/10.17159/sajs.2024/16138Review Article • Future studies are required to investigate the relationship between selection, recruitment and development and the preparedness of emergency care providers.