Prehospital Medicine in Zanzibar

Emergency Medical Service (EMS) is provided by a variety of individuals, using a variety of methods. To some extent, these are determined by country and locale, with each individual country having its own ‘approach’ to how EMS should be provided, and by whom. In some parts of Europe, for example, legislation insists that efforts at providing Advanced Life Support (ALS) services must be physician-led, while others permit some elements of that skill set to specially trained nurses but have no paramedics. Elsewhere, as in North America, the UK and Australia, ALS services are performed by paramedics, but rarely with the type of direct “hands-on” physician leadership seen in Europe.

The goal of emergency medical services is to either provide treatment to those in need of urgent medical care, with the goal of satisfactorily treating the malady, or arranging for timely removal of the patient to the next point of definitive care. This is most likely a Casualty at a hospital or another place where physicians are available. The termEmergency Medical Service (EMS) evolved to reflect a change from a simple transportation system (ambulance service) to a system in which actual medical care occurred in addition to transportation. In some developing regions, the term is not used, or may be used inaccurately, since the service in question does not provide treatment to the patients, but only the provision of transport to the point of care.

In Zanzibar, EMS is a relatively new concept, where the most dominant model is the Emergency transportation services. As of December 2021, more than 630 ambulances are operating under Ministry of Health across Zanzibar. Some other islands use conventional boat as ambulance boat, and some agencies operating the EMS in Zanzibar as for basic transportation services (without stabilization care) in the PPP mode through multiple agencies (mostly NGOs,) contracted at district/block level.

Various studies, including a review by the health ministry found the following gaps in the existing EMS in Zanzibar:

  • Hospital infrastructure, especially in public hospitals, for treating and managing medical emergencies need further strengthening.
  • Lack of training and training infrastructure for training health staff (public or private) and other stakeholders in medical emergency management/first aid. 
  • Fleet of existing government owned ambulances not liked in terms of operational linkages and standardization across fleet.
  • Legal framework defining and regulating roles and liabilities of various stakeholders (like ambulance operators, emergency technicians, treating hospitals and staff, etc.) needs further clarity/transparency, standardization and enforcement across the Zanzibar.

Keeping in view the above-mentioned gaps, the proposed EMS for Zanzibar would necessitate focusing on the following components, as a necessary part of the system:

  1. Ambulance – operations and maintenance
  2. Call Centre – for ambulance dispatch and control
  3. Empanelled health facilities/hospitals – ensuring quality of care.
  4. Information System and Knowledge Management – using multi-media and multi-channel data management.
  5. Training – for emergency case management on-site, in-transit, and in hospitals
  6. Health Education – among general public
  7. Legal framework – to define roles and liabilities of various stakeholders.
  8. Governance – for transparency and regulation

Regarding the financial implications of a national EMS, it was estimated that Operating cost, at current level of operations and prices, is approximately US$ 18,037.63 to US$ 20,442.64 per ambulance per year (including an annualised capital cost of Rs.  US$ 3,607.86 to US$ 6,013.10 per year). These costs could be expected to rise further. Thus, the currently estimated US$ 56,743,450 required per year for a projected fleet of 2,500 ambulances needed nationwide (accounting for around one ambulance per 25,000 population) could finally be two to three times this amount. In a scenario where the commitment to raise health care expenditure to 3% of the GDP is adhered to, this US$ 56,743,450 to US$ 100,135,500 commitment would help reach this goal. These cost estimates do not include financial implications of increased training and health education, and infrastructure strengthening needed for public hospitals for managing medical emergencies.

The proposed EMS would also need to have linkages with existing ambulance fleet of the Zanzibar. The existing fleet of government owned ambulances, especially at secondary and tertiary level hospitals may be converted to Advanced Life Support (ALS) standard, exclusively for inter-institution transfers. Integration of EMS would also be needed within the framework of Ministry of Health to establish links with identified hospitals to provide emergency care and also for payments through Zanzibar Health Service Fund. On the other hand, facility upgradation in public hospitals for trauma units, ICU/CCU, blood bank, etc., may be undertaken under Ministry of Health Zanzibar.

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