Emergency medical services in Ethiopia: Drivers,challenges and opportunities

Abstract

BACKGROUND:

Ethiopia has a well established health care system but lacks significant improvements on emergency medical services and suffers a shortage of equally initiative among all regional states and city administration of Ethiopia. This study aimed to examine the drivers, challenges, and opportunities of Emergency Medical Services (EMS) and to identify new evidence for future policy making in Ethiopia.

METHOD:

A narrative review of the literature related to EMS was undertaken to describe the drivers, challenges, and opportunities for EMS in Ethiopia from July, 2000 to September, 2018. The search was done from four relevant electronic databases: MEDLINE, Science Directs, Scopus and PubMed by using Google Scholar and Google with key search words used mainly as “Emergency Medical services in Ethiopia”. The inclusion criteria were an original study or review studies involving Emergency Medical Services in Ethiopia. Among the available papers, the relevant articles were selected while the irrelevant ones were excluded.

RESULTS:

There was lack of trained emergency medical providers and misdistribution of trained professionals, immaturity of the program, lack of partnership and stakeholders and lack of motivation towards Emergency medical services. Emergency medical services hamper significant problems similar to other African countries that required being addressed in Ethiopia context for achieving the program and in order to obtain intended outcomes for the country.

CONCLUSION:

A long-term discussion is needed to further improve the services system in various health care facilities. An Emergency Medical services policy making and analysis framework is needed to make quality emergency medical care at Emergency department in hospitals and outside the hospitals.

Keywords

Emergency medical services challenges opportunities Ethiopia

1. Introduction

Emergency medical services provides a vital benefits to the community around the world nations. Hence, it is a system which provides urgent emergency medical care in response to individual and mass health and health related emergencies. For instance, most of motor vehicle crashes and other types of injuries related to intentional and unintentional accidents are commonly registered [1]. Evidence shown that emergency medicine is still youngest discipline globally. Moreover, the program is immatured in the developing countries [2].

According to world health organization Global burden of diseases (2008) found that the total mortality rate regarding to injuries and other related violence were estimated about 5.1. Million people in 2008 [3]. It indicated that injury is one of the most critical countries. Hence, road traffic crashes, fall and drowning had been reached about 9% of world health in 2012 [4].

The community’s who are critically ill and injuries has passed to an acute and emergency medical care as person by itself or group of population that facing the seriousness of the issues [5]. Emergency medical services such as emergency treatments including medicine and well- designed emergency medical department also vital portion of general health care delivery systems [6].

Now a day, the public health management system is significantly changed when compared with EMS [7]. However, EMS such as pre-hospital emergency medical care, ambulance services, and at emergency department care system in hospitals has provided to improve the outcomes of Emergency situation [8].

In developing countries, Traumatic injuries have continuing as to be vital cause of increasing number of victims and deaths. For example, the burden of injury in Ethiopia is very high; however, there have not received attention to its incidence and health impact [9].

The formal pre-hospital care or at hospital emergency medical care centers is still a recent event in Ethiopia [2]. As a result, the government and other partners have started to give training for both Emergency Medical Technicians and paramedics in order to assist victims who injured due to traumatic accident, transport acutely critical ill or injured people to hospital and to provide advanced emergency medical care services [10]. Moreover, the infrastructure which supporting well –developed EMS and staffs is highly variables and odd in Ethiopia. Especially, many of regional State of Ethiopia, there is a rising gap between the type of emergency care equipment available in target health settings and that is in fact in utilize [11].

According to World health organization “The World Health Assembly, in Resolution 60.22, recommended improved organization and planning for provision of trauma and emergency care as an essential part of integrated health-care delivery.” [12]. Triage is used to ensure the most severely injured and ill patients receive timely care before their condition worsens [13]. However, Triage system need of urgent or emergency attention from among the larger number presenting to the emergency departments [14]. As an assessment parameter, triage scoring system and vital sign are not included at various emergency departments [15].

Evidence shown that less than 10% of the severely injured due to vehicle accidents and other critical illnesses has transported by ambulance. Moreover, about 5.5% cases permamanently disabled regarding to road traffic crashes [16]. It indicated that Ethiopia still having shortage of transportation system and other EMS program. In spite of the Ethiopian government attempts to minimize the severity of road traffic injuries and its magnitude, injury is increasing at an upsetting speed and constitute around half of all medical and surgical emergencies [17]. Few researchers also agreed that traumatic and non-traumatic injuries due to accident statistics including documentation systems in the country provides very little awareness on magnitude, severity and prevention of the emergency cases [18]. Therefore, this study aims to explore the drivers, challenges and opportunities for EMS in Ethiopia.

2. Methods

A narrative review was performed through searching peer-reviewed journal articles using databases such as MEDLINE, Science Directs, Scopus and PubMed that were published between July, 2000 to September, 2018. The resulting Boolean search string was as follows: (“Emergency Medical Services” OR “drivers” OR “Challenges” OR “Opportunities” OR “Policy making process” OR “Ethiopia”) AND (“Emergency Medical Services” OR “drivers”) AND (“Challenges” OR “Opportunities”) AND (“Policy making process” OR “Ethiopia”). Moreover, the combination of all key words (“Emergency Medical Services” AND “drivers” AND “Challenges” AND “Opportunities” AND “Ethi-opia”).

2.1 The drivers of EMS in Ethiopia

The health organization can benefit enormously from the use of emergency medical services. EMS is characterized by victims’ transportation, communication and saving life. The advantages of prehospital care including paramedic can improve the quality emergency care through protection of public health. Schooling of health specialists, facilitate collaboration among emergency medical services researchers and cost reduction for emergency care and ambulance services have roles to improve the quality emergency care in Ethiopia. EMS promises clinical care as core capabilities. Patient desire for pre-hospital care and communication with their health care providers is likely to change the course of both pre-hospital and emergency care at hospital. The health care reform, road traffic safety, financial consideration and aging population are the major drivers of EMS policy making in Ethiopia.

The Ethiopian Health Reform initiated in 2010 was one of the main factors that brought EMS to the policy Agenda in Ethiopia. The FMoH applied several measures to enhance and expand the quality and capacity of acute emergency care through a variety of efforts. In other words, it has laid the underpinning for Emergency medical services improvement. Hence, it helps policy makers provide continued reform efforts in the future and provides insight into possible levels of improvement in the health care system [19].

The Ethiopian Hospital Services Transformation plan highlighted the importance of EMS [20]. The guidelines have asked hospitals to implement triage for emergency medical care at hospital [21]. In 2010, a national hospital performance monitoring system was launch that incorporated 124 hospital management standards, several of which specifically mandated the conducting of emergency triage [22]. As a result, a significant improvement of EMS has been demonstrated at district, regional and national levels [23]. Governmental health care settings such as health posts, health centers, and hospitals at the regional and national levels are increasingly contributing to the EMS program. In addition, the private health sector is becoming active participant in the development of EMS program in the country [23]. The private health sector has plays vital role in expanded a networking system of health care facilities for emergency medical service system in Ethiopia. They are contributed widely to meet increasing health care demands, to mobilize resources, and to improve efficiency in health care system. Moreover, the sectors have also been contributing on improvement of efficiency, quality and health equity based on health care reform [24]. For instance, “Tebita Ambulance”, creates by Ethiopian nurse anesthetist Kibret Abebe, is the first private EMS Company in Ethiopia.

The sector has consisted 11 ambulances and most of the staffing necessary to make a difference in filling Ethiopia’s prehospital medicine needs. Tebita Ambulance uses grants and tiered pricing to offer quality emergency aid to people of all incomes and reduce the number of preventable deaths [25]. Tebita Ambulance collaborated with Weber State University professors are working to improve emergency medical care for people in need. This private sector has been also contributing on level of service Tebita keeps patients stable while transporting them to one of hospitals, access to ambulance services fast and easy for those in an emergency, reduce the burden on hospitals with limited bed space and offers first aid and paramedic training and sells well-equipped first aid kits [26].

The health reform improved the access to quality EMS, and reduced the cost for patients in the country [27]. Patients, policy makers and other key stakeholders are now more concerned about the quality emergency medical care centers [28]. Even though EMS is in its early stage of development in the country, it is currently a priority area of medical services.

The health policy implementation in these settings are characterized by assorted stakeholders, interaction between clients and health care providers’, evidence based researches and capability of policy makers. It helps to enhance the delivery of emergency care via continuation of life saving care with pre-hospital and hospital care. Moreover, staff motivation; increased number of partnerships, supporting research activities and collaborations with other sectors in the country’s might facilitates the improvement in the delivery of quality emergency care in Ethiopia [29].

Evidences in Ethiopia showed that government is now considering the application of national road safety and law to save life of the community. For instance, the Interim National Road Safety, coordination office and technical committee were established in 2002. Later on, the National Road Safety plan was approved. Furthermore, road fund office also allocated 3% of its annual collections for financing road safety programs at the national and regional levels in 2003. This amounts to 1 to 1.2 million dollars per budget year [40]. This indicated that the government has been concerned with the importance of safety program in the country. Hence, it could be expanded throughout the national regional state of the country and city administration. Regional Road Safety Committees established in some regions in 2004. In line, the program has been supported by government and other stakeholders. Overall, the Regional Road Safety Committees established in all regions, revised penal code issued and revised transport Proclamation issued in 2005. Now a day, almost all regions are now using this law to minimize the severity of road accident in the country [30].

Although Ethiopia has a low small vehicle per population ratio, the country is considered as one of highly affected by road traffic accidents [31]. According to Integrated Regional Information Networks (2011) report [32]. the fatality rate of accident victims in Ethiopia is estimated about halve of the current rate by 2020. As a result, Ethiopia has developed the National Road safety plan in 2011 [33]. Moreover; the government has provided first aid services to alleviate the emergency cases [32].

In Ethiopian context, health care services for elderly people are differing from health care services for other age groups. Evidence shown that the variation depends on economic status, social interaction, cultural, demographic condition and their need of health care. Hence, age is one of the determinants of health service utilization, although elderly populations are rare in Ethiopia [34].

2.2 The challenges of emergency medical services policy making in Ethiopia

Financial, governance, documentation, advocacy, Politics and Education are the major challenges of Emergency Medical Services policy making in Ethi-opia.

According to National Health Accounts, there is an increasing a total spending on health care system in Ethiopia. For example, the national health expenditures was projected to reach ETB 26.5 billion (US $1.64 million) in 2010/11. It has shown that the projection represents an ETB 15.4 billion (US $ 0.44 million) increase in the health share by 2010/11 compared with 2007/8 [35]. Even though the reform in health care financing have been implemented to increase health resources, protect the poor, and introduce equitable financing in the majority of the regions in Ethiopia, the government has had planned to increase HSDP IV target of growing the total health budget from 16.1 USD/Capita to 32.2 USD per capita in the country [29]. Evidence shown that still there is lack of sustainable funding for emergency medical services [29].

Health service utilization had been improved during the period of implementing Health sector development plan in Ethiopia. However, a number of obstacles continue to stand in the way of developing emergency medical services policy making. There has been lack of policy adoption by various health organizations. Besides, the ministry of health Ethiopia has never gives great attention on the adoption of EMS health policy making like other diseases preventive policy in the country. Most clients are still not aware that they may access specialists on EMS at health settings. The availability and efficiency of an adequate pre-hospital care system in Ethiopia is very limited [36]. Although the Ethiopian Ministry of Health has provided the access to the emergency medical services in the country, but the service utilization is still immature [37].

There is no enough emergency medical services datas with regard to the availability of resources and services that strengthen and institutionalize the emergency coordinators team activity. Consequently, it indicated that Ethiopia has poor documentation systems in Emergency Medical service program such as report, [34] researches and other relative evidence for policy making process.

Advocacy on Emergency medical services and short- and long-term training workshops are very important indicators to improve the health care systems. There was some EMS workshop which focused on how to make the right diagnosis but not on the principle of triage and emergency management [27]. The training was not quite enough and there had no standardized training or certification for Ethiopian emergency medical technicians [38]. The country lacks the basic infrastructures, facilities, equipments, and human resources for delivery of quality emergency medical services. Community involvement in emergency medical care system is needed to promote community awareness on the emergency care among community members. In fact, the community network is using the available community resources [39].

Road traffic accident risk factors such as head injury is the most common cause of morbidity and mortality in various cities in Ethiopia. As a result, it has arisen the severity and magnitude of trauma but also it is one of the challenges to population regarding developing emergency systems in the country [40]. However, there is lack of well-developed accessory services such as ICU and trauma units [41]. Moreover, inadequacy of basic infrastructure in the health systems is also the major factors to deliver emergency care for communities in the country [42]. High car accidents, less demand for ambulance services, shortage of skilled or trained emergency medicine personnel, and lack of resources was identified as critical issues related with EMS in the country. However, both”Tebita Ambulance” and those partners university, Weber state University (the one that started community life saving work with Ethiopian emergency medical sciences) are working together to improve the emergency medical services in order to satisfy the clients in need of critical care [43].

The high demand for acute care services is one of the most common challenges of emergency medical services policy making in Ethiopia [8]. Few research findings show that shortage of skilled health care providers is critical problem [44], for example, trained emergency medical providers [41].

Overall findings shown that the burden of trauma, infectious and chronic diseases is high in Ethiopia. Due to poor health care access for numerous reasons, including long distances to hospitals, limited transportation, limited ability to pay for care and a severe human health resources (HHR) shortage, patients often present for care in Extremis, at late stages of illness and post-injury, making quality emergency care provision imperative [45].

2.3 Opportunities for emergency medical services in Ethiopia

Currently, democratization, and political commitments, decentralization leading to better EMS decision and actions, external funding opportunities, partnership with international institutes and universities, increase economic growth and development and EMS and health system reforms Initiative are most commonly expected opportunities to develop quality EMS in Ethiopia.

Recently, political commitments have becoming to improve quality health care system. Specially, the government of Ethiopia and Ministry of Health has planned to develop well-organized EMS. In 1952, ERCS has started emergency care transportation including emergency ambulance services, pre-hospital services delivery for victims or acute ill-persons and other by Standers training in Ethiopia. Even though there are no specific equipped and staffed emergency centers to provide critical care for prolonged period of time [46], ERCS was continued to develop the EMS program in some of the border area of Ethiopia. Hence, there has been an opportunity to established emergency health care centers to provide quality EMS in Ethiopia [47].

Another opportunity is decentralizations leading to better EMS development decision and action. Evidence shown that there have been a long history of supporting health financing reform initiatives to improve quality of health delivery via decentralized budgeting, financial management systems and effective use of health resources at the health facility level [48]. There had been tradition of centralist authorian governments in Ethiopia before 1991 [49]. However, Federal Democratic Republic of Ethiopia is established by Constitution which consisting of nine regional States, and two city administration (Addis Ababa and Dire-Dawa) [50]. Hence, the legal framework based on Constitution has enabled freely participation of the regional States in matters that concern them [51]. Moreover, each regional State of Ethiopia and city administration have developed specific “City Proclamation” that specify the powers, duties and responsibilities of the cities [51].

In Ethiopia, there has many way of financing resources for health sectors. Most of these are depends on the government treasury such as federal, regional and woreda/district levels. Moreover, bilateral and multilateral donors, household out-of-pocket expenditure, international and local non-governmental organization (NGOs), private and parastal Employers, and Insurance Companies. Nearly half of Ethiopian health care expenditure comes from the rest of the world, followed by household expenditure and government expenditure [52].

In Ethiopia, partnership with internal institutes and universities are found that strong and unanimous openness to collaboration for system-wide research. One of the strong opportunity from the FMoH were both essential in establishing institutional trust and network support [53]. Research finding indicated that there had made significant improvement of training of key emergency medical personnel. However, a lot of work remain and there has numerous opportunities exist to make further improvements in EMS training in Ethiopia [27]. Due to this opportunity, Ethiopia had enjoyed a growing and developing economy status with an increasing the country’s health care infrastructure and overall health care coverage’s [54]. Evidence shown that the life expectancy of the Ethiopian population is increasing significantly due to absolute changes in diseases epidemiology and transition [55, 56]. Even though the majority health problems in Ethiopia were preventable communicable diseases and nutritional disorders since decades [57], currently non-communicable disease and injuries are becoming major concerns in the country [58].

Regarding health care systems including EMS the current health care reforms have contributed to help health policy makers who able to continued efforts towards reforms in the next decades. Because, it might have succeeded or failed with various factors; however, it is critical opportunity for quality health care services in the country [19].

For instance, some of the stakeholders like Ethiopian Red Cross Society have working on EMS and coordinated pre-hospital emergency ambulance services. Now a day, there is increasing the number of ambulance Stations, ambulance vehicles, and beneficiaries. Evidence shown that there is a total of 215 Red Cross Ambulance Stations, 308 ambulances vehicles/year and more than 300,000 beneficiaries could be delivered by ERCS [47].

The Ethiopian health care reform is contributing to allocate many service partners, for example, some of services partners more than 50,000 ETB/year for health care services operational cost in Ethiopia. In addition, Tebita ambulance private sector also has contributed on the development of EMS. Besides, this private sector has currently consists 11 ambulances and a total of 63 employees [59] another opportunity there is increasing number of first emergency and paramedical training centers. Specially, Addis Ababa, capital city of Ethiopia had good opportunities to improve EMS. Tebita ambulance is officially launched various types of emergency services in Addis Ababa and it has provided emergency ambulance services to more than 40,000 clienets and emergency medical care short and long term training to more than 25,000 trainees in Ethiopia. It indicated that a health care reform helps to improve quality health care delivery system including EMS [59].

Moreover, the Ethiopian traffic accident control system has achieved data and overall information on various aspects of the traffic system which includes traffic systems which includes traffic volume, concentration and vehicle accidents [60]. There is neither strictly enforces speed limits on Urban roads nor controls blood alcohol levels in drunk-driving. However, there are some laws on road safety management towards a major risk factors in Ethiopia [61]. There are also another multi-sectoral and combined enforcement strategies opportunities that are the most efficient way to respond to the crisis due to road accident [62].

2.4 Future directions

The study findings shown that there is lack program maturity. Therefore, the Ethiopia Ministry of health should be considered how short and long term plan must link to develop well-organized and matured EMS program in the country. Moreover, pre-hospital care system in Ethiopia is increasingly fragmented. Therefore, the Federal Democratic Republic of Ethiopia government should support to integrate, standardize and coordinated the pre-hospital services with over all EMS program at health settings.

These results indicated that Ethiopia’s Emergency Medical Services are complicated and have shortage of emergency care specialist as pre-hospital care services and emergency center at hospital level. Hence, the Minstry of health should be collaborated with various stakeholders in order to design appropriate long time study and sufficiently trained health professionals on EMS. In general, the study findings shown that economic difficulties are one of the major problem to develop EMS program in the country. Therefore, the Government should be secured additional funding for short and long term EMS training.

3. Conclusion

The results of this study showed that there is a need for Emergency medical services development in Ethiopia and around all Rural and Urban areas in order to find over all non-communicable diseases and injuries related to accident and emergency cases in the country. Moreover, still it required the continuity of an effort and policy advocacy to motivate, develop and sustain contemporary EMS program in Ethiopia. Regarding for well-developed and designed Emergency medicine Guideline and strategic plan, the Ethiopian Government should be given an attention to mature this new program. Finally, all stakeholders such as higher educational Institutes, Minstry of health and other relevant stakeholders must be provided EMS training and long time specialist program to ensure a local and national applicability and sustainability of the services in the country.

Furthermore, the health policy makers may guide in all hospitals levels in improving strategic plan and policy implementation on EMS and the prioritization of emergency cases and community health care needs in future development. Therefore, a comprehensive health policy making and analysis framework implementation is urgently needed to minimize the risk related with policy making process in the country.

Footnotes

Conflict of interest

The authors declare that they have no competing interests.

Authors’ contributions

Addis Adera Gebru conceived and designed the study participated in all stages of data extraction and synthesis, and provided supervision of Ali Mohammad Mosadeghrad and Ali Akbari Sari. Conducted an initial literature scoping exercise and synthesis together, collated and summarized articles under close supervision of Addis Adera Gebru. Addis Adera Gebru, Ali Mohammad Mosadeghrad and Ali Akbari Sari and MIkiyas Amare Getu drafted different sections of this review paper, and Addis Adera Gebru revised the paper as a whole and contributed to revisions and the final version of the manuscript. MIkiyas Amare Getu contributed to the early design concepts for the narrative review of the manuscript. All authors contributed revising various version of the manuscript. Moreover, all authors read and approved the manuscript.

References

Van Milligan

Mitchelkl III

J.P.

Tucker

and Caravalho

, An analysis of prehospital Emergency medical services as essential services and as a public good in Economic theory [Report No DOT HS 81000a], Washington DC: National Highway Traffic safety Administration, USA, 2014.

Azazh

Teklu

Woldetsadi

Seyoum

Geremew

Busse

Tefera

Wubben

Rankin

Tupesis

J.P.

Maskalyk

Landes

Mehari

and Derbew

, Emergency medicine and its development in Ethiopia with emphasis on the role of Addis Ababa University, School of Medicine, Emergency Medicine Department, Ethiopian Medical Journal (Suppl2) (2014), 1–12.

World Health Organization, Health systems: Emergency care systems, WHA 60.22. Geneva, Sixteenth World Health Assembly (2008), 21–3.

Bartolomeos

Kipsaina

Grills

Ozanne-Smith

and Peden

, Editors, Fatal injury surveillance in mortuaries and hospitals: A manual for practitioners, Geneva: World Health Organization, 2012.

Mould-Millman

N.K.

Naidoo

de Vries

Stein

and Wollis

L.A.

, AFEM Consensus conference, 2013, AFEM out-of hospital Emergency care Workgroup Consensuses Paper: Advancing out-of–hospital emergency care in Africa-advocacy and development, Africa Journal Emergency Medicine 4(2) (2014), 90–95.

Nicks

Spasive

and Watkins

, The state and future of emergency medicine in Macedonia, World Journal of Emergency Medicine 7(4) (2016), 245–250.

Zhe

Chan

E.Y.Y.

Liu

K.S.

and Yeung

M.P.S.

, The Disaster and Emergency management system in China: Collaborating center for Oxford University and CUHK for disaster and medical Humanitarian Response (CCOUC), The Chinese University of Hong Kong: Policy Brief, China, 2016.

Mould-Millmon

N.K.

Rominiski

S.D.

Bogus

Ginde

A.A.

Zakariah

A.N.

Boatemaah

C.A.

Yancey

A.H.

Akoriyea

S.K.

, and Campbell

T.B.

, Barriers to Accessing Emergency medical services in Accra, Gahana: Development of a survey instruments and initial application in Ghana, Global Health Sciences and Practice 3(4) (2015), 577–590.

Negussie

Getie

Manaye

and Tekle

, Prevalence and outcome of injury in patients visiting the emergency Department of Yirgalem General Hospital, Southern Ethiopia, Bio Medical Center Emergency Medicine 18(14) (2018), 1–5.

10.

Valencia College, Emergency medical services Technology: Associate in Sciences, 2018 http://nets1.valenciacollege.edu/future-students/degree-opiton/associates/emergency-medical-services-technology/[AccessedApril,05,2018].

11.

Eastern Maine community College, Emergency medical services, At the Crossroads in 2007: Chapter 5 advancing infrastructure, 2018. http://www.nap.edu/read/11629/chapter7[AccessedApril,05,2018].

12.

World Health Organization, Sixtieth world health assembly, Resolution WHA 60.22: Agenda item 12.14. Health systems: Emergency-care systems, 2014. http://www.who.int/gb/ebwha/pdf_files/WHA60/A60_R22-en.pdf[accessedJanuary17,2014].

13.

Rominski

Bell

S.A.

Oduro

Among

Oteng

and Donkor

, The implementation of the South African Triage Score (SATS) in an urban teaching hospital, Ghana, African Journal Emergency Medicine 4(2) (2014), 71–75.

14.

Buys

Muloiwa

Westwood

Richardson

Cheema

and Westwood

, An adapted triage tool (ETAT) at Red Cross War Memorial Children’s Hospital Medical Emergency Unit, Cape Town: An evaluation, South African Medical Journal 103(3) (2013), 161–165.

15.

Widgren

B.R.

, and Jourak

, Medical emergency triage and treatment system (METTS): A new protocol in primary triage and secondary priority decision in emergency medicine, The journal of Emergency Medicine 40(6) (2011), 623–628.

16.

Federal Democratic Republic of Ethiopia Ministry of Health, Health Sector Transformation Plan 2015/16–2019/20 (2008–2012 EFY), 2015. http://www.moh.gov.et/documents/26765/0/Health+Sector+Transformation+Plan/5542a23a-9bc7-46a2-8c1f-8b32c2603208?Version=1.0[AccessedOctober,2015].

17.

International labor organization, estimating the economic costs of occupational injuries and illnesses in developing countries: Essential information for decision-makers, Geneva: European Union, ILO, 2012.

18.

Woldemichael

and Berhanu

, Magnitude and pattern of injury in jimma university specialized hospital, South West Ethiopia Ethiopian Journal Health Science 21(3) (2011), 155–166.

19.

Manyazewal

Matlakala

M.C.

, Implementing health care reform: Implications for performance of public hospitals in central Ethiopia, Journal Global Health 8(1) (2018), 010403.

20.

Federal Democratic Republic of Ethiopia Ministry of Health, Annual Performance Report Health Sector Transformation Plan-I; Chapter 4 Quality Improvement and Assurance: Quality Improvement: Hospital Reform Ethiopian Hospital Reform Implementation Guidelines (Ehrig) Revision EFY 2009 (2016/17) Version 1, 2017. https://www.itacaddis.Org/docs/2017_11_10_09_48_31_ARM%202017.compressed.pdf [Accessed June, 30, 2018].

21.

Ministry of Health. Ethiopian Hospital Reform Implementation Guidelines, Addis Ababa, Ethiopia, Volume 1/2, 2010.

22.

McNatt

Linnander

Endeshaw

Tatek

Conteh

and Bradley

E.H.

, A national system for monitoring the performance of hospitals in Ethiopia, Bull World Health Organ 93(10) (2015), 719–726.

23.

Benin-Goren

Halperin

Amir

and Tesfay

M.B.

, Establishment of emergency medical services in Addis Ababa, Ethiopia: 20th International Symposium on Intensive Care and Emergency Medicine, Critical Care 4(Suppl 1) (2000), 197.

24.

Nair

V.D.

Morankar

Jira

and Tushune

, Private Hospital Sector development: An exploratory study on providers perspective in Addis Ababa, Ethiopia, Ethiopian Journal Health Sciences 21(Suppl 1) (2011), 59–64.

25.

Robertson

, Weber state university and Ethiopian EMS work together to save lives, Weber State University, Dumke college of Health Professions, Orden, Utah, 2018.

26.

United State Agency International Development from American People (USAID), UKaid, Tebita Ambulance and pre-hospital Emergency medical services, The Strengthening Health Outcomes through the Private Sector (SHOPS) project, Abt Associates Inc, USA, 2015.

27.

Germa

Bayleyegne

Kebede

Ducharme

and Bartolomees

, Emergency medicine development in Ethiopia: Challenges, progress and Possibilities, African Journal of emergency Medicine 3(1) (2013), 3–9.

28.

O’Neill

, Building emergency medicine in Ethiopia, International Development research Cenetre, University of Toronto; TAAAC-EM project, Canada, 2016.

29.

Ministry of Health Ethiopia, PMNCH, WHO, World Bank and AHPSR, Participants in the Ethiopia multistakeholder policy review, Success Factors for Women’s and Children’s Health: Ethiopia, 2015.

30.

United Nations Economic Commission for Africa, Road safety in Ethiopia, case study final report: ECA/NRID/019, 2009 [Accessed August, 20, 2017].

31.

World Health Organization, Global status report on road safety: Time for action.Geneva, Switzerland: WHO, 2009.

32.

Integrated Regional Information Networks (IRIN), Government moves to address road- accident toll, Addis Ababa, Ethiopia, 2011. https://reliefweb.int/report/Ethiopia/government-moves-address-road-accident-toll[AccessedJune,26,2018].

33.

Asefa

Assefa

and Tesfaye

, Magnitude of, trends in, and associated factors of road traffic collision in central Ethiopia, BioMedical Center Public Health 14 (2014), 1072.

34.

Amente

and Kebede

, Determinants of health service utilization among older adults in bedele town, Illubabor Zone, Ethiopia, Journal Diabetes Metabolism 7(11) (2016), 1–7.

35.

Ethiopia Federal Ministry of Health, Ethiopia’s Fifth National Health Accounts Highlight of Major Findings Briefing Notes, Addis Ababa, Ethiopia, April 2014.

36.

World Health Organization, Global Status Report on Road Safety 2015” (PDF) (official Report), Geneva: World Health Organization (WHO), pp. Vii, 1–14, 75 ff (Countries, 264–271) (table A2), 316–332 (table A10). ISBN 978924 1565066 [Accessed July, 20, 2018].

37.

Tsegaye

Abdella

Ahmed

Tadesse

and Bartolomeos

, Pattern of fatal injuries in Addis Ababa, Ethiopia: A one-year Audit East and Central African Journal of Surgery 15(2) (2010), 10–7.

38.

Ethiopian Red Cross Society, Ambulance and First Aid Service, 2012, http://www.Redcrosseth.Org/resource/ambulance-and-first-aid-service [Accessed November, 20, 2017].

39.

Beharu

Bekele

Birhanu

and Yimamam

, Cultural sensitiveness in Healthcare delivery of Jimma University specialized and Teaching hospital, South west Ethiopia, 2016, Quality in Primamry Care 25(3) (2017), 109–128.

40.

Landes

Venugopal

Berman

Haffernan

Maskayk

and Azazh

, Epidemiology, clinical characteristics and outcomes of head injured patient in an Ethiopian emergency centre, Africa Journal of Emergency Medicine 7(3) (2017), 130–134.

41.

Landes

Maskalyk

Hunchak

and Fremes

, Partnering to establish emergency medicine in Ethiopia: Development, implementation and evaluation of a postgraduate residency training program at Addis Ababa University, Ethiopia: Final Technical Report. Wilson Centre, University Health Network, 2014.

42.

Fikire

Bayeleyegne

Kebede

Ducharme

and Bartolomeos

, Emergency medicine development in Ethiopia: Challenges, progress and possibilities, African Journal of Emergency Medicine 3(1) (2013), 3–9.

43.

Robertson

, Weber state university and Ethiopian emergency medical sciences work together to save lives, Weber state university, Duke College of health professions, 2017. http://www.weber.edu/CHP/Ethiopia.EMS.html [Accessed October, 29, 2019].

44.

Philpott

and Derbew

, Use of a Continuing Medical Education (CME) workshop to introduce and promote the specialty of family medicine in Ethiopia, African Journal of promotion health care Family Medicine, North America 2(1) (2010), 1–3.

45.

Meshkat

Teklu

Hunchak

and On behalf of TAAAC-EM and the Global Health Emergency Medicine (GHEM) organization at the Division of Emergency Medicine, University of Toronto, Design and Implementation of a postgraduate curriculum to support Ethiopia’s first emergency medicine residency training program: the Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM), Bio Medical Center Medical Education 18 (2018), 71.

46.

Weingart

S.D.

Sherwin

R.L.

L Emlet

Tawil

Mayglothling

and Rittenberger

J.C.

, Emergency department intensive care units American Journal Emergency Medicine 31(3) (2013), 617–620.

47.

Ethiopian Public health Institute, Ethiopian providing Emergency medical services to Returnees from Djibouti, Addis Ababa, MoH, Ethiopia, 2018.

48.

United State agency for international Development (USAID), Government of the United States of America: Ethiopia: Financing reform aims to improve quality of health services, 2009. http://reliefweb.int/report/ethiopia/ethiopia-finanacing-reform-aims-improve-quality-health-services[AccessedOctober,29,2018].

49.

Chaury

and Mukim

, Decentralization in Ethiopia: Who benefits? 101709. Open Knowledge, World Bank Organization, 2015.

50.

World Bank’s Ethiopia, Local Government Revenue study, Addis Ababa, Ethiopia, 2014.

51.

Shiferaw

Soderbom

Siba

and Alemu

, Road infrastructure and enterprise dynamics in Ethiopia, Working Paper 129, 2013.

52.

Federal Ministry of Health, Emergency medical services timely delivery of life saving medical interventions Federal MOH 16th national Annual Review meeting group discussion, Medical service directorate, Addis Ababa, Ethiopia, October 2014.

53.

Silvestri

Abebe

and Dida

, 194 EMF forging a locally driven public sector emergency care research network in Ethiopia, Annals of Emergency Medicine An International Journal 70(4) (2017), S78.

54.

Central Statistical Agency (CSA) [Ethiopia] and ICF, Ethiopia Demographic and Health Survey 2016, Addis Ababa, Ethiopia (CSA), and Rockville, Maryland, USA (ICF), July 2017.

55.

Abraham

, Minimizing preventable deaths: The “Should Be” focus in Ethiopian health system, Ethiopian Journal Health Science 24(2) (2014), 100.

56.

World Health Organization, Global status report on non-communicable diseases 2014, Geneva, World Health Organization Press, 2014.

57.

Misganaw

HailemMariam

and Araya

, The double mortality burden among adults in Addis Ababa, Ethiopia, 2006–2009, Prevention Chronic Diseases 9 (2012), E84.

58.

Getachew

Ali

Tayler-Smith

Hedt-Gauthier

Silkondez

Abebe

et al., The burden of road traffic injuries in an emergency department in Addis Ababa, Ethiopia, Public Health Action 6(2) (2016), 66–71.

59.

Pillsbury

, Tebita Ambulance providers a persuasive example of the important role that social enterprise can play in support of the sustainable development Goals: Award winning Ethiopian social enterprise saves lives and wins minds, 2016, http://www.whysgbs.org.Tebita-ambulance [Accessed October, 29, 2018].

60.

Beshah

and Hill

, Mining Road traffic accident data to improving safety: Role of road related factors on accident severity in Ethiopia 2016, pp. 14–20.

61.

World Health Organization African Region, Road safety in the WHO African Region: The facts 2013. Brazzaville; WHO/AFRO, 2014.

62.

Chisholm

and Naci

, Road traffic injury prevention: An assessment of risk exposure and intervention cost-effectiveness in different world regions, HSF Discussion paper, Geneva; WHO, 2008.