Prehospital Research in SubSaharan Africa - Wiley Online Library

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services (EMS) inventory or assessment has been con- ducted, the literature ... is a critical step in the advancement of the field.18 The AFEM 2011 consensus.


Prehospital Research in Sub-Saharan Africa: Establishing Research Tenets Nee-Kofi Mould-Millman, MD, Scott M. Sasser, MD, and Lee A. Wallis, MBChB

Abstract Prehospital care constitutes an important link in the continuum of emergency care and confers a survival benefit to injured and ill persons. As development of acute and emergency care in sub-Saharan Africa expands, there is a strong need to improve the delivery of prehospital care to help relieve the overwhelming regional morbidity and mortality attributable to time-sensitive, life-threatening conditions. Effective research is integral to prehospital care development, as it helps quantify the need for prehospital care and tests effective solutions. Unfortunately, there is limited consensus guiding such research in the low-resource nations of sub-Saharan Africa that face unique challenges. This article aims to assimilate the current pertinent literature to demonstrate research success stories and challenges, and ultimately to build on previous efforts to establish prehospital research priorities for sub-Saharan Africa. Region-specific obstacles hindering prehospital research include the lack of epidemiologic data on emergency conditions, the underdevelopment of in-hospital emergency care, confusing prehospital terminology, poorly defined prehospital research priorities, the lack of qualified local prehospital researchers, and a poor understanding of local prehospital care systems. Solutions are offered to overcome each challenge by building on previous recommendations, by proposing new guiding principles, and by identifying areas where further consensus-building is needed. These guiding principles and suggestions are designed to steer discussions and output from future global health meetings targeted at improving prehospital research and development in sub-Saharan Africa. ACADEMIC EMERGENCY MEDICINE 2013; 20:1304–1309 © 2013 by the Society for Academic Emergency Medicine


he dire need for development of emergency care in the countries of sub-Saharan Africa is undisputed.1–6 Time-sensitive, life-threatening illnesses and injuries are among the leading causes of morbidity and mortality in these low- to middle-income countries (LMICs).1–3 These include medical conditions such as pediatric respiratory and diarrheal illnesses, maternal hemorrhage, and acute complications from HIV/AIDS, which have captured worldwide attention, resulting in the United Nation’s health-related Millennium Development Goals (MDGs 4, 5, and 6, respectively).2,7 Although not articulated in the MDGs, in the past few decades, no condition has been a better indicator for the need for emergency care in Africa than trauma. In response, the World Health Organization (WHO) has strongly advocated developing basic trauma care systems to address the disproportionate death and disability from trauma in sub-Saharan Africa.3,4 This positive attention

has especially focused efforts on prevention, early treatment, and development of facility-based emergency care of trauma. In high-income nations, a prehospital chain of survival in cardiac arrest, acute stroke, and trauma care has been demonstrated, emphasizing the critical role of prehospital care in improving mortality.5,8–10 African and international comparative studies have demonstrated that the lack of prehospital care systems contributes to unnecessary death and disability in the region.3–5 In trauma, the lack of timely and appropriate prehospital care in sub-Saharan Africa directly contributes to worse patient outcomes compared to high-income nations with developed prehospital care systems.5,7 WHO-proposed mechanisms for specifically developing LMIC prehospital trauma care systems will hopefully help address this inequity; in addition, the mortality benefit of a well-functioning basic prehospital trauma

From the Department of Emergency Medicine, University of Colorado-Denver (NM), Aurora, CO; the Department of Emergency Medicine, Emory University (SMS), Atlanta, GA; and the Division of Emergency Medicine, University of Cape Town (LAW), Cape Town, South Africa. Received March 13, 2013; revision received July 12, 2013; accepted July 15, 2013. The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: David C. Cone, MD. Address for correspondence and reprints: Nee-Kofi Mould-Millman, MD; e-mail: Nee-Kofi[email protected]


ISSN 1069-6563 PII ISSN 1069-6563583

© 2013 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12269

ACADEMIC EMERGENCY MEDICINE • December 2013, Vol. 20, No. 12 •

care system extends to other nontraumatic emergency conditions.3,11 Despite the overwhelming need for prehospital care in sub-Saharan Africa, there is a paucity of such care systems. Although no Africa-wide emergency medical services (EMS) inventory or assessment has been conducted, the literature suggests the existence of only a few EMS systems in various stages of development, distributed among only a few countries.6,7 In a recent survey of prehospital care systems, EMS leaders in 13 LMICs were purposefully surveyed. While only three African countries were represented (Ghana, Kenya, and South Africa), the study reported a dearth of prehospital care systems in these three nations. Furthermore, it was reported that where EMS systems exist, they are underdeveloped and unable to meet local needs.6 Where formal prehospital care systems are lacking or are in early stages of development, informal systems have been tested, where lay people (for example taxi drivers and police officers) are trained as first responders. Such models have been successfully demonstrated on a small scale in countries such as Ghana, Uganda, and Madagascar.12–14 Although such informal systems are relatively cheap and advantageous, especially in remote African settings, the need for a second tier of formal EMS systems is equally important and necessary, according to WHO, to further reduce morbidity and mortality in the region.3 To improve existing prehospital care systems and to advocate for the development of new systems, further research is needed to systematically conduct assessments and quantify the local or regional need for prehospital care and to scientifically test solutions.15 However, expert-level, internationally agreed upon recommendations guiding research on prehospital systems in sub-Saharan Africa are lacking.3,6,7 According to the Global Forum for Health Research, a “10–90” gap exists in research of prehospital care in LMICs, where less than 10% of research investments are for problems affecting 90% of the world’s population.16 Kobusingye et al.7 were among the first to offer recommendations to help reduce this gap. First, they suggest using a burden of disease approach to assessing prehospital systems, given the appropriate heterogeneity within prehospital systems across sub-Saharan Africa, which makes applying standardized assessments challenging. Second, they assert that priority-setting for research and development on prehospital care needs to be conducted, at a region-specific or preferably country-specific level, and should be based on emergency-specific epidemiologic data.7 As educational initiatives, clinical services, public policy, and research in acute and emergency care are gradually advanced in sub-Saharan Africa, the need exists for further consensus to guide prehospital research in an effort to improve prehospital care systems as an integral part of the chain of survival.15 Gathering stakeholder perspectives and establishing consensus are essential first steps in the development of a collaborative acute care framework for Africa, especially given the paucity of emergency-specific data.17 In November 2011, the first African Federation for Emergency Medicine (AFEM) consensus conference on


acute and emergency care convened in Cape Town, South Africa.17,18 While the AFEM prehospital working group raised the urgent need for prehospital research, no specific consensus was reached except to “identify emergency care research priorities.”18 In November 2013, the AFEM prehospital workgroup will reconvene to focus on establishing a prehospital research agenda and develop a white paper on prehospital and out-ofhospital emergency care systems.18 To inform the AFEM prehospital workgroup’s output, and to help focus attention on the need for a sub-Saharan prehospital research agenda, we assimilate current literature and build on previous expert opinion toward establishing research tenets for prehospital care in sub-Saharan Africa. A. There is a paucity of epidemiologic data specific to emergency conditions in sub-Saharan Africa. These data are needed to quantify the morbidity and mortality, and to demonstrate the dire need for prehospital emergency care in the region. Recommendations: 1. Identify, promote, and create locally appropriate, sustainable mechanisms for the accurate collection of data specific to emergency medical conditions. The 2001 Global Burden of Disease Project reported that approximately 45% of deaths and 36% of disabilityadjusted life-years were potentially addressed by EMS in LMICs. According to the second edition of Disease and Mortality in sub-Saharan Africa, sub-Saharan Africa is by far the region of the world with the highest level of mortality.19 However, to date, no specific data exist that demonstrate the regional or country-specific burden of death and disability attributable to emergency and prehospital conditions. Recently, leaders and champions of acute and emergency care in Africa have stressed that the burden of acute disease in the region is severely underdocumented, emphasizing that collection of such epidemiologic data is a critical step in the advancement of the field.18 The AFEM 2011 consensus conference recommended that acute care metrics be integrated into existing surveillance strategies and also recommended specific indicators for infrastructure improvement (such as mortality rates and percentages of appropriate therapy for acute presentations).18 In addition to helping focus and prioritize research efforts, generation of these acute care epidemiologic data is vital to capturing the attention of local health care policy-makers, targeting disease-specific funding, and directing patient care efforts. Furthermore, local data collection systems will be valuable to monitor and evaluate changes in the morbidity and mortality of these emergency conditions potentially attributable to developments in prehospital care. 2. Develop region-specific prehospital emergency research priorities as the broad target for further prehospital development and research. Across sub-Saharan Africa, region-specific variances in morbidity and mortality from acute and emergency conditions have been noted, including trauma, HIV/AIDS, acute manifestations of malaria, and childhood diarrheal illnesses. The overall mortality rate is highest in Southern and Eastern Africa compared to countries in Western Africa and the Indian Ocean.19 Therefore, advocating for and develop-



ing acute care systems should ideally be tailored to address the acute burden of disease in the respective subregions. Hence research priorities within the subregions should be based on such broad existing epidemiologic morbidity and mortality data. 3. Prehospital research priorities in sub-Saharan Africa must be tied to the global health care agenda. In creating a list of subregional priority emergency conditions, further efforts should be made to align acute care development with global health priorities. For example, at least three of the United Nation’s MDGs (child health, maternal care, and infectious diseases) can be significantly improved with well-researched and well-developed acute care systems.18 While the MDGs have captured the global health spotlight, no large-scale efforts have been made to align improvement of MDGs with the development of acute care systems in sub-Saharan Africa. This is a missed opportunity. Champions of prehospital care in sub-Saharan Africa should capitalize on the momentum around the MDGs and other key public health interventions to advance research and development in prehospital care. A handful of such success stories in sub-Saharan Africa do exist. Most recently, relatively inexpensive cellular phone SMS technology and motorcycle ambulances were successfully used as prehospital interventions in Rwanda and Malawi, respectively, to improve outcomes in maternal patients facing obstetric emergencies.20,21 B. Facility-based emergency care is underdeveloped in many sub-Saharan African nations. Given this fundamental problem, there is debate as to whether investment in research and development in prehospital care is appropriate or ethical. Recommendation: 1. Prehospital care systems can and should be developed and researched in tandem with facilitybased development. The literature suggests a mortality benefit is conferred by prehospital care independently of in-hospital emergency care resources. This is best exemplified by prehospital trauma care. A comparative trauma study by Mock et al.5 demonstrated worse prehospital outcomes in severely injured patients in Kumasi, Ghana (51%), compared to Mexico City (40%) and Seattle, Washington (21%). The worse outcomes in Ghana and Mexico were attributable to poor prehospital care, independent of in-hospital care. The authors encouraged development of prehospital care to address this excess mortality in underdeveloped prehospital settings.5 Non-EMS prehospital care systems have also been shown to confer a survival advantage, independently of facility-based care. This was well demonstrated in northern Iraq where community first responders were trained to provide field care of injured and interface with paramedics if needed. The penetrating trauma mortality rate over 8 years declined from 91% to 15%, and land mine mortality dropped from 28% to 9%. After controlling for other variables, the authors concluded that this improvement was attributable to the prehospital first-responder intervention.22 Hence, development of locally appropriate prehospital care systems, formal or informal, should be encouraged. While such systems can be developed independently of fixed facilities, WHO advocates for an integrated

approach when possible, such that “informal” prehospital systems interface with “formal” care in fixed facilities thereby creating a system of emergency care. Ultimately, the degree to which a prehospital system should be designed, built, and researched in advance of in-hospital definitive care is ultimately a local decision and requires balancing the local acute burden of disease with existing resources. C. Terminology around prehospital care is not standardized, thereby breeding confusion in research. Recommendations: 1. There needs to be a consensus-building process to further clarify and define terminology in the context of prehospital global emergency care research and development. A consensus statement from the AFEM consensus conference in 2011 indicates that terminology around prehospital and acute care in sub-Saharan Africa is confusing. The AFEM prehospital workgroup adopted the term “acute care referral system” to apply to care delivered outside the walls of formal health care facilities in the conduct of interfacility patient transfers, for example.18 Similar consensus-building processes around other prehospital concepts will lend both standardization and clarity of purpose to future prehospital research and development. 2. The terms “prehospital,” “out-of-hospital,” and “emergency medical services” are used inappropriately and interchangeably in the context of LMICs. Prehospital care implies that a fixed health care facility is the ultimate destination of the patient, but this may be impractical in areas with limited health care facilities or even unaccepted due to local medico-socio-cultural practices. Out-of-hospital implies the provision of acute or emergency care that is informal or that may not involve fixed facilities, e.g., basic first aid delivered by a trained community volunteer, or arrested labor managed by a skilled birthing attendant at home. In the limited resource context of sub-Saharan Africa, such out-of-hospital interventions that exclude fixed facilities may be completely appropriate due to the unavailability of emergency transportation or the lengthy distance to definitive care. The term emergency medical services (EMS) needs further definition in the sub-Saharan context. The WHO asserts that in low-resource settings, an EMS system should form an integral part of a larger prehospital care system.3 In its most classic form, EMS represents a system of ground, air, or water ambulances, using trained prehospital providers to deliver safe and timely care while transporting the patient to definitive care in a coordinated manner. The most essential attributes, structure, and function of an EMS agency or system in sub-Saharan Africa need further clarification, possibly through expert consensus. 3. The terms “formal” versus “informal” care systems need further clarification. To date, the reference for formal prehospital care systems is implicitly the “Western” standard. While a taxi driver or communitybased system of trauma care may seem informal to a western observer, in the African context, such a system may be accepted and formalized by the local community. Pilot programs of such first-responder programs, where lay people such as taxi drivers, police officers, and local councilmen are trained, have proven

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successful in several African settings, including Ghana, Madagascar, and Uganda.12–14 Regardless of whether a system of out-of-hospital care is formal or informal, both should possess attributes of local appropriateness, timeliness, sustainability, and efficacy as advocated by WHO.3 Further consensus is needed to determine what prehospital elements define formal versus informal, to allow accurate categorization of such systems during prehospital research and development. D. Prehospital care research priorities should be well delineated. Recommendations: 1. Prehospital care is one link in the chain of survival and should be studied in the context of the larger care system. The preponderance of existing literature focuses on individual components, such as prehospital transportation, communication, or firstresponder training. However, as a chain of survival, an emergency care system is only as strong as its weakest link.15 A Tanzanian study illustrates this point by reporting a correlation between increased mortality in patients with road traffic injuries and longer delays in admission to intensive care units, a critical upstream resource in trauma care systems.23 Therefore, a system with individually well-functioning elements of care has the largest potential for overall quality of acute or emergency care. Preferably, researchers should initially assess these systems in their entirety to identify strengths and weaknesses and then propose specific components for further detailed assessment. 2. Measuring the efficacy of basic prehospital care systems should be prioritized. Given the sparse health care resources in sub-Saharan Africa, a strong need exists to identify successful interventions, especially those that are dependent on the simplest of technologies, are most locally-appropriate and consume the least amount of resources. This especially applies to informal “home-grown” prehospital care systems usually found at the community and district level. Illustrative examples are the cost-effective, sustainable, effective first-responder trauma programs in Uganda and Madagascar and emergency obstetric programs in Malawi and Rwanda.13,14,20,21 3. Baseline assessments of existing local prehospital practices should be conducted. These should be done to both demonstrate a need for improvement of existing processes and as a test-of-change after an intervention. We advocate for individuals experienced in prehospital care systems in sub-Saharan Africa, in partnership with local acute care experts, to preferentially perform these technical assessments to provide meaningful recommendations. 4. Other important attributes of prehospital care systems should be measured by prehospital research. Such vital elements, for example those emphasized by WHO, including cost-effectiveness, timeliness, accessibility, efficacy, sustainability, and integration with overall health care system.3 5. Assessments and investments in prehospital educational initiatives should be prioritized as a fundamental prerequisite to delivering high-quality prehospital clinical care. The NIH’s Fogarty International Center Medical Education Partnership Initiative grants and International Collaborative Trauma and


Injury Research Training grants, for example, have emphasized and funded quality, innovative, competency-based medical education in low-resource nations by partnering African with U.S.-based institutions to create effective networks.24 Out of such partnerships, quality in-hospital emergency care educational assessment methods and initiatives have arisen. These should be tested, and successful educational tools and models should be applied to prehospital care. 6. Outcomes-based research should be emphasized and prioritized to demonstrate the link between prehospital initiatives and morbidity and mortality. Although such research is understandably challenging to conduct, and causal relationships are difficult to demonstrate, these efforts must be prioritized.7 Studies, such as the Iraqi experience with training volunteer first responders who drastically improved mortality from penetrating trauma and landmine injuries, are most powerful because an outcome improvement was measured and directly correlated to the intervention.22 Similar efforts should be replicated in prehospital studies to discover those interventions that are lowest cost, effective, and most sustainable. 7. A prehospital or out-of-hospital care system inventory needs to be conducted across the sub-Saharan region, to define areas with developed, developing, or nonexistent prehospital care systems. Such an inventory will be useful in demonstrating areas in most dire need of prehospital care, thereby directing research and development. E. Prehospital research, in itself, is a skill and a crucial element for improving local prehospital care systems. Recommendation: 1. Efforts should be continued to educate and train Africans in conducting meaningful and effective prehospital research. Non-African prehospital researchers working in sub-Saharan Africa should strive for local knowledge transfer and local institutionalization within a well-identified, reasonable time frame. Wisborg et al.,15 in a 2011 commentary on trauma research in LMICs to strengthen the chain of survival, note that local researchers are critical to helping identify the most promising areas for prehospital development. However, the authors astutely note that limited resources in lowresource settings pose significant challenges to conducting and prioritizing research efforts, so they encourage “East–West” collaborative research enterprises to advance such prehospital research.15 We advocate building local capacity around prehospital research and knowledge transfer in an effort to empower local EMS advocates and practitioners to advance the field. F. Research and development of traditional, nonWestern prehospital care systems in sub-Saharan Africa is lacking. Recommendations: 1. There is a need to measure efficacy, efficiency, and scalability of home-grown local systems of care where they exist as per items D2 and D3 above. Promising pilot programs of such innovative, locally appropriate, sustainable, and scalable systems of prehospital care have been reported in sub-Saharan Africa, where lay person volunteers are recruited and trained. Mock,25 in a 2009 editorial in response to the successful Uganda volunteer first-responder model, encourages ongoing



long-term assessment, especially measuring outcomes (mortality rates), recognizing the inherent challenges of such work. A small, prospective trauma database study from Mumbai, India, assessed formal versus informal modes of prehospital care and transport. The authors discovered that police and citizens, not EMS, transported the majority of injured victims to the hospital. The local authors concluded that given the high cost and low penetration of EMS, that encouraging informal modes of transport were most realistic in their lowresource environment.26 Successes identified from assessments of these locally grown systems, both African and non-African, are ripe targets for further research to determine feasibility, efficacy, and scalability across the sub-Saharan region. 2. The “Western” model of prehospital care is not necessarily the best model of prehospital care for other geographic regions. Well-intentioned prehospital consultants from developed nations (and inexperienced local EMS advocates) should be cautioned against advocating for Western-style EMS systems. In Malaysia, for example, the Ministry of Health, Ministry of Education, and Civil Defense authority merged resources to create a national ambulance service. To expand the ambulance service’s coverage area, instead of investing heavy capital and resources to grow the singular agency (as is typical in most western models), the Malaysian governmental agencies resourcefully partnered with nongovernmental, local ambulance organizations such as Red Crescent, St. John’s Ambulance, and hospitalbased ambulances to expand EMS coverage geographically and maximize prehospital emergency services to the population. The various EMS agencies are unified through communication and operations by several government-operated dispatch centers.27 Lessons learned from middle- to upper-income countries, like Malaysia, can be extrapolated to sub-Saharan nations, thereby underscoring the importance of local innovation and local appropriateness. CONCLUSIONS Understanding that effective research can be challenging, costly, and requires expertise, the authors hope that this article will guide further discussion and movement toward consensus-building to establish policy, guidelines, and tenets of research around prehospital care systems in sub-Saharan Africa in an effort to help address the large burden of death and disability attributable to prehospital acute and emergency conditions. References 1. World Health Organization. World Statistics. Geneva: World Health Organization, 2010. Available at: http:// Accessed Sep 1, 2013. 2. United Nations. The Millennium Development Goals Report. New York, NY: United Nations Department of Economic and Social Affairs, 2009. Available at: http:// Accessed Sep 1, 2013.

3. World Health Organization. Prehospital Trauma Care Systems. Geneva, Switzerland: World Health Organization, 2005. Available at: http://www.who. int/violence_injury_prevention/publications/services/ 39162_oms_new.pdf. Accessed Sep 1, 2013. 4. World Health Organization. Guidelines for Essential Trauma Care. Geneva, Switzerland: World Health Organization, 2004. Available at: http://whqlibdoc. Accessed Sep 1, 2013. 5. Mock CN, Jurkovich GJ, nii-Amon-Kotei D, ArreolaRisa C, Maier RV. Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development. J Trauma. 1998;44:804–12. 6. Nielsen K, Mock C, Joshipura M, Rubiano AM, Zakariah A, Rivara F. Assessment of the status of prehospital care in 13 low- and middle-income countries. Prehosp Emerg Care. 2012; 16:381–9. 7. Kobusingye OC, Hyder AA, Bishai D, Joshipura M, Hicks ER, Mock C. Emergency medical services. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd ed. Washington DC: World Bank, 2006, Chapter 68. Available at: http://www.ncbi.nlm.nih. gov/books/NBK11744/. Accessed Sept 1, 2013. 8. Neumar RW, Barnhart JM, Berg RA, et al. Implementation strategies for improving survival after out-of-hospital cardiac arrest in the United States: consensus recommendations from the 2009 American Heart Association Cardiac Arrest Survival Summit. Circulation. 2011; 123:2898–910. 9. Adams HP, del Zoppo G, Alberts MJ, et al. AHA/ ASA Guideline: Guidelines for the Early Management of Adults With Ischemic Stroke. Stroke. 2007; 38:1655–711. 10. Centers for Disease Control and Prevention (CDC). Guidelines for Field Triage of Injured Patients. Recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep. 2012;61(RR1):2–17. 11. World Health Organization. Sixtieth World Health Assembly. Resolution WHA 60.22: Agenda Item 12.14. Health Systems: Emergency-care Systems. Available at: WHA60/A60_R22-en.pdf. Accessed Sept 1, 2013. 12. Tiska MA, Adu-Ampofo M, Boakye G, Tuuli L, Mock CN. A model of prehospital trauma training for lay persons devised in Africa. Emerg Med J. 2004; 21:237–9. 13. Geduld H, Wallis L. Taxi driver training in Madagascar: the first step in developing a functioning prehospital emergency care system. Emerg Med J. 2011; 28:794–6. 14. Jayamaran S, Mabweijano J, Lipnick M, et al. First things first: effectiveness and scalability of a basic prehospital trauma care program for lay firstresponders in Kampala. Uganda. PLoS One. 2009; 4: e6955. 15. Wisborg T, Montshiwa TR, Mock C. Trauma research in low- and middle-income countries is urgently needed to strengthen the chain of survival. Scand J Trauma Resusc Emerg Med. 2011; 19:62.

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16. Global Forum for Health Research. The 10/90 Report on Health Research 2001-2002. Available at: http:// 92e/s14792e.pdf. Accessed Sept 1, 2013. 17. Reynolds TA, Wallis LA. Addressing African acute care needs through consensus building. Afr J Emerg Med. 2013; 3:1–2. 18. Calvello E, Reynolds T, Hirshon JM, Buckle C, Moresky R, O’Neill J, Wallis LA. Emergency care in sub-Saharan Africa: results of a consensus conference. Afr J Emerg Med. 2013; 3:42–8. 19. Jamison DT, Feachem RG, Makgoba MW, et al., editors. Disease and Mortality in Sub-Saharan Africa, 2nd ed. Washington, DC: World Bank, 2006. 20. Hofman JJ, Dzimadzi C, Lungu K, Ratsma EY, Hussein J. Motorcycle ambulances for referral of obstetric emergencies in rural Malawi: do they reduce delay and what do they cost? Int J Gynaecol Obstet. 2008; 102:191–7. 21. Ngabo F, Nguimfack J, Nwaigwe F, et al. Designing and implementing an innovative SMS-based alert system (RapidSMS-MCH) to monitor pregnancy and reduce maternal and child deaths in Rwanda. Pan Afr Med J. 2012; 13:31.


22. Wisborg T, Murad M, Edvardsen O, et al. Prehospital trauma system in a low-income country: system maturation and adaptation during 8 years. J Trauma. 2008; 64:1342–8. 23. Chalya PL, Dass RM, Mchembe MD, Matasha M, Mabula JB, Mahalu W. Trauma admissions to the intensive care unit at a reference hospital in northwestern Tanzania. Scand J Trauma Resusc Emerg Med. 2011; 19:61. 24. Paina L, Ssengooba F, Waswa D, M’imunya JM, Bennett S. How does investment in research training affect the development of research networks and collaborations? Health Res Policy Syst. 2013; 11:18. 25. Mock C. Strengthening prehospital trauma care in the absence of formal emergency medical services. World J Surg. 2009; 33:2510–1. 26. Roy N, Murlidhar V, Chowdry R, et al. Where there are no emergency medical services–prehospital care for the injured in Mumbai. India. Prehosp Disaster Med. 2010; 25:145–51. 27. Hisamuddin NA, Hamzah MS, Holliman CJ. Prehospital emergency medical services in Malaysia. J Emerg Med. 2007; 32:415–21.

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