Historically, global health policy emphasized multiple, vertically oriented programmes that concentrated on maternal and child health and the control of communicable childhood diseases (1). This resulted in major public health agencies focusing their support on selective programmes that address priority diseases and activities (2). Unfortunately, vertical programmes do not encourage the development of strong and efficient health care delivery systems. The weakness of this approach is most apparent during, crises, such as medical emergencies or incidents involving large numbers of casualties.
Fortunately, experts in global health are beginning to take a more comprehensive view of health, including the provision of emergency medical care, than was traditionally the case. Thus the World Bank's minimum package of health services includes six cost-effective interventions, one of which is a series of non-specialized interventions for emergencies, known collectively as limited care (3). WHO and UNICEF are placing substantial emphasis on the strengthening of triage and emergency care within the context of the integrated management of childhood illnesses (4).
Some governments are attempting to provide a basic package of emergency services. For example, shortly after independence in 1979, Mozambique made emergency care one of its four priority areas in health (5). One of the elements of the Health Investment Fund Project in the Republic of Moldova, funded by the World Bank, is the development of basic emergency care services (6). In Romania, the Health Sector Reform Project, supported by the World Bank, aims to improve emergency medical services as a key component of the overall health programme (7).
We make the case in the following paper for developing a simple but comprehensive approach to emergency medical care in developing countries.
Emergency medical care
The purpose of emergency medical care is to stabilize patients who have a life-threatening or limb-threatening injury or illness. In contrast to preventive medicine or primary care, emergency medical care focuses on the provision of immediate or urgent medical interventions. It includes two major components: medical decision-making, and the actions necessary to prevent needless death or disability because of time-critical health problems, irrespective of the patient's age, gender, location or condition.
Emergency medical care and health system performance
The three fundamental functions of a health system are to improve the health of the population, respond to people's expectations, and provide financial protection against the costs of ill-health (8). Emergency medical care can contribute positively to these functions. There are no empirical data on the number of lives or disability-adjusted life-years (DALYs) saved through emergency medical care. Nevertheless, it is clear that many of the conditions that contribute to the burden of disease in low-income and middle-income countries can be mitigated through prompt treatment (Table 1).
Enhancing a health system's responsiveness to people's expectations leads to improved utilization of services and better outcomes (8). Access to medical care for urgent or life-threatening conditions is a key expectation in many communities. A study conducted in rural Nepal revealed that people used their primary health care centre more often for medical emergencies than for preventive services, such as family planning or prenatal care. The population perceived a strong need for accessible emergency medical and surgical services throughout the district (9). A survey conducted in two communities in Sri Lanka revealed that people expected to receive emergency care from the primary care system. In most instances they used traditional home remedies for minor ailments but turned to primary care medical facilities for acute complaints or when a child seemed seriously ill (10). …