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Developing and Implementing

Emergency Medicine Programs Globally

Tamara L. Thomas, MD, FACEP Department of Emergency Medicine, Loma Linda University,

11234 Anderson St. A-108, Loma Linda, CA 92354, USA

Changing health needs in countries experiencing economic and social

growth are creating a greater demand for all types of emergency medical

services. Factors contributing to this include globalization and rapid

urbanization with resultant changes in demographics and disease patterns.

Due to these factors, many countries recognize the necessity and value of

establishing quality emergency health care systems and are striving to create

efective emergency medical programs. With this increased international

interest in emergency medicine (EM), emphasis has shifted toward inter-

national EM development and capacity building abroad.

International EM programs focus on assisting in the development of EM

as a specialty and in providing physicians from abroad with the knowledge

and skills to develop EM programs. Systematic development of emergency

services requires more than applying another country's design; it requires

a comprehensive assessment in concert with a well-thought-out plan.

Comprehensive emergency medical care has much to ofer to many

countries, including quality, high volume, unscheduled outpatient visits,

reduced hospitalizations, up-to-date immediate resuscitation of all patient

groups, and integrated prehospital and hospital systems. Many visitors to

the emergency departments in the developing world would confirm the

organizational and system challenges these departments face, not to

mention the huge patient volumes. There are tough questions that need to

be answered. Which is the best system? How do you approach changing

a system? What are the real priority needs? What is it going to cost? Where

does emergency medicine rank among the overall health needs of the

country? Individual physicians working in international health must accept

the responsibility of answering these questions for themselves [1].

178

Types of programs

THOMAS

International emergency medicine (IEM) means diferent things to

diferent people. Multiple intervention and program types are included

under this term and contain all or parts of the categories listed in Box 1.

Understanding systems Worldwide systems

Working within an unfamiliar medical system necessitates understanding

of various approaches to providing emergency medical services. Although

some system components are universal to all medical systems, there are

a myriad of unique ways these components are translated or identified

regionally. It is confusing and complicated trying to sort them out, and some

attempts at describing regional EM models follow. There is no single EM

system that serves the needs of all.

Box 1. Types of international emergency medicine programs Education and training

, Developing EM and emergency medical service training

programs

, Conducting exchange programs for health care

personnel

Clinical development of emergency medicine

, Developing clinical EM facilities (hospital-based versus

freestanding EM care)

, Establishing facilities primarily dedicated to providing

emergency health services

, Staffing medical facilities

, ''Charity'' clinical service

Emergency medicine systems development

, Encompasses the development of EM as a specialty

Humanitarian relief

, Providing medical care and system development to

postconflict regions.

Disaster training and relief

, Recent increasing interest in preparedness issues

, Disaster relief

DEVELOPING AND IMPLEMENTING PROGRAMS 179

Historic regional description models

Geographic identifiers have been used to distinguish between EM

systems. Although these models may have initially illustrated regional

emergency medical system dissimilarities, they have oversimplified the

systems [2,3].

''Bringing the hospital to the patient''—the Franco-German model

In this model, patients access the prehospital system through physicians

(anesthesia, critical care, or emergency medicine) who initiate medical care

and transport to the hospital. EM is practiced primarily in the prehospital

setting, with patients being triaged and admitted directly to inpatient

specialty units. The traditional Franco-German model is not limited to

France and Germany proper, and countries classified under this model

practice EM in many forms. This description oversimplifies a multidisci-

plinary system of emergency medical care practiced in many countries.

''Bringing the patient to the hospital''—the Anglo-American model

In this model, patients access the prehospital system through physician

extenders (emergency medical technicians and paramedics) who provide

initial care and transport to the hospital. Emergency physicians usually

assume care upon arrival to the emergency department (ED) in the hospital

and provide medical control to the prehospital providers.

The specialty model versus the multidisciplinary model The specialty model

The specialty model is an organizational system in which EM is viewed as

a uniquely integrated horizontal body of medical knowledge and skills

(horizontally crossing many unique areas of specialty). Patients are treated

within EDs in some countries and in the out-of-hospital environments in

others. These skills cover the acute phases of all types of disease and injury.

The key component of this system is that EM is recognized as an

independent medical specialty within the health care system [4,5].

The multidisciplinary model

In the multidisciplinary model, EM is made upof several vertically oriented

(specialty) areas of medical knowledge and skills that dependon other medical

specialties, such as internal medicine, obstetrics, pediatrics, anesthesia, or

surgery. In this model, non-EM specialists are felt to be the most qualified to

deliver emergency medical care in their areas of expertise [4,6-8].

Comparing systems

Accurately describing an emergency medical care system is difcult

because these systems are complicated, multifactorial entities. A study

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attempting to describe and compare EMS systems in Europe found the

complex information difcult to compare even across European borders

because there is no uniform nomenclature [9]. No one generic description

can be universally applied. However, the underlying universal principle is

that acute episodic emergency care of medical conditions has to be

addressed.

How do you compare systems? The diferent EM practice models cannot

be directly compared because the necessary patient outcomes data are

unavailable. Determining which model is best for any given country is

difcult [1]. No comparative multinational studies exist that demonstrate the

superiority of one model over the other [2,3,9]. Likewise, no international

standardization process exists. Areas that would benefit from international

standardization include education, training curriculum, and clinical practice

guidelines [4,9,10].

What components of emergency medical care systems are universal? Is

there a generic basic framework for EM development? It has been suggested

that development can result in a commonly shared structure regardless of

national or cultural diferences. This would imply that many evolving

emergency care models undergo similar developmental stages, characterized

by systems on which further development is built [2]. This basic anatomy of

development incorporates building emergency care capacity and infrastruc-

ture followed by training and clinical care standardization and leadership

development [11]. Universal components of development can be seen in

a series of published articles describing the state of EM in many countries

[12-40]. Establishing EM as an independent medical specialty benefits

health care systems in many ways. EM development results in a group of

in-country specialists who improve and refine the out-of-hospital and in-

hospital emergency medical care systems in their country, ranging from

clinical operations to administration.

Developing a successful program

Many international EM exchange and development programs take place

on a case-by-case basis. There is no ''one size fits all'' emergency system for

all countries. Even within a country, each city and hospital has unique needs

[41]. Future eforts must address system-wide improvements and larger

issues of system capacity. In addition, the necessity for an information

resource and evaluation methodology should be recognized to maximize the

beneficial efects [11,42].

Establishing a framework for system design is necessary for successful

program development. Program goals may range from developing an EM

system from rudimentary stages or refining an existing system. A project in

Addis Ababa, Ethiopia defined essential steps to develop an EM system [43].

Successful program development includes these necessary ''pieces of the

puzzle'' (Box 2).


Box 2. Steps for developing an emergency medicine system Reliable and identified partners

, Physician group interested in developing EM

Support

, Governmental support

, Support from other physician specialties

Infrastructure components

, Health care facilities capable of providing

emergency care

, Transport and communication systems for patient access

, Referral and follow-up care availability

Training programs for physicians and other emergency health care

personnel

Define the scope of the project from the beginning. Addressing all aspects

of an EM system in one program is difcult, costly, and time intensive. A

small project can be useful when it is planned with the current system needs

in mind. If your project is to conduct one training course in a developing

country, you want to maximize the impact of this program by addressing the

goals of all the stakeholders. Be creative and set layered goals for the course.

Make strategic choices to leverage the benefit of the course. Consider the

needs, wants, and agendas of the varying constituents for the project to yield

a maximum benefit.

Fig. 1 outlines an example of a program that meets multiple constituent

goals. A disaster-training course was conducted in Panama by the

nongovernmental agency, Emergency International, Inc. The basic in-

tervention was a disaster training course at a single hospital. By evaluating

the agendas of the multiple constituents, the benefit of the course could be

maximized. Emergency International had the opportunity to develop

a useful, generic disaster training course that could be disseminated. The

local hospital staf goals of increased awareness of disasters and specific

disaster training could be met. The local disaster agency could pilot

a hospital disaster course and initiate community disaster planning, and the

Ministry of Health could investigate potential opportunities for future

national disaster training. Although it was only one course, it could fulfill

the goals of multiple constituents. The varying agendas were creatively

woven so that the most could be obtained from the temporal, personal, and

financial resources used. In addition, the course could be used in other

settings and locations.

182 THOMAS

Fig. 1. Strategic layered goals of a program that meets multiple constituent goals.

After a project's goals are defined, systematically plan your program

(Fig. 2) [44]. Where do you begin when planning a program? Start with

answers to these basic questions:

, Assessment: Where are we now?

, Planning: Where do we want to go? How will we get there?

, Implementation: Put the plan into action.

, Monitoring: Are we on track?

, Evaluation: Have we arrived where we wanted to go?

Educational planning

Education for international programs takes many forms. Because we

often teach what we are familiar with, some programs start with modular

training courses. Modular courses are standardized, allowing participants to

be trained to the same level. They can provide focused training on a topic in

a short amount of time for teachers and participants. Teaching materials are

easily available, and courses can be ''plugged'' into other curricula. They are

relatively inexpensive to conduct. Participants value the provider certificate


Fig. 2. Program planning cycle.

obtained. However, the United States-based courses may not focus on

locally relevant clinical problems. In addition, a 1- or 2-day course cannot

replace supervised clinical training. Modular courses can be easily

conducted in a short time, but they are less useful if not a part of a long-

term development plan.

When setting educational goals, do not let the logistics of the course set

the purpose of the course. Do not allow the course location, time, contents,

and instructors to be decided before students, resources, needs, local

strengths, and weaknesses are considered. EM-based projects can range

from a focused training program to system-wide interventions, such as EMS

development to academic-based projects like EM residency development.

Curriculum design for these projects should be needs based and realistic [10].

A cooperative project in Addis Ababa, Ethiopia planned a flexible

curriculum. The seven main categories included (1) EM in Ethiopia; (2)

basic and advanced cardiorespiratory care; (3) basic and advanced trauma

care; (4) critical issues in emergency medicine; (5) ED planning, stafng,

equipping, and so forth; (6) out-of-hospital EMS; and (7) disaster

preparedness in the ED. This course was divided between lectures and

hands-on training and emphasized Israeli instructors learning about the

local system before lecturing and receiving input for changes throughout the

course [43]. Curriculum for non-United States-based physicians has been

published for visiting postgraduate fellowships or externships to assist in

faculty development for international EM programs [45].

Emergency-based educational seminars in postwar Rwanda prospectively

showed that greater sustained efects were seen in behaviors requiring

minimal equipment and noncomplex medical decision making, such as

wound management principles and blood/bodily fluid precautions. Less

sustained efects were seen with advanced airway management trauma

184 THOMAS

resuscitation procedures [46]. Further curriculum evaluation in diferent

global settings will be useful for future training eforts.

Analysis Assessing systems System identification and analysis

A major goal for EM systems assessment is to identify the role EM plays

in the health care system of the target country. It is important to understand

existing health care systems, economic development, and societal structures

of other countries before attempting to integrate EM into medical systems.

Follow a patient's steps in accessing the emergency care system from

diferent locations and see where the system breaks down. Look at the

health care facilities participating in the system and identify factors such as

the bed capacity, patient acuity, personnel, level of training, surgical

capability, radiology, and laboratory support. These factors afect the

patient outcomes and planning goals. Efective development addresses all

aspects of the system, and identifying these components helps you address

support and integration.

Environmental evaluation

Culture has no single definition but is a complex whole of beliefs,

practices, likes, dislikes, and habits; it is a set of rules we use for living. It is

helpful to try to identify any preconceived perceptions you might have about

the local area. Approach a new location with a maximum of flexibility and

a minimum of judgment. There are many ways to reach a goal; if the local

partners accomplish it diferently than you do, it does not mean it is ''the

wrong way.'' Although culture afects what our actions are, it also afects

a person's interpretation of what we do and say. Attempt to understand how

your local program partner may view you or your actions.

Local culture and expectation influence how medicine is practiced.

Gender issues and other cultural beliefs and practices must be addressed in

some countries and may afect the way female patients are treated [32].

Previous history can also influence the environment for change. For

example, developing countries have experienced many previous interna-

tional aid projects, some of which have failed or have terminated

prematurely due to funding constraints, leaving stakeholders feeling wary.

Technical considerations

An analysis of the technical needs and limitations should be made. The

assumption that high technology is synonymous with high quality has not

been proven. Be practical, and consider the appropriate level of technology

in the development plans. Focus on strong fundamentals of good medical


care that are cost efective and sustainable. For example, a Vietnam

development project proposed a low-tech and preventive intervention of

helmet use by motorbike riders that would have a positive efect on health

care expenditures for trauma and would significantly reduce morbidity and

mortality from such injuries [35].

Technology transfer has not played a large role in international EM

development. Although some technology is necessary, development

primarily depends on changes in systems and not on expensive medical

equipment [2,12].

Political considerations

The local, regional, and national authorities must support the assimila-

tion of any new health program into a community or country. It is

important to address varying levels of support from the program's creation

because the fundamental issues of funding, manpower, training, and health

system integration depend on them. System oversight; budget control; and

local, regional, and national political relationships must be carefully

delineated.

Political stability afects the growth of a specialty. Although EM

development has faced numerous obstacles over the last decade in Bosnia,

the greatest has been political instability. Without the ability to plan for the

future, it has been difcult for Bosnian physicians to proceed with a new

specialty [23].

Factors influencing emergency medicine development regionally

Regional factors influence EM development. Negative perceptions from

other specialties toward the emergency medicine specialist afect the

successful growth of the specialty [47]. Physicians' payment mechanisms

can also influence practice patterns. For example, because Afghanistan

physicians receive a flat fee for hospital work and supplement their income

with their private practices, educational course scheduling must accommo-

date this. In some systems, there is not significant financial or professional

motivation to become a hospital-based physician. It is reported that early in

Hungarian EM development, the prevailing socialistic ideology prohibited

physicians from earning more than the average worker, and physicians

relied on gratuities directly from inpatient services to supplement their

income. As such, the emphasis was on admitting as many patients as

possible, frequently for inappropriate reasons, to provide health services

that were often unnecessary [27].

Needs assessment

To provide appropriate advice to countries in the early phase of

emergency health care development, careful assessment of national

resources, government structure, population demographics, culture, and

health care needs is necessary. An assessment-based list of health care needs

186 THOMAS

should be completed before the implementation of any EM development

project, and data from this should be outlined in the planning document.

A lack of a detailed early assessment impedes the ability for organizers to

develop specific achievable objectives, increasing the likelihood of failure.

An Armenian EMS development project defined their needs assessment

process as follows: assessment trips focused specifically on emergency and

trauma medicine, organization of the system, elucidation of the hospital

and ambulance substation network, identification of the key players, and

inventory of strengths and weaknesses (including equipment needs) [12].

There is no single, fixed way to conduct a needs assessment. Identify the

resources or tools you need to meet your goals (see Appendix) [48-50].

Gather quantitative and qualitative data. Locate reliable existing quantita-

tive information sources through existing records and documents, surveys,

and hospital records. Qualitative data gives you information about

stakeholder-based needs and can be obtained through observation of local

facilities and practitioners and through interviews with key informants or

stake holders.

Decide what additional information is needed. The questions to be asked

depend on local circumstances. Resources and expertise are generally

limited, so be selective in deciding what information to collect. Take care in

choosing your information options, because the assessment is directly

related to the quality and accuracy of your information.

For each proposed question, ask:

, Is the information essential for our local needs?

, Does the information already exist?

, Can the information be easily collected?

, Will the information be worth the time and energy spent on gathering it?

, Can the information be easily analyzed?

, Will the information be directly useful in program planning?

Decide how to obtain the information. Information should be gathered

through quantitative and qualitative assessment methods. If specialist

expertise is unavailable, three fundamental tools can be used: (1) review of

existing records and documents, (2) observation, and (3) interviews with key

informants.

Because you are receiving data from multiple sources, a simple way to

cross-check your data is called ''triangulation.'' Triangulation is confirming

the accuracy of information by asking several people from diferent

backgrounds the same question or by obtaining information from more

than one source [48]. Simple methods of data collection can produce

information that is relatively bias free and accurate.

Assessment

After you collect and analyze the information, carefully review the

assessment findings with the key informants early. This helps identify


information discrepancies. Identify needs, possible interventions, and

resources. After analysis and observation, the assessment team should be

able to list the following:

, Unmet emergency needs of the community

, Possible interventions to meet these needs

, Resources available, from within the community and outside the

community, to meet these needs

Most published EM needs assessments focus on humanitarian relief or

disaster response [51-54]. Bradt et al [52] analyzed rapid epidemiologic

assessment protocols from leading agencies. They proposed an instrument,

comprising a Minimum Essential Data Set, with the purpose of

standardizing data collection for disaster relief. Nelson et al [53] looked at

a multimodal assessment of the primary health care system of Serbia. This

assessment involved quantitative and qualitative methodologies that

focused on (1) system characterization and observation, (2) focus group

discussion, (3) free-response questionnaires, and (4) Q-methodology. This

study ofered an example of an assessment that focused on local needs and

incorporated stakeholder attitudes in the process of identifying needs,

problems, and potential barriers to primary health care development in

Serbia. This assessment method was also applied to emergency services in

postconflict Kosovo [54].

Although there are similarities with emergency disaster assessments and

post-conflict assessments, there are also diferences. How do you cover an EM

system in an assessment? Start by identifying the role of EM in the medical

community. Developing a list of assessment questions can be done several

ways. One approach is to develop a checklist of questions using EM sys-

tem components such as administrative system components, clinical care

system components, academic system components, or specialty-based system

components (Fig. 3). An alternative approach is to use a diagnosis-based

approach and to assemble a clinical performance checklist (Fig. 4).

Planning Establishing objectives

After general goals are agreed upon and the initial assessment is

completed, outline specific realistic objectives for the development of the

system. Address the feasibility of the objectives in terms of financial and

institutional sustainability. Complete a written project description and

a timetable for implementation. In your initial planning, include outcome

measures to assess the program.

Prioritize system improvement objectives and keep them simple.

Objectives may focus on issues such as educational goals, training

standards, access to care, or prehospital coordination. Setting realistic

188 THOMAS

Fig. 3. System-based emergency medicine assessment. This is an example of questions to get

started with and is not designed to be a comprehensive and complete evaluation.

Fig. 4. Diagnosis-based assessment. This sample list is not an assessment questionnaire; its

function is to guide the assessor toward areas that need to be explored when planning an

assessment. This is an example of questions to get started with and is not designed to be

a comprehensive and complete evaluation. All other diagnosis groups need to be added. For

a true performance assessment, time frames for key treatment items could be added.

190 THOMAS

goals can avoid problems later in the project. Try to set layered goals to

meet the needs of as many constituents as possible.

Project finances Financial assessment

Implementing or upgrading emergency services in a community is

expensive and can depend on relatively advanced technology and resources.

In developing countries with limited financial resources, choices must be

made regarding the benefit of emergency versus other health services. A

cost-benefit analysis of a community's needs is an important early step and

should be carefully thought out as resources are considered for the

development and maintenance of an emergency system. The evaluation of

the health infrastructure must be coupled with the consideration for health

education and preventive health measures. Developing programs may

underestimate the degree of financial support an emergency system

demands. A realistic assessment is helpful in identifying the cost of many

interventions. In addition to starting costs, the ongoing cost of maintaining

and upgrading the system components is substantial. Verify financial

arrangements to support the project before project implementation (with

copies of documents verifying the existence of financial support).

Several resource allocations and cost-analyses for international EMS

systems have been reported [55-61]. Kuala Lumpur, Malaysia estimated the

costs and benefits of developing a prehospital care system: The cost would

be approximately $2.5 million per year, seven lives would possibly be saved,

three of which would be marred by significant neurologic injury. It was

determined to leave the transport of patients with police or private vehicle

[57]. Researchers in Taipei, Taiwan used a computer simulation to evaluate

EMS use and found that by reducing the number of ambulances to one at

each of the 36 response units they increased their use from 8.78% to 15.47%

without compromising the service quality level [61]. Such financial

evaluation is necessary in this day of limited resources and funds.

Personnel

Ongoing project costs include the payment of administrative personnel to

promote, develop, and oversee operations. In addition, technical providers

and trainers must be paid. VanRooyen et al [62] suggested that assessment

of personnel needs at the recipient level (in former Yugoslavia), in addition

to standard relief assessments, is required early in models of complex

emergencies.

Project administration

Identify local and expatriate leadership early to build leadership capacity

throughout the project. List participating personnel along with their specific


duties and responsibilities. Leadership within the government structure is

important for the successful development and subsequent integration of the

system.

Legislation and governmental commitment

Formal governmental recognition of the project is imperative to solidify

the government's commitment to the program. Ofcial legislation may be

difcult to obtain, causing delays in implementation. Interagency agree-

ments are important to avoid conflicts between potentially competing

agencies. Document support of appropriate health care facilities and

supervising government agencies.

Implementation Course of action

After the emergency system assessment and achievable objectives have

been completed, a detailed action plan should be outlined for the system

implementation steps. Be certain your local partners are identified and that

they agree with the action plan. Anticipate early contingency planning.

Development of local leadership

Local providers and administrators must be developed concurrently with

program implementation. These leaders are the driving force behind

continued program development and the future of the project. A mentor

approach can be used to link local leaders with expatriate personnel

throughout the program's development.

Educational programs

Setting educational goals provides guidance for training and oversight

and is helpful to the long-term success of the program.

Evaluation

There is a need for information resources and evaluation methodology

for international EM projects. No central repository of EM project reports

or uniformly applied evaluation of the structure and benefits of diferent EM

projects exists. Further discussion and research on outcome studies of EM

assistance and development projects are needed. An independent evaluation

of the feasibility and usefulness of the proposed project provides partic-

ipants with feedback regarding recommendations to enhance the structure,

feasibility, and outcomes of the program.

192 THOMAS

Recently, Holliman et al [42] proposed evaluation guidelines for

international emergency medicine assistance and development projects.

Specific program elements are evaluated using a five-point evaluation scale

under these general evaluation categories: (1) compatibility with laws, health

system, and culture of the country; (2) project; (3) structure and goals; (4)

project personnel; and (5) project finances, outcome assessment, and

follow-up.

The evaluation purpose may be formative (to provide ongoing feedback

so that the program can improve) or summative (to provide a final

''grade'' assessment of the performance of the program) [63]. The

formative process can provide feedback while the program is being

developed and helps to detect weaknesses and improve outcomes before

the program is fully implemented. Although many international EM-based

assistance and development projects have taken place, there remains little

scientific evidence regarding their impact. This remains a challenge for the

future.

Integration of results into future planning

When planning future programs, use your evaluation data to guide the

next development steps of the EM system. Gather feedback from the

stakeholders at all levels. Possible future priorities could include extending

EM systems beyond the urban areas, using research to identify future system

needs, and further training of emergency care providers [10,52]. Although

international research is challenging, it is essential for future programs and

to validate existing development projects [2,11].

Troubleshooting

There are many examples of successful EM development programs

worldwide. When planning programs, where do we go wrong? The most

common areas of program downfall include the following:

, Lack of an assessment of the needs

, Programs that do not focus or receive input from all stake holders

, Frequent changing of the stake holders

, Environment of change is unpredictable

, The many ''land mines'' of agendas

, Failure to adequately develop leadership

, Program support (legislative, financial)

, Eforts that are not a part of a coordinated long-term plan

, Unrealistic planning and expectations

Examples of the problems encountered follow.


Programs that do not focus on all stakeholders

A failure to consider all stakeholders in a system can lead to many

complications. For example, a large urban city in a developing country

attempting to develop an EMS program ran into program problems. The

three existing groups of EMS providers had no set guidelines or standards to

follow and therefore raced to the scene and fought over patients. A visiting

team planned a trauma course only to discover that these prehospital groups

refused to sit in the same room. After interacting with all three factions, an

initial training program was scheduled separately for the groups. At the

conclusion of a trauma module, a large-scale Multi-Casualty Incident

(MCI) was scheduled with all three groups. While participating in the MCI,

the groups came to the realization that working together helped the system

work. They were able to train together in the future, laying the framework

for prehospital standards to be set—cooperative mutual agreements and

standard certification for all groups.

Programs that focus on only one piece of the system

Interventions can occur on any scale; however, regardless of the

magnitude of the program, it is helpful to take the whole picture into

account in the planning. How does this program fit into the bigger picture?

Does this small intervention interfere with another piece of the system? An

educational exchange that took place in a Latin American prehospital

program discovered this lesson the hard way. A visiting group focused

exclusively on the prehospital system and planned a course on advanced

cardiac skills and airway management training. At the conclusion of the

course, airway equipment was donated to the prehospital agency. A follow-

up trip revealed significant system problems. The public hospital that the

prehospital patients were being transported to had no ventilators. In

addition, because there were no mechanisms in place for the prehospital

agency to have their equipment replaced, they were somewhat reluctant to

leave the endotracheal tubes at a hospital with no hopes of getting them

replaced. Careful attention to several key items and being acquainted with

the emergency medical system at the program's beginning could save

significant problems in the long run.

Summary

International EM development requires a comprehensive assessment of

the current system and careful planning to ensure that the most important

needs are addressed. Modeling a country's EM system after an existing

foreign system underestimates the complex needs for instituting appropriate

system interventions. Planning must include all stakeholders. With

appropriate planning, international interventions can contribute to health

system advancement.

194 THOMAS

Appendix. Generic needs assessment tools [48-50] Set assessment priorities Objectives

Provide hospital, health care planners, and policy makers at local and

national levels with necessary tools to

, Describe availability, use, and quality of EM services at all levels of

health care system

, Identify gaps in the ''provision of this care''

Assess Identify information sources

, Identify existing information

, Inspection of the sites

, Interviews of key persons

Categories of information:

, Community composition

, Community organization and structures

, Community relationships, gender relationships

, Community capacity

, Physical environment

, Socioeconomic environment

, Disease and disability

, Attitudes toward EM

, Emergency medical services

, Health policy and funding

Aims:

, Gather relevant information

, Look at community/information/attitudes

, Identify unmet emergency care needs

, Interventions to meet emergency medical care needs

, Existing resources (inside and outside the community) to meet needs

Collect data

, Review available information and decide what additional information is

needed

, How to obtain information

, Plan of action/time table

, Identify and train assessment team

, Collect information


Analyze information

Review findings:

, Identify needs, possible interventions, and resources

, Use and disseminate findings

Present results

, Feedback on assessment to all stakeholders

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