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Introduction: Emergency medical services (EMS) are minimally developed in many African countries. We sought to document the achievements and challenges faced by the National Ambulance Service (NAS) of Ghana during its 20-year nationwide expansion, and to understand how well it is providing access to previously unserved, remoter areas., Methods: Data routinely collected by NAS from 2004 to 2023 were analyzed, including structure and capacity (number of stations, ambulances, employees) and utilization and process of care (number of patients served, demographics, medical conditions, response site). Per population indicators of capacity and utilization were compared across Ghana's 16 regions., Results: From 64 emergency medical technicians (EMTs) and nine ambulances in 2004, NAS has grown to 3,473 EMTs and 356 ambulances. From covering three cities in 2004, NAS now has at least one station in each of Ghana's 261 districts. From transporting 205 patients in 2004, NAS transported 38,393 patients in 2022. There have been interruptions due to financial restrictions, with numbers of patients transported per year in 2017-2019 decreasing by over 50% from the prior peak ( n = 20,236 in 2014). In 2022, there were 1.13 ambulances per 100,000 people and 0.33 transports/100,000/day. Most (81.3%) transports are inter-facility transfers. Among Ghana's 16 regions, there is moderate variation in utilization from 0.16 to 0.50 transports/100,000/day. However, the three lowest-income, remoter regions currently have utilizations of 0.16, 0.30, and 0.37 transports/100,000/day, mostly near the National average of 0.33., Conclusion: Despite periodic limitations due to finances, the NAS has expanded to cover all of Ghana's 261 districts and has largely achieved geographic equity. Sustainability has been aided by having a training school directly under NAS's control, assuring a steady supply of EMTs. Challenges include assuring financial stability and increasing utilization for emergencies at the scene, in addition to the current high utilization for inter-facility transfer., Competing Interests: The authors declared no conflicts of interest., (© 2024 The Authors. Published by Elsevier B.V. on behalf of African Federation for Emergency Medicine.)

Introduction This study aimed to document the growth and challenges encountered in the decade since inception of the National Ambulance Service (NAS) in Ghana, West Africa. By doing so, potentially instructive examples for other low- and middle-income countries (LMICs) planning a formal prehospital care system or attempting to identify ways to improve existing emergency services could be identified., Methods: Data routinely collected by the Ghana NAS from 2004-2014 were described, including: patient demographics, reason for the call, response location, target destination, and ti1mes of service. Additionally, the organizational structure and challenges encountered during the development and maturation of the NAS were reported., Results: In 2004, the NAS piloted operations with 69 newly trained emergency medical technicians (EMTs), nine ambulances, and seven stations. The NAS expanded service delivery with 199 ambulances at 128 stations operated by 1,651 EMTs and 47 administrative and maintenance staff in 2014. In 2004, nine percent of the country was covered by NAS services; in 2014, 81% of Ghana was covered. Health care transfers and roadside responses comprised the majority of services (43%-80% and 10%-57% by year, respectively). Increased mean response time, stable case holding time, and shorter vehicle engaged time reflect greater response ranges due to increased service uptake and improved efficiency of ambulance usage. Specific internal and external challenges with regard to NAS operations also were described., Conclusion: The steady growth of the NAS is evidence of the need for Emergency Medical Services and the effects of sound planning and timely responses to changes in program indicators. The way forward includes further capacity building to increase the number of scene responses, strengthening ties with local health facilities to ensure timely emergency medical care and appropriateness of transfers, assuring a more stable funding stream, and improving public awareness of NAS services. Zakariah A , Stewart BT , Boateng E , Achena C , Tansley G , Mock C . The birth and growth of the National Ambulance Service in Ghana. Prehosp Disaster Med. 2017;32(1):83-93.

Background: Conditions requiring emergency treatment disproportionately affect low- and middle-income countries (LMICs), where there is often insufficient prehospital care capacity. To inform targeted prehospital care development in Ghana, we aimed to describe spatial access to formal prehospital care services and identify ambulance stations for capacity expansion., Methods: Cost distance methods were used to evaluate areal and population-level access to prehospital care within 30 and 60 minutes of each of the 128 ambulance stations in Ghana. With network analysis methods, a two-step floating catchment area model was created to identify district-level variability in access. Districts without NAS stations within their catchment areas were identified as candidates for an additional NAS station. Additionally, five candidate stations for capacity expansion (e.g., addition of an ambulance) were then identified through iterative simulations that were designed to identify the stations that had the greatest influence on the access scores of the ten lowest access districts., Results: Following NAS inception, the proportion of Ghana's landmass serviceable within 60 minutes of a station increased from 8.7 to 59.4% from 2004 to 2014, respectively. Over the same time period, the proportion of the population with access to the NAS within 60-minutes increased from 48% to 79%. The two-step floating catchment area model identified considerable variation in district-level access scores, which ranged from 0.05 to 2.43 ambulances per 100,000 persons (median 0.45; interquartile range 0.23-0.63). Seven candidate districts for NAS station addition and five candidate NAS stations for capacity expansion were identified. The addition of one ambulance to each of the five candidate stations improved access scores in the ten lowest access districts by a total 0.22 ambulances per 100,000 persons., Conclusions: The NAS in Ghana has expanded its population-level spatial access to the majority of the population; however, access inequality exists in both rural and urban areas that can be improved by increasing station capacity or adding additional stations. Geospatial methods to identify access inequities and inform service expansion might serve as a model for other LMICs attempting to understand and improve formal prehospital care services.