Audit report reveals inadequacies in emergency medical care services

Kenya has limited emergency medical care services, especially at the community level, and most citizens do not know how to handle emergency cases, a new report says.

The audit report also says many Kenyans are not aware of community health promoters in their locality, in addition to revealing that there is limited access to critical care services, a lack of Intensive Care Unit (ICU) facilities, and an inconsistent supply of medical drugs and consumables for the provision of emergency medical care.

To this end, the critical hour at the scene of the incident often lacks professional management, thereby negatively impacting the victim's recovery and survival.

This is contained in Auditor General Nancy Gathungu’s performance audit report on the provision of emergency medical care services.

In the report, Gathungu has said there is an inefficient ambulance transport system at both the national and county levels, mainly due to a lack of established ambulance dispatch centres.

“Most counties lack real-time ambulance monitoring technologies and have an inadequate number of ambulances to serve the population in the respective counties. Further, the available ambulances are not well-maintained and sufficiently fuelled in readiness for emergency response.

"Ambulances lacked the required equipment and personnel to handle emergency cases during transit and these inefficiencies have resulted in slow ambulance response times of up to 60 minutes,” she said.

According to the report, this implies that the critical "golden hour" needed to provide emergency medical care to a patient in order to avoid further damage to an injured or ill person is lost and emergency medical care services at all levels of health facilities in the country are inefficient.

“Even though most of the Level 4 and higher-level facilities had accident and emergency departments, these departments lacked adequate personnel, were not well-equipped, and often lacked the required medicine and other essential consumables. This resulted in delays in stabilisation and saving the lives of patients received at the emergency departments.

She also said there is limited access to critical care services in the country, as most of the Level 4 and Level 5 hospitals, which are the main referral hospitals in the country, do not have intensive care units.

The report states that the few facilities that have these units lack an adequate number of ICU beds and personnel with a speciality in critical care service and that the units often have an erratic supply of essential consumables and medicines.

Gathungu has raised concerns about the prioritisation of emergency medical care services at the county level, saying they do not ring-fence funds for this purpose, which are left to compete with other services, disregarding the uncertainties with which emergencies occur.

The audit focused on the provision of emergency medical care services in public health facilities in the country by the Ministry of Health and county governments.

This included public awareness on pre-hospital emergency services at the community level, ambulance services and hospitals' emergency medical care services, with the audit covering four Financial Years, 2021/2022 to 2024/2025, and carried out between March 2023 and February 2025.

The audit team conducted physical verification of emergency departments and ambulances in the sampled 114 health facilities.

The report has stated that a survey administered to 615 members of the public at the sampled health facilities revealed that only 8 per cent had been sensitised on how to handle emergencies, 26 per cent were aware of the numbers to call in case of an emergency, and only 21 of the respondents had basic first aid skills.

The low level of public awareness on response to emergencies was attributed to an inadequate number of community units and community health promoters, resulting in insufficient dissemination of information to the public on response to emergencies.

A review of eight out of 16 sampled counties, whose ambulance dispatch records were available, revealed delays in ambulance response time, ranging from 20 to 60 minutes.

The review, for instance, indicated that only Machakos dispatched ambulances on time.

The delayed response time was mainly attributed to non-establishment and inefficiencies in ambulance dispatch centres, an inadequate number of ambulances, ill-equipped ambulances, inadequate fuelling and maintenance of ambulances, and insufficient ambulance staff.

At the same time, the report states that the country lacks a national ambulance dispatch centre to centrally coordinate ambulance services, though 12 out of the 16 sampled counties had ambulance dispatch centres.

Despite the 12 counties having ambulance dispatch centres, there were inefficiencies in their operations caused by a lack of a real-time electronic system for tracking ambulances and recording call logs, insufficient communication gadgets, a lack of toll-free numbers for ease of communication by the public, insufficient personnel, challenges with internet connectivity and a lack of backup generators.

Similarly, the audit in 10 of 16 counties had the required number of ambulances to serve their population, while six counties had deficits ranging from one to 30 ambulances in a county.

“The inadequate number of ambulances was attributed to non-functional ambulances, as 92 out of the sampled 269 ambulances, representing 34 per cent, were non-functional. Further, the ambulances lacked necessary equipment and staff, did not have sufficient fuel and were not well maintained,” the report states.

According to the report, Levels 6, 5, and 4 hospitals are expected to have separate accident and emergency departments for adults, adolescents and paediatrics, which should be equipped and staffed to provide rapid and varied emergency care.

The audit established that the four sampled Level 6 hospitals had established accident and emergency departments for adults, adolescents, and paediatrics.

Further, 11, representing 73 per cent of the sampled 15 Level 5 hospitals, had operational accident and emergency departments; however, they lacked a separate accident and emergency department for paediatrics.

Only three, representing 9 per cent, out of the sampled 33 Level 4 hospitals had accident and emergency departments, but none had a separate paediatric section.

“Analysis of staff data revealed that seven of the 14 Level 4 and Level 5 facilities that had accident and emergency departments did not meet the minimum requirement for at least 10 accident and emergency nurses; they each had between one and four of these nurses,” the report says.

“As a result of the shortage of accident and emergency nurses, emergency patients were attended to by general nurses who did not have the Kenya Registered Accident and Emergency Nursing qualification, which equips nurses with training to handle critical situations and deliver advanced emergency medical treatment,” it adds.

The audit established that the estimated nurse-to-patient ratio, within 24 hours, in the departments receiving emergency patients ranged from 1:5 to 1:100 in the sampled Level 4 facilities and 1:8 to 1:122 in sampled Level 5 facilities.

This is contrary to the WHO requirement that the nurse-to-patient ratio should not exceed 1:4 at the accident and emergency department. The audit team also established that Level 3 and Level 2 facilities experienced a shortage of both clinical officers and nurses.

Inadequate essential equipment for handling emergencies was reported.

According to Gathungu, accident and emergency service areas typically must have their own diagnostic equipment for the timely provision of emergency medical services.

But the audit established that the sampled health facilities did not have adequate equipment for the provision of emergency medical services.

This included equipment for airway breathing, monitoring and circulation, diagnostic equipment for emergency examinations, and other essential equipment for emergency medical care services.

For instance, 90 per cent of the sampled Level 4 and 46 per cent of the sampled Level 5 hospitals lacked piped oxygen, while 84 per cent and 80 per cent lacked ventilators, respectively.

All sampled Level 2 and Level 3 facilities lacked piped oxygen and out of the sampled facilities, 83 per cent of Level 2 and 62 per cent of Level 3 facilities lacked oxygen cylinders.

“Shortage of essential equipment leads to missed or delayed diagnosis that can lead to adverse outcomes for the patients, including increased risk of complications, permanent disability or fatalities. The shortage of imaging equipment results in increased referrals for cases that can be handled at lower-level facilities, thereby contributing to delays in treatment,” Gathungu said.

The audit established that 90 per cent of the sampled Level 4 hospitals and 33 per cent of the sampled Level 5 hospitals did not have intensive care units and high dependency units and there was inefficient provision of critical care services in facilities that had operational critical care units.

This was attributed to inadequate bed capacity, owing to inadequate equipment, staff, and medical commodities.

She has also said that it is a mandatory requirement for Level 4, Level 5 and Level 6 hospitals to have six, 12 and 24 functional ICU beds, respectively, as per the Kenya Medical Practitioners Hospital Checklist for Categorisation of Health Institutions, 2019.

But out of the 15 sampled Level 5 hospitals, only the Coast General Teaching and Referral Hospital met this requirement, while none of the 33 Level 4 hospitals met the requirement.

“These hospitals had deficits of between three and 12 ICU beds. All the sampled Level 6 hospitals met the minimum requirement for ICU bed capacity. As a result of the inadequate ICU bed capacity in Level 4 and Level 5 hospitals, patients were referred to Level 6 hospitals for critical care services, thereby straining the resources in Level 6 hospitals,” Gathungu said.

In other cases, due to a lack of functional High Dependency Unit beds, patients would be moved from the ICU directly to the wards and there were also instances of patients being retained at the ICU for recuperation, further limiting the availability of the already-strained ICU bed capacity in the hospitals.