Post-crash response

Key messages

Policy and legal framework:

Six countries in the Region reported having a universal access law guaranteeing financial protection or free emergency care.
Seventeen countries have a national law requiring that healthcare centers treat anyone suffering a health emergency.
Three countries (Canada, the United States, and Panama) have a national Good Samaritan law.
Twelve countries reported having legislation guaranteeing rehabilitation medical care “without exception”. Six countries provide such care with “some exceptions”.
Eighteen countries reported having free access to public and government psychological assistance services.
Twenty-seven countries reported having national legislation making third-party liability insurance mandatory for all motor vehicles.
Twenty-five countries have a leading office, agency, or department within the Ministry of Health, or another ministry, responsible for emergency care.
Two countries included a response target time in minutes in their road safety strategies, although neither reported this indicator. Fourteen other countries quantified a national response time target, and five specified a subnational target.

Comprehensive assessment: Five countries (Belize, Costa Rica, Jamaica, Paraguay, and Trinidad and Tobago) have conducted a comprehensive assessment of their national emergency and critical care systems, to identify gaps and priority actions to strengthen emergency care. They used the WHO Emergency and Critical Care Systems Assessment (ECCSA) tool to perform this activity.
Telephone number: Thirteen countries reported having a single emergency services telephone number with nationwide coverage. Barbados, Colombia, and the Dominican Republic have made progress since the 2018 report.
Human resources:

Certifying providers:

Eleven countries reported having an official, government-endorsed certification pathway for pre-hospital care providers. Canada, Jamaica, and Uruguay have made progress since 2018.
Five countries have national legislation on mandatory training, licensing, or certification for first responders.

Postgraduate specialization:

Fourteen countries reported offering postgraduate specialization courses for nursing staff working in emergency or trauma care. Argentina, Paraguay, El Salvador, and Uruguay reported progress in this area since 2018.
Twenty-three countries reported offering emergency medicine specialization courses. El Salvador reported progress since the 2018 report.
Nineteen countries reported offering medical specialization courses in trauma surgery, including Argentina, Belize, Bolivia (Plurinational State of), the Dominican Republic, Guyana, Jamaica, and Trinidad and Tobago, which did not offer this specialization in 2018.

Capacity building (ongoing education):

Through the joint efforts of PAHO, WHO, and the Latin American Federation of Emergency Medicine, 164 professionals have been certified as basic emergency care (BEC) providers, and 58 facilitators have been trained to teach this course throughout the Region.
Two countries have institutionalized a cascading training strategy for the BEC course, for the ongoing education and certification of health personnel.

Trauma registries: Fifteen countries reported maintaining trauma registries with data provided by different national facilities. Progress was reported in Argentina, Bolivia (Plurinational State of), Brazil, Dominica, and Guyana since the 2018 report.

The information gathered to prepare this report allows follow-up on the recommendations to strengthen trauma emergency care (20). It thus addresses PAHO’s mandate from Member States through various United Nations General Assembly and World Health Assembly resolutions. The two most recent, approved in 2023, aim to implement additional efforts to consolidate those made over the last 20 years, on a global scale.

In May 2023, the World Health Assembly approved Resolution 76.2: Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies (21). Later, in October 2023, the United Nations General Assembly approved Resolution 78.4: Political declaration of the high-level meeting on universal health coverage, which aims to scale up efforts to address the specific physical and mental health needs of all people, including those injured in road traffic crashes, by strengthening integrated emergency,⁵⁸ operative, and intensive care systems (22).

Designing a policy

Establishing a policy that supports sustainable funding, effective governance, and universal access to safe, high-quality emergency, operative, and intensive care, based on the needs of the population, is the goal (20). Ideally, such a policy would be supplemented by explicit legal or regulatory frameworks inextricably linked to the leadership capacity of national authorities, enabling governance. Clear legal and mandatory standards for sustainable funding would also ensure the availability of sufficient financial resources. In this report, six countries in the Region⁵⁹ reported having a universal access law guaranteeing financial protection or free emergency care. Another 15 countries have a law guaranteeing access to emergency care, ensuring that no payment is required before care is provided.⁶⁰ Two countries (Belize and Mexico) reported having legislation providing access to emergency services, with the cost of care depending on an individual’s ability to pay. In certain cases only, payment is required before care is provided. One country (Haiti) reported having some legislation on access to emergency care, but almost everyone has to pay before receiving it. Finally, two countries (Dominica, and Trinidad and Tobago) reported having no laws guaranteeing access to emergency care services.

During the validation process, WHO had access to legal instruments from participating countries in the Region. It concluded that 17 of them⁶¹ have a national law requiring healthcare facilities to treat anyone suffering a health emergency. In three of these countries (Argentina, Costa Rica, and Cuba), the mandate applies to public health facilities only. This does not restrict access to services, however, since their health systems are rooted in the public sector. In eight countries, it applies to both public and private facilities.⁶² By way of context, the analysis conducted in 2015 found that only two countries (Ecuador and Nicaragua) had laws stipulating that hospitals must provide free stabilization services to all injured persons arriving at emergency services.

Providing early-stage rehabilitation services has been proven to significantly reduce hospital stays and costs, making emergency care even more cost-effective (23). Twelve countries in the Region⁶³ reported having legislation guaranteeing rehabilitation medical care “without exception”. Six countries provide such care with “some exceptions”⁶⁴ (Table 15). Based on a review of various legal instruments, WHO concluded that eight countries⁶⁵ have a national law on access to rehabilitation regardless of individuals’ ability to pay. While 18 countries reported free access to public and government psychological assistance services, ⁶⁶ the WHO legal instrument review concluded that three countries (Argentina, Mexico, and Suriname) have a national law providing victims and their families with psychological care, regardless of their ability to pay. Both services are key to comprehensive post-disaster response (24).

Table 15. Exceptions to guaranteed rehabilitation medical care for injured persons

Eighteen of the participating countries reported having specific government-allocated funds for the medical care and treatment of road traffic injuries.⁶⁷ A further 15 have funds to rehabilitate survivors,⁶⁸ and 13 for survivor palliative care.⁶⁹

Twenty-seven countries⁷⁰ reported having national legislation making third-party liability insurance mandatory for all motor vehicles. With the exception of Bolivia (Plurinational State of), which reported that its legislation does not apply to passenger buses, these 27 countries’ legislation covers all two- to four-wheeled motor vehicles, buses, and freight vehicles. In the Bahamas, Guatemala, Peru, and Trinidad and Tobago, the legislation applies to bicycles. In Bolivia (Plurinational State of), Guatemala, Guyana, Peru, and Saint Lucia, it also applies to personal mobility vehicles (including electric scooters). Third-party liability protection covers personal injury in 22 countries, death in 21, disability in 20, and legal support in five. To protect the occupants of insured vehicles, personal injury was included in 17 countries, death in 18, disability in 16, and legal support in five (Table 16).

However, there is a clear need to move towards universal insurance for motor vehicles, especially those used for public or private passenger transportation. The percentage ratio of total insured vehicles to total registered vehicles was 25% or less in Brazil, the Dominican Republic, Guatemala, Honduras, Panama, and Peru. It ranged from 26% to 50% in Mexico and Uruguay; from 51% to 75% in Bolivia (Plurinational State of), Colombia, and Costa Rica; and was over 100% in Chile and Nicaragua.⁷¹

Table 16. Country-reported mandatory vehicle third-party liability insurance coverage

Ministry of Health office responsible for emergency care

Countries should have a policy with a governance mechanism that coordinates routine emergency care services and forges links with agencies from other sectors, to respond to disasters and outbreaks. To achieve this, PAHO recommends that each country in the Region designate an office or area responsible for emergency care within the Ministry of Health.

Twenty-five of the participating countries⁷² reported having a leading office, agency, or area within the Ministry of Health, or another government ministry, responsible for emergency care (Table 17). It should be further analyzed how many of these entities are responsible for the entire care process, from receiving calls in dispatch centers to pre-hospital care services, hospital emergency units, critical and operative care, and patient rehabilitation services. Consolidating authority in this way would facilitate effective management. Conducting a national ECCSA exercise would be extremely useful.

Table 17. Name of the Ministry of Health department or other agency responsible for emergency care

Note: It is worth noting that the Belize Emergency Response Team (BERT) is a non-governmental organization (NGO) supporting pre-hospital care, primarily in Belize City. It is funded by the country’s Ministry of Health and Wellness, but is not part of the Ministry itself. The Belize Red Cross is also an NGO; however, the National Emergency Management Organization (NEMO) is the only department of the Belize Government and authority responsible for keeping Belize in a state of readiness for any emergency that may require a national response (i.e., a disaster). It is also responsible for training and coordination between the public and private sectors. The Ministry of Health and Wellness is working alongside the Pan American Health Organization to strengthen the country’s emergency and critical care.

Situation analysis

To strengthen emergency trauma care, PAHO recommends identifying areas for improvement and prioritizing strengthening actions by using the ECCSA tool to conduct a situational diagnosis. More countries in the Region of the Americas have started using the WHO-designed, standardized tool in recent years, to help develop roadmaps to comprehensively strengthen emergency care.

While five countries (the Dominican Republic, Ecuador, El Salvador, Mexico, and the United States) reported having conducted a standardized assessment of their emergency care systems in 2018, only the Dominican Republic reported using the WHO tool.⁷³ Table 18 presents the tools used by the other four countries. By 2023, five more countries reported having carried out this exercise. However, Costa Rica, Paraguay, and Trinidad and Tobago used the ECCSA tool. In 2023, Belize and Jamaica completed this exercise, after collecting information for this report (Box 12). These latest assessments led to an emergency care priority action plan. This will enable these countries’ health ministries and other participating institutions to make more strategic steps forward.

Table 18. Other tools for assessing pre-hospital emergency care systems

Box 12. Emergency and Critical Care Systems Assessment in the Americas

Since 2019, when the World Health Assembly approved Resolution 72.16, requesting that the World Health Organization (WHO) provide guidance and technical cooperation to strengthen emergency care systems, five countries have used WHO’s Emergency and Critical Care Systems Assessment (ECCSA) tool: Trinidad and Tobago (2019), Paraguay (2022), Costa Rica (2022), Belize (2023), and Jamaica (2023). More recent progress has been made in the dialogue to implement this tool in other countries in the Region.

The ECCSA is a standardized tool that facilitates locally adapted strategic planning. It was designed to help policymakers and planners comprehensively assess national and regional emergency care systems (including critical care), identify gaps or deficiencies, and prioritize actions. It is based on the emergency care system framework developed by WHO and a group of experts.

Health ministries are leading this assessment exercise, with the coordinated support of all three levels of WHO (Headquarters in Geneva, regional office, and Pan American Health Organization country representative offices). It brings together local expert and professional policymakers, providers and administrators of public and private pre-hospital and hospital services, and researchers and epidemiologists with emergency care experience, to represent different levels and regions within the country. This exercise promotes consensus on the diagnosis and priority actions that can (or should) be taken to strengthen emergency and critical care. In doing so, it aids the development of roadmaps or action plans to implement these measures in the short, medium, and long term, identifying opportunities for joint work and technical cooperation.

Note: For more information about the activities performed in different countries:

Source: Prepared by the authors, based on Pan American Health Organization materials. Strengthening Post-crash Response in the Region of the Americas. Washington, D.C.: PAHO; 2023; Pan American Health Organization. WHO Emergency care system framework. Washington, D.C.: PAHO; 2022.

Strengthening the legal and regulatory framework

Legal and regulatory frameworks⁷⁴ must incorporate various essential elements. As a matter of priority, they must ensure integrated emergency, critical, and operative care, rehabilitation, and psychological assistance, regardless of the injured individual’s ability to pay, as well as legal protection for those who in good faith assist the injured, through so-called Good Samaritan laws.⁷⁵ WHO’s legal instrument review for this exercise concluded that only Canada and the United States⁷⁶ have national Good Samaritan laws. After the 2023 global report was published (3), it was reported that Panama also had a Good Samaritan law (Box 13). Seven countries (Bolivia [Plurinational State of], the Dominican Republic, Ecuador, Honduras, Mexico, Nicaragua, and Paraguay) also reportedly have national laws requiring bystanders to assist anyone involved in an emergency or road traffic crash. Four of these countries (the Dominican Republic, Ecuador, Nicaragua, and Paraguay) define “road traffic crashes” in these laws, but only the Dominican Republic clearly defines a “health emergency”.

The legal instrument review concluded that five countries (the Dominican Republic, Ecuador, Jamaica, Mexico, and Paraguay) have national laws requiring the training, licensing, or certification of first responders. Other key elements not included in the review can be consulted in previous publications (20, 25).

Box 13. Panama’s Good Samaritan Law

Following the preventable death of Dr. Kreslyn Rodríguez, aged 43, who was riding his motorcycle on 29 July 2016, the Republic of Panama National Assembly published Law 57 on 30 November 2016. This law (also known as the “Good Samaritan Law”) establishes legal protection for those who assist and care for others in an emergency. On 26 December 2017, the Ministry of Health published Executive Decree No. 346 regulating this law.

As with many deaths on public roads, a key aspect was the delay in medical care. According to local reports, the recorded response time in this case may have been between 50 and 77 minutes. Countries therefore adopted Target 12 of the Global Plan 2021-2030, on providing emergency care in road traffic crashes, committing to ensure that “by 2030, all countries establish and achieve national targets in order to minimize the time interval between road traffic crash and the provision of first professional emergency care”.

This case also demonstrated the importance of having a law to protect anyone who may have assisted Dr. Rodríguez at the scene. The story went viral on social media, as Dr. Rodríguez, a physician himself, asked several passersby for help, but no one came to his aid. Even security personnel with basic skills, following a physician’s instructions, could have saved his life. Until this law was passed, Panamanians were afraid to report or assist those injured in road traffic crashes, due to the risk of prosecution for the results of their actions, or the obligation to appear as a witness during the police investigation.

In addition to the Good Samaritan Law —which provides legal protection to those trying to save the lives of people injured in road traffic crashes— the corresponding procedures should also be reviewed or simplified. Public awareness campaigns should be implemented, and all public servants providing direct services should be trained.

Following this event, the importance of providing first aid training to personnel linked to the emergency care system was also recognized, to help prevent these types of accidents. The World Health Organization is about to launch a training program to support community first aid response (CFAR), which will be rolled out in the Region of the Americas in the near future.

Source: Prepared by the authors, based on the Republic of Panama National Assembly. Law 57, of 30 November 2016, establishing legal protection for people who assist in and respond to emergencies. Gaceta Oficial Digital N.º 28169-A, Year CXV, 1 December 2016. Available from: https://www.gacetaoficial.gob.pa/pdfTemp/28169_A/GacetaNo_28169a_20161201.pdf; Ministry of Health. Executive Decree No. 346, of 26 December 2017, which regulates Law 57, of 30 November 2016, establishing legal protection for people who assist in and respond to emergencies. Gaceta Oficial Digital N.º 28439, Year CXVII, 5 January 2018. Available from: http://gacetas.procuraduria-admon.gob.pa/28439_2018.pdf; Zeballos E. Nuevas medidas tras la muerte del médico Kreslyn. El Siglo, Nacionales, 4 August 2016 [Accessed 24 October 2023]. Available from: https://elsiglo.com.pa/panama/nacionales/nuevas-medidas-tras-muerte-medico-kreslyn-FVES23954363; World Health Organization/United Nations. Global Plan for the Decade of Action for Road Safety 2021-2030. Washington, D.C.: WHO/UN; 2021. Available from: https://www.who.int/publications/m/item/global-plan-for-the-decade-of-action-for-road-safety-2021-2030

Effective access to pre-hospital emergency care

Access to pre-hospital emergency care should be guaranteed to all injured persons in all countries, through informal or formal systems. Such systems are implemented according to each country’s available resources. Providing formal pre-hospital emergency care requires a single, universally accessible, toll-free telephone number, to activate the system and trigger a timely response.⁷⁷

In 2023, 13 countries reported having a single emergency services number with nationwide coverage.⁷⁸ Five countries had a nationwide number, and other numbers with partial coverage (Canada, Cuba, Haiti, Saint Lucia, and Trinidad and Tobago). Nine countries still have multiple emergency numbers that, as a whole, provide nationwide coverage.⁷⁹ Five countries reported having one or more of these numbers, with only partial coverage (some parts of the country have no coverage) (the Bahamas, Brazil, Guyana, Peru, and Suriname). Figure 33 shows how this indicator has changed between 2018 and 2023.

Barbados, Colombia, and the Dominican Republic (which had multiple numbers in 2018) reported progress in this regard, as did Panama and Uruguay (which had other numbers in the 2018 report). Trinidad and Tobago has gone from having multiple emergency numbers to a single number with nationwide coverage (811), although other numbers do still exist. Argentina and Bolivia (Plurinational State of) have improved their national coverage, but still have multiple numbers (9).

Figure 33. Availability of a single, universally accessible emergency telephone number, 2018 and 2023

Note: Unlike 2023, the Bahamas, Haiti, the British Virgin Islands, and Nicaragua did not participate in 2018, while Grenada and Venezuela (Bolivarian Republic of) did.

In 11 countries,⁸⁰ the effective coverage of formal pre-hospital care ⁸¹ for all is 96%. Four countries (Brazil, Dominica, the British Virgin Islands, and Uruguay) reported effective coverage between 76% and 95%. Coverage is between 51% and 75% in three countries (Chile, Haiti, and Nicaragua), and between 25% and 50% in another four countries (Ecuador, El Salvador, Guyana, and Paraguay). Belize and Jamaica still have work to do to expand coverage. They reported that less than 25% of people have access to effective pre-hospital care. Figure 34 analyzes how pre-hospital care coverage has changed over time.

Figure 34. Report on pre-hospital care coverage in different years: 2013, 2015, and 2023

Note: The following countries participated in 2023, but not 2013: Antigua and Barbuda, Haiti, and the British Virgin Islands. Haiti and the British Virgin Islands did not participate in 2015. The following countries participated in 2013, but not 2023: Saint Kitts and Nevis, Saint Vincent and the Grenadines, and Venezuela (Bolivarian Republic of). Saint Vincent and the Grenadines participated in 2015. The following countries did not specify this percentage for 2013: Brazil, Chile, Guyana, and the Dominican Republic. The following countries did not specify this percentage for 2015: Belize and Chile. The following countries did not specify this percentage for 2023: Colombia, Honduras, and Suriname. The 2013 and 2015 data refer to seriously injured individuals taken to hospital by ambulance. The 2023 data refer to effective coverage by a formal pre-hospital ambulance system (including care at the scene and during transport) for all individuals, under all circumstances.

Effective access to specialized medical care in hospital centers

For the system to work, hospitals at all levels must have an emergency unit operating 24 hours a day, seven days a week, where injured individuals can receive a proper diagnosis and definitive treatment (20).

No countries believed they had adequate nationwide emergency care systems; in other words, the number, level, and distribution of hospital emergency units and access to them do not meet the needs of both the urban and rural population.⁸² Ten countries believed that the distribution of, coordination between, and access to health units still creates gaps in access.⁸³ Another 10 countries⁸⁴ reported adequate emergency care in most urban areas, but only partially available emergency care in rural areas. The number and level of emergency care facilities are therefore inadequate, or they are not well distributed to meet the general population’s needs. Eight countries⁸⁵ reported some emergency care in urban areas, although not enough to meet the population’s needs. In rural areas, emergency care was either non-existent or minimal.

Of the 18 countries that reported having a law guaranteeing access to rehabilitation care, with or without exceptions, El Salvador reported that less than 25% of people with road traffic injuries received rehabilitation care. This percentage ranged from 75% to 100% in Colombia, Cuba, Guatemala, Guyana, Nicaragua, and Uruguay.

Finally, of the 18 countries that reported having free access to psychological assistance for road traffic victims or their families, Barbados, Colombia, Guyana, El Salvador, and Uruguay reported that less than 25% of people surviving a road traffic injury received psychological care. Cuba, Nicaragua, and the British Virgin Islands reported that between 75% and 100% accessed this service. It is important to highlight some of the progress made in countries such as Argentina and Belize (Boxes 14 and 15).

Box 14. Psychological support, an essential part of post-crash response for victims and their families: the situation in Argentina

Being the victim of a road traffic crash is a traumatic experience which has a profound impact on people. As well as potential physical injuries, there are emotional, family, work-related, administrative, and legal consequences. These last far beyond the initial and immediate impact of the crash and can significantly affect individuals’ quality of life. Post-crash response must therefore include a comprehensive approach to meet the needs of victims and their families and create strategies to address them. In 2020, Argentina’s National Road Safety Agency created the Center for Assistance to Victims and Families of Victims of Road Traffic Crashes. This is a guidance service operating nationwide through a free telephone line (149), available 24 hours a day, all year round. The center offers comprehensive care to victims and their families, providing guidance and advice on psychological, legal, social, and medical assistance. Callers are given all available information and advice on how to access various benefits and services. The action protocol involves coordination with other organizations and institutions. Coordinating with local institutions makes it possible to provide victims with the professional services they need (psychological care, legal advice, etc.), close to where they live. The protocol also includes devices for monitoring cases.

Note: More information about this experience:

Source: Prepared by the authors, based on Pan American Health Organization materials. Implementación de medidas de seguridad vial prioritarias en América Latina y el Caribe. Washington, D.C.: PAHO; 2023:63.

Box 15. Psychological emergency training program in Belize

The mental and psychosocial health project for victims of road traffic crashes was implemented between April 2022 and September 2023, in collaboration with the Government of Belize. This project aimed to help improve the quality of mental health and psychological support services for victims of road traffic crashes and their families.

In Belize, road traffic injuries are a major issue, as they are the eighth leading cause of death. The country’s mortality rate was 23.6 per 100,000 inhabitants in 2019 as a result, indicating a significant public health problem. Road traffic injuries have significant negative consequences, including emotional and psychological effects on victims and their families. They also entail a financial burden, an increase in the number of healthy life years lost, loss of productivity and income for victims and their caregivers, and an increase in the country’s mortality and morbidity rates.

In this context, the Pan American Health Organization (PAHO) —in collaboration with the Government of Belize, through the Ministry of Finance, Economic Development and Investment, and with funding from the Caribbean Development Bank (CDB)— agreed to provide technical cooperation to implement the Mental Health and Psychosocial Support Services Project for victims of road traffic crashes. This forms part of Phase II of the Road Safety Project, a long-term initiative of the Government of Belize, supported by the CDB, to improve the country’s road safety.

The project considered important recommendations that emerged from the situation analysis. It is noteworthy that Belize has established a technical working group on mental health and psychological support services. The primary purpose of this working group is to discuss technical aspects of emergency scheduling in Belize, harmonize interventions, avoid duplication, facilitate referrals and counter-referrals, and incorporate the PAHO framework and Inter-Agency Standing Committee (IASC) Guidelines on mental health and psychosocial support.

More than 120 emergency response workers have also been equipped with the skills and resources necessary to provide emergency psychological first aid to road traffic victims and their families, without stigma or discrimination. Twenty-five of these trained individuals are now trainers themselves. They are able to provide ongoing training within their respective districts and fields of work to ensure continued and sustainable capacity-building for the project.

Developing and implementing key communication and publicity materials also helped raise awareness about the country’s available services, and increased the visibility of the project, the donor partner, and other key implementing partners. The project’s successful implementation and completion was made possible thanks to the support and working relationship with PAHO and key stakeholders in Belize. The Government of Belize’s completion and approval of all documents and the successful implementation of this project’s capacity-building aspect are clear indicators of Belize’s progress in the field of mental health and psychosocial support.

Note: For more information on these activities, click here

Training, certifying, and professionalizing human resources

Human resources are crucial to the success of emergency trauma care. Countries must therefore implement regularly updated training strategies on emergency trauma clinical care at different levels. This will give care providers the opportunity to access the most current information on recommended strategies, and provide quality care (20).

In this report, 11 countries⁸⁶ reported having an official government-endorsed certification pathway for pre-hospital care providers.⁸⁷ This includes special certification for paramedics, technicians, nursing staff, and other professionals. Canada, Jamaica, and Uruguay, which reported not having this official certification in 2018, have made progress in this area (9). Countries such as Costa Rica, Cuba, Ecuador, Guatemala, Honduras, Mexico, Panama, and Saint Lucia had previously reported having an official certification pathway. However, in this report, they said that they did not have such a pathway or were unaware of it.

Implementing regularly updated emergency clinical care training and specialization programs for all health personnel is equally important. In this report, 14 countries⁸⁸ said that postgraduate specialization courses were available for nursing staff working in emergency or trauma care. Argentina, El Salvador, Paraguay, and Uruguay said that they had made progress on this issue since 2018. In contrast, Bolivia (Plurinational State of), Chile, Colombia, Costa Rica, Guatemala, and Panama reported that such courses do not currently exist or they were unaware of them, despite saying that they were available in 2018 (9).

Twenty-three countries reported emergency medicine specialization courses.⁸⁹ El Salvador reported progress since the previous report. Panama and Trinidad and Tobago said that they were unaware of such programs, despite saying that they were available in previous reports (9, 26, 27). Nineteen countries⁹⁰ reported offering courses specializing in trauma surgery. These included Argentina, Belize, Bolivia (Plurinational State of), the Dominican Republic, Guyana, Jamaica, and Trinidad and Tobago, which did not report offering this specialization in 2018. Colombia, Costa Rica, and Peru reported that they did not have or were unaware of trauma surgery specialization courses in their countries, despite saying that they were available in the previous report (9).

WHO, in collaboration with the International Committee of the Red Cross and the International Federation for Emergency Medicine, developed the course “Basic Emergency Care: approach to the acutely ill and injured”. PAHO has been supporting various countries in the Americas in organizing a cascading training strategy for this course, and aims to expand its coverage (Box 16).

Box 16. Implementing the Basic Emergency Care course in the Americas

With the invaluable support of the Latin American Federation of Emergency Medicine (FLAME) and a significant group of professionals committed to emergency care, in 2023, the Pan American Health Organization (PAHO) launched a cascading training program for the Basic Emergency Care (BEC) course in various countries in the Region. This course was developed by WHO in collaboration with the International Committee of the Red Cross and the International Federation for Emergency Medicine (through its regional office, FLAME).

In 2023, a total of six courses were held in the Region. As a result, 164 professionals were certified as BEC providers and 58 facilitators were trained to teach this course. Thanks to coordination between all three levels of the World Health Organization (Headquarters in Geneva, regional office, and PAHO in-country offices), courses were held in Costa Rica (February), Paraguay (May), Costa Rica again (June), Argentina (August), Mexico (September), and Costa Rica for a third time (October).

This last course was the first to be conducted with local staff only, including facilitators from the fire department, the National Insurance Institute, and the Costa Rican Social Security Fund. The BEC course to recertify medical personnel has also been approved by the College of Physicians and Surgeons of Costa Rica. Through these actions, Costa Rica has made considerable progress in consolidating this training program. Similarly, the Paraguayan Ministry of Health declared this course “of institutional interest” on 23 May 2023. This is a major step towards consolidating this strategy in Paraguay, making it a priority action of the Directorate of Non-Communicable Disease Surveillance in its National Program for Managing Accidents and Injuries from External Causes.

It is important to highlight that this effort builds on the work previously carried out by the Red Cross and other professionals who have been working tirelessly on this issue in various countries of the Region, including Belize, El Salvador, Guatemala, and Honduras.

Note:For more information, see:

Costa Rica: World Health Organization. Basic Emergency Care Course. San José, Costa Rica: WHO; 2023. Pan American Health Organization. Personal de instituciones costarricenses se capacita en atención básica de emergencias. Washington, D.C.: PAHO; 2023.

Mexico: Pan American Health Organization. Personal de salud de Durango recibe capacitación en Atención Básica de Emergencias. Washington, D.C.: PAHO; 2024.

Source: Prepared by the authors, based on Pan American Health Organization materials. Fortalecer la atención de emergencias traumatológicas en la Región de las Américas. Washington, D.C.: PAHO; 2023. Pan American Health Organization. Virtual seminar entitled: Strengthening Post-crash Response in the Region of the Americas. Washington, D.C.: PAHO; 2023.

Technology and comprehensive information system to monitor and assess performance

Using information systems with standardized, essential data from trauma registries enables better understanding of the nature of emergency care issues and facilitates the implementation of programs to improve quality of care. In this report, 15 countries⁹¹ reported having trauma registries containing data from various national facilities. Canada and Jamaica reported having state or subnational registries. Belize, Guatemala, Honduras, Mexico, and Suriname reported having registries from only a few facilities throughout the country. Antigua and Barbuda, the Bahamas, Paraguay, and Saint Lucia were unaware that these registries existed.

This suggests improvements in Argentina and Bolivia (Plurinational State of) (which in 2018 reported trauma registries in only a few facilities), and in Brazil, Dominica, and Guyana (which reported not having trauma registries in 2018). Although Mexico reported having these records in 2018, in this report it acknowledged having them only in a few facilities scattered across the country.

Twenty-five countries reported having national or subnational road safety strategies.⁹² Eleven of these said that the strategies aimed to improve emergency response times⁹³ nationally⁹⁴, while four countries hoped to achieve this at the subnational level (Canada, Mexico, Nicaragua, and Peru). However, only Chile (15 minutes, but only in urban areas) and Mexico (less than 10 minutes, but only in Mexico City) specified this goal in minutes. Neither of these countries quantified this indicator, however; therefore, the level of compliance is unknown.

Table 19 shows that 14 countries quantified the response time indicator at the national level, and five did so at the subnational level. Despite not including a specific target response time in their road safety strategies, nine countries⁹⁵ quantified this indicator at the national level, and three countries also did so at the subnational level (Dominica, Honduras, and Jamaica). It is important to note that the national indicator needs to reflect most, if not all, cases observed. Six countries (the British Virgin Islands, Cuba, the Dominican Republic, El Salvador, Trinidad and Tobago, and the United States) reported that it covered most injured people (75% to 100%) Three countries (Guatemala, Suriname, and Uruguay) said that it only represented 50% to 74%. Seven countries (Costa Rica, Dominica, Ecuador, Guyana, Honduras, Jamaica, and Paraguay) said that this percentage was unknown.

Two years ago, the average response time in countries reporting this indicator nationally was 21.82 minutes (minimum 8.13 minutes and maximum 45 minutes). Last year, it was 19.89 minutes (minimum 8.3 minutes and maximum 35 minutes). In countries reporting subnational data, two years ago the average response time was 21.25 minutes. Last year, it was 20 minutes (minimum 10 minutes and maximum 30 minutes, in both years). Jamaica only reported data for one year in urban and rural areas (15 minutes and 20 minutes, respectively) (Table 19).

Table 19. Response time in the last two years

--; data not available.

In its effort to support countries on this issue, PAHO has developed the Medical Emergency Information System (SISMED911), which has been successfully implemented in different countries of the Region, including Ecuador (28, 29). Box 17 presents the components of this tool so that interested countries can benefit from it.

Box 17. Pan American Health Organization Medical Emergency Information System

The Medical Emergency Information System (SISMED911) is a technological solution for responding to inter-hospital and pre-hospital emergencies. It is a free information system, developed by the Pan American Health Organization, designed to support the entire emergency cycle, from the request for help to its resolution. It comprises technical tools for each stage of the emergency: receiving the call, regulating media, decision-making, coordinating and monitoring mobilized resources, hospital service information, and service resolution. It contains the following process modules:

Inter-hospital. Managing and monitoring patients in referrals and counter-referrals.
Pre-hospital. Registering, characterizing, and dispatching available resources for pre-hospital emergency care.
Med-Surg. Monitoring and following up hospital services.
Ambulance. Managing service maintenance and fuel.
E-clinical. Patient admission, triage using algorithms, and emergency room care.
E-reports. Dashboards and process statistics.

The SISMED911 system uses multiple parameters, facilitates resource optimization by effectively utilizing available resources, and allows each part of the system to operate autonomously and independently. The flexibility afforded by its structure and the design of interfaces using standard and free technologies enables interaction with other PAHO subsystems.

Source: Prepared by the authors, based on Pan American Health Organization materials. Fortalecer la atención de emergencias traumatológicas en la Región de las Américas. Washington, D.C.: PAHO; 2023.

The international community recognizes advances made in emergency care in countries in the Americas, with PAHO’s support. The outlook for the future is positive, as countries continue to make progress on this important issue (Box 18). Support from major funders —such as the United Nations Road Safety Fund— may be key to capitalizing on the renewed interest of health ministries and road safety coordinating agencies in improving post-crash response in general, and integrated emergency, critical, and operative care, in particular. PAHO/WHO has therefore developed various tools to strengthen emergency care.⁹⁶

Box 18. Outlook for the future: a project funded by the United Nations Road Safety Fund to strengthen emergency care in the Americas.

To support in-country efforts, the Pan American Health Organization (PAHO) launched two publications in 2023. On 18 May 2023, thanks to the invaluable support of the PAHO Collaborating Centre at the University of California, San Francisco, the Department of Emergency Medicine published the document Fortalecer la atención de emergencias traumatológicas en la Región de las Américas [Strengthening emergency trauma care in the Region of the Americas].^a On 8 November 2023, the publication Implementación de medidas de seguridad vial prioritarias en América Latina y el Caribe [Implementation of priority road safety measures in Latin America and the Caribbean] was launched. Both publications document experiences from different contexts in which progress implementing priority road safety measures, including emergency care, has been made. They show that progress is possible, as is saving lives.

This work has not gone unnoticed. Nor has the push for a strategic plan based on local needs and characteristics, involving: i) the World Health Organization (WHO) Emergency and Critical Care Systems Assessment (ECCSA) tool, ii) preparing and promoting a regional strategy to accelerate the implementation of the Global Plan 2021-2030 (including a regional workshop, held in Honduras from 28 to 30 March 2023, to equip local actors with useful skills and tools to promote this strategy), iii) and the Basic Emergency Care (BEC) course cascade training program. Given some countries’ commitment to working on this important issue, the United Nations Road Safety Fund (UNRSF) decided to fund the PAHO Representative Office to follow up on this priority work agenda in different countries in the Region from 2024 to 2026.^b

PAHO thus reaffirms its ongoing commitment to providing technical cooperation focused on local needs and priorities to strengthen emergency care in the Region.

This will also drive regional progress on the most recent mandate established by resolution of the 77th World Health Assembly in May 2024, requesting that WHO develop a global strategy for integrated emergency, critical, and operative care to support the implementation of Resolution WHA76.2 for the period 2026-2035. It also requested that this strategy be made into an action plan with clear goals to be met by the end of this period.

Note: a More information here about the publication launch; b To view the briefing on the approved regional office project, click here.
Source: Prepared by the authors, based on Pan American Health Organization materials. Fortalecer la atención de emergencias traumatológicas en la Región de las Américas. Washington, D.C.: PAHO; 2023; Pan American Health Organization. Implementación de medidas de seguridad vial prioritarias en América Latina y el Caribe. Washington, D.C.: PAHO; 2023. United Nations Road Safety Fund. 2023 Call for proposals: Top ranked eligible concept notes. Geneva: UNRSF; 2023. World Health Organization. Development of a global strategy and action plan for integrated emergency, critical and operative care, 2026-2035: Draft decision proposed by the 47 Member States of the WHO African Region, the 27 Member States of the European Union, Brazil, China and Egypt [Agenda item 6, EB154/CONF./5]. Geneva: WHO; 2024; World Health Organization. Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies [Resolution 76.2]. Seventy-sixth World Health Assembly; 30 May 2023. Geneva: WHO; 2023.

Conclusions

Policies promoting sustainable funding and effective governance —ideally with explicit legal or regulatory coverage that is implemented and assessed— are needed to achieve universal health coverage through integrated emergency (pre-hospital and in health units), critical, operative, psychological, and rehabilitation care. These services must be prioritized in national or local health plans or in primary healthcare models.
Reviewing, creating, and, where appropriate, strengthening the legal framework helps to consolidate these policies, ensuring the necessary resources for their implementation and respect for human rights. This will achieve and sustain their positive impact on health.
The first step is conducting a diagnostic exercise and creating a strategic plan to implement action plans tailored to local contexts and needs. The aim is to establish a roadmap for implementing priority actions to strengthen emergency care. The WHO ECCSA tool and technical cooperation from all three levels of the Organization may effectively support this work (including legal and regulatory assistance).
PAHO has other resources and tools to support countries in implementing an effective strategy to strengthen the health system’s response to trauma and health emergencies.

Footnotes

58 Although the terms “urgencies” and “emergencies” may have different connotations in the countries of the Region of the Americas, in this publication they are considered synonymous. Therefore, the term “emergency” is used throughout to cover “situations or conditions requiring immediate intervention to avoid serious, risky consequences”.

59 Barbados, Bolivia (Plurinational State of), the British Virgin Islands, Ecuador, Panama, and Uruguay.

60 Argentina, the Bahamas, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, the Dominican Republic, El Salvador, Guyana, Nicaragua, Peru, Saint Lucia, and the United States.

61 Argentina, Brazil, Colombia, Costa Rica, Cuba, the Dominican Republic, Ecuador, El Salvador, Jamaica, Mexico, Nicaragua, Paraguay, Peru, Saint Lucia, Suriname, the United States, and Uruguay.

62 Colombia, the Dominican Republic, Ecuador, El Salvador, Nicaragua, Paraguay, Peru, and Uruguay.

63 Argentina, Bolivia (Plurinational State of), Brazil, Costa Rica, Cuba, the Dominican Republic, Guatemala, Guyana, Jamaica, Nicaragua, Paraguay, and Uruguay.

64 Canada, Chile, Colombia, El Salvador, Suriname, and the Virgin Islands.

65 Argentina, Costa Rica, Cuba, Ecuador, El Salvador, Jamaica, Nicaragua, and Suriname.

66 Argentina, Brazil, Barbados, the British Virgin Islands, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala, Guyana, Jamaica, Mexico, Nicaragua, Paraguay, Trinidad and Tobago, and Uruguay.

67 Argentina, Belize, Bolivia (Plurinational State of), Brazil, Costa Rica, Cuba, the Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Mexico, Panama, Paraguay, Peru, Trinidad and Tobago, and Uruguay.

68 Argentina, Belize, Bolivia (Plurinational State of), Brazil, Costa Rica, Cuba, the Dominican Republic, El Salvador, Guatemala, Guyana, Honduras, Paraguay, Suriname, Trinidad and Tobago, and Uruguay.

69 Argentina, Bolivia (Plurinational State of), Brazil, Cuba, the Dominican Republic, El Salvador, Guatemala, Guyana, Honduras, Paraguay, Suriname, Trinidad and Tobago, and Uruguay.

70 Antigua and Barbuda, Argentina, the Bahamas, Barbados, Belize, Bolivia (Plurinational State of), Brazil, the British Virgin Islands, Canada, Chile, Colombia, Costa Rica, Dominica, the Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Jamaica, Nicaragua, Panama, Peru, Saint Lucia, Suriname, Trinidad and Tobago, and Uruguay.

71 It is worth noting that both Chile and Nicaragua reported having more insured vehicles than registered motor vehicles. Since the number of insured vehicles in both countries only includes two- to four-wheeled motor vehicles, buses, and freight transport, local analysis must be carried out to see whether 100% of vehicles on these countries’ road are registered, and whether this could be the cause of the discrepancy.

72 Antigua and Barbuda, the Bahamas, Barbados, Belize, Bolivia (Plurinational State of), Brazil, Chile, Colombia, Costa Rica, Cuba, Dominica, the Dominican Republic, Ecuador, El Salvador, Guyana, Haiti, Jamaica, Mexico, Nicaragua, Paraguay, Peru, Saint Lucia, Trinidad and Tobago, the United States, and Uruguay.

73 There is no evidence in the WHO Clinical Services and Systems Unit records to validate this information.

74 See Table 2 in Chapter 4 of Pan American Health Organization. Fortalecer la atención de emergencias traumatológicas en la Región de las Américas. Washington, D.C.: PAHO; 2023.

75 A Good Samaritan law can be defined as “a law that protects people from legal repercussions when they believe another person is injured and decide to help them out”. According to the SaveLIFE Foundation of India, a Good Samaritan “is a person who, in good faith, without expectation of payment or reward and without any duty of care or special relationship, voluntarily comes forward to administer immediate assistance or emergency care to a person injured in an accident, or crash, or emergency medical condition, or emergency situation”. See: European Bank for Reconstruction and Development. Post-crash emergency response toolkit. London: EBRD; 2021. Available from: https://www.ebrd.com/documents/environment/postcrash-emergency-response-toolkit.pdf.

76 In the United States, the Good Samaritan law is enacted at the state level. Forty-four states have a Good Samaritan law.

77 Ideally, the same number should cover different emergency services (i.e., police, fire, ambulance, etc.).

78 Antigua and Barbuda, Barbados, Belize, the British Virgin Islands, Colombia, Costa Rica, the Dominican Republic, Ecuador, Honduras, Mexico, Panama, the United States, and Uruguay. This number is used in all areas; there is no other number.

79 Argentina, Bolivia (Plurinational State of), Chile, Dominica, El Salvador, Guatemala, Jamaica, Nicaragua, and Paraguay. There is no single number for the entire country; however, all areas are covered by a particular number.

80 Antigua and Barbuda, Argentina, the Bahamas, Barbados, Canada, Costa Rica, Cuba, Dominica, Mexico, Trinidad and Tobago, and the United States.

81 Including care at the scene and during transport to the health unit.

82 Costa Rica, Cuba, and Dominica selected two response options. In this report, the one with the lowest level of progress was taken as reference.

83 The Bahamas, Barbados, Canada, Costa Rica, Cuba, Dominica, Saint Lucia, Trinidad and Tobago, the United States, and Uruguay.

84 Argentina, Brazil, the British Virgin Islands, Dominica, Ecuador, El Salvador, Guatemala, Guyana, Jamaica, and Nicaragua.

85 Antigua and Barbuda, Belize, Chile, Haiti, Mexico, Paraguay, Peru, and Suriname.

86 The Bahamas, Barbados, the British Virgin Islands, Canada, Colombia, the Dominican Republic, Guyana, Haiti, Jamaica, the United States, and Uruguay.

87 It is worth noting that Ecuador, Mexico, and Paraguay reported not having this certification pathway, despite the WHO legal instrument review concluding that they had laws requiring training, licensing, or certification of first responders.

88 Argentina, Brazil, Canada, Cuba, Ecuador, El Salvador, Guyana, Jamaica, Mexico, Paraguay, Peru, Trinidad and Tobago, the United States, and Uruguay.

89 Argentina, Barbados, Bolivia (Plurinational State of), Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, the Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Jamaica, Mexico, Nicaragua, Paraguay, Peru, Suriname, the United States, and Uruguay.

90 Argentina, Barbados, Belize, Bolivia (Plurinational State of), Brazil, Canada, Chile, Cuba, the Dominican Republic, Ecuador, Guatemala, Guyana, Haiti, Jamaica, Mexico, Paraguay, Trinidad and Tobago, the United States, and Uruguay.

91 Argentina, Bolivia (Plurinational State of), Brazil, Colombia, Cuba, Dominica, the Dominican Republic, Ecuador, El Salvador, Guyana, Haiti, Nicaragua, Peru, the United States, and Uruguay.

92 Argentina, Belize, Bolivia (Plurinational State of), Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, the Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Trinidad and Tobago, the United States, and Uruguay.

93 For the purposes of this report, response time was defined as the interval between activating the emergency response system and first contact with professional or specialized emergency response personnel, either at the scene or in a hospital unit. Both Antigua and Barbuda and Saint Lucia reported that they were developing these strategies, and said that they would include a target response time.

94 Belize, Bolivia (Plurinational State of), Brazil, Chile, Colombia, the Dominican Republic, Ecuador, El Salvador, Guatemala, the United States, and Uruguay.

95 The British Virgin Islands, Costa Rica, Cuba, Dominica, Guyana, Honduras, Paraguay, Suriname, and Trinidad and Tobago.

96 Several of these tools are available at the following link: https://www.who.int/teams/integrated-health-services/clinical-services-and-systems/emergency-and-critical-care/emergency-care-toolkit.