In the rolling highlands of Northwest Ethiopia, where a single ambulance may serve tens of thousands of people scattered across mud-road villages, a new study has delivered one of the clearest pictures yet of why emergency medical transport so often fails the people who need it most. Researchers from Debre Markos University, reporting in the Journal of Emergency and Disaster Medicine, found that just 16.6 percent of emergency department patients in the East Gojjam Zone arrived at the hospital by ambulance. The rest came by commercial three-wheeled bajaj taxis, private cars, or on foot, often after delays that can mean the difference between survival and death in trauma, obstetric, and cardiac emergencies.
The research team, led by Mengistu Abebe Messelu, conducted a multi-center, institution-based cross-sectional study using a mixed sequential explanatory design between March 1 and July 30, 2024. Five public hospitals were randomly selected from the zone’s twelve hospitals, and 428 emergency department patients or their attendants completed interviewer-administered questionnaires, a response rate of 95.3 percent. Quantitative data were captured with KoboCollect and analyzed in STATA version 17, using binary logistic regression with adjusted odds ratios to isolate the factors driving ambulance use. The qualitative arm added in-depth interviews with twelve patients and attendants and key-informant interviews with eight officials, clinicians, and Red Cross workers, analyzed thematically until saturation was reached.
The statistical analysis pointed to four independent determinants of ambulance utilization. Patients who knew the ambulance call number had 2.68 times higher odds of using the service, those who presented at night had 6.60 times higher odds, those with a triage score of seven or above had 9.76 times higher odds, and those with prior ambulance experience had 2.99 times higher odds. Each finding carries a practical message. Knowledge of the emergency number roughly doubles the chance of calling an ambulance, familiarity with the service builds trust that translates into repeat use, and severity of illness, as captured by triage acuity, remains the strongest predictor of all.
The night-time effect is particularly telling. With fewer transport options and less accessible care after dark, patients and families perceive the ambulance as the fastest and most reliable route to the emergency department, a pattern consistent with large observational studies of emergency call behavior in high-income countries. In daytime hours, when bajajs, buses, and commercial vehicles are readily available, most patients opt for these alternatives, even though only three percent of participants owned a car and 60.5 percent owned a mobile phone. Strikingly, 80.1 percent of participants did not know the ambulance call number at all, a knowledge gap the authors identify as one of the most fixable barriers in the entire system.
The qualitative interviews revealed why availability, not merely awareness, lies at the heart of the problem. Although more than 120 ambulances nominally operate across the zone’s 21 districts and 480 kebeles, respondents described vehicles that were chronically unavailable, mechanically broken, or diverted to non-emergency duties. One 38-year-old man told interviewers that ambulances were not performing their primary tasks of transporting laboring mothers and injured patients, but instead served government officials and transported wood and coal. A 45-year-old participant said ambulances were being used for security services and for carrying non-emergency or deceased patients for the financial gain of drivers. More than half of survey respondents, 58.2 percent, cited simple unavailability as the reason they could not use an ambulance.
Armed conflict emerged as a dominant structural barrier. Ongoing fighting in the Amhara region, particularly between the Fano armed group and government forces, has made it impossible or perilous to move ambulances between districts and health facilities. A 41-year-old attendant explained that ambulances once served anyone with medical illness, obstetric emergencies, or accidental trauma, but that the conflict had made transport to hospital effectively unattainable. Interviewees also reported that ambulances feared attack, could not move freely between woredas and kebeles, and were sometimes commandeered by armed groups. The study authors caution that conducting research during active conflict may itself have led to an underestimation of true utilization, since emergency transport was routinely diverted or disrupted.
Communication and infrastructure failures compounded the crisis. In rural kebeles, where half of participants lived, unreliable electricity makes it hard to charge phones, patchy mobile networks make calls to dispatchers unreliable, and ambulance drivers frequently did not answer or were unreachable. Many residents did not know the direct numbers of ambulance drivers or health extension workers. Road infrastructure posed an equally severe obstacle, particularly in villages off the main roads, where seasonal rains turn tracks to mud. One 35-year-old mother described waiting so long for an ambulance during labor that she was forced to deliver at home, while another recalled a driver claiming he was stuck in the mud as a patient deteriorated. These narratives echo qualitative findings from Libreville, Gabon, where infrastructure flaws were likewise identified as the leading barrier to prehospital care.
The 16.6 percent utilization rate in East Gojjam sits below figures from other Ethiopian settings, including Jimma at 39.5 percent, Addis Ababa at roughly 20 to 23 percent, and Southwest Ethiopia at 79 percent for pregnant and laboring women, differences the authors attribute to road quality, community awareness, response times, and the presence of private ambulance operators in urban centers. By contrast, the figure exceeds Ghana’s Accra, where only 4.5 percent of respondents had ever used an ambulance, likely because Ethiopia’s government-subsidized service removes cost barriers. The stakes of closing this gap are enormous. Globally, adequate emergency medical services are estimated to prevent up to 45 percent of deaths and 35 percent of disability-adjusted life years, and roughly one-third of maternal deaths in low- and middle-income countries are directly attributed to the absence of emergency transport. With about 74 percent of ischemic heart disease deaths occurring before hospital arrival, prehospital care is often the only chance of survival.
The community itself proposed the remedies. Participants called for sufficient ambulances for every kebele and health institution, stationing vehicles at health facilities rather than administrative offices to slash response times, and publicizing emergency numbers through mass media and traditional gatherings such as Idir and Ekub. The researchers echo these recommendations, urging increased ambulance fleets, decentralized ambulance stations at kebele or health center level, round-the-clock coordination among hospitals, health centers, and health posts, regular monitoring of vehicle functionality and crew performance, and sustained public awareness campaigns. Above all, they stress that resolving the armed conflict and securing emergency medical transport is the prerequisite for any lasting improvement, and they call for longitudinal studies that adjust for socioeconomic status, distance to care, and comorbidity to track whether these interventions finally move the needle on a system in which five of every six emergency patients are still left to find their own way to the hospital.
Beyond its headline findings, the study offers a methodological template for emergency care research in fragile settings. The sequential explanatory design allowed the quantitative results to shape the qualitative sampling, with participants for in-depth interviews selected purposively to explain, rather than merely describe, the patterns observed in the survey data. Statistical rigor was reinforced by entering only variables with a p-value below 0.25 in bivariable analysis into the multivariable model, and by confirming model fit with the Hosmer–Lemeshow goodness-of-fit test, a safeguard against overfitting in a modest sample of 428 respondents.
The research also situates East Gojjam within a broader epidemiological transition underway in Ethiopia. While road traffic injuries and obstetric emergencies have long dominated the prehospital burden, the growing prevalence of cardiovascular disease and diabetes raises the stakes further, since time-sensitive conditions such as acute myocardial infarction depend heavily on rapid transport to definitive care. The World Health Organization and the African Federation for Emergency Medicine have both emphasized that timely physical access to health facilities is a foundational element of emergency care systems in low- and middle-income countries, making ambulance availability a policy priority rather than a logistical afterthought.
The scale of the study area underscores how thin emergency coverage remains. East Gojjam Zone is home to nearly 2.5 million people distributed across 632,353 households, served by one comprehensive specialized hospital, one general hospital, nine primary hospitals, 102 health centers, and 406 health posts. Even with more than 120 ambulances nominally in operation, the effective ratio of vehicles to population and geography leaves rural kebeles acutely exposed. The Ethiopian Federal Ministry of Health has invested in ambulance distribution and regional dispatch centers over the past decade, yet the study suggests these assets frequently function as transport-only vehicles without trained crews, equipment, or supplies, limiting their clinical value even when they do arrive.
Subject of Research: Ambulance service utilization and its barriers among emergency patients in Northwest Ethiopia
Article Title: Utilization of ambulance services in Northwest Ethiopia: a mixed sequential explanatory study of practice, barriers, and community-led perceived solutions
Article References: Messelu, M. A., Amlak, B. T., Tiruneh, B. G., Nibret, G., Yechale, M., Alem, D. T., Amha, H., Gedfew, M., Gete, M., Ayenew, T., Birhanie, S. A., & Ayenew, T. (2026). Utilization of ambulance services in Northwest Ethiopia: a mixed sequential explanatory study of practice, barriers, and community-led perceived solutions. Journal of Emergency and Disaster Medicine, 2(1), Article 17. https://doi.org/10.1007/s44467-026-00019-8
Image Credits: AI Generated
DOI: 10.1007/s44467-026-00019-8
Keywords: ambulance services, emergency medical services, Ethiopia, prehospital care, armed conflict, triage, mixed methods, health barriers, road infrastructure, community solutions, East Gojjam, global health
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Ophelia Keating. (September 11, 2026). Only One in Six Emergency Patients Reach Hospital by Ambulance in Conflict-Hit Ethiopia. Scienmag. https://scienmag.com/only-one-in-six-emergency-patients-reach-hospital-by-ambulance-in-conflict-hit-ethiopia/
Ophelia Keating. “Only One in Six Emergency Patients Reach Hospital by Ambulance in Conflict-Hit Ethiopia.” Scienmag, 11 September 2026, https://scienmag.com/only-one-in-six-emergency-patients-reach-hospital-by-ambulance-in-conflict-hit-ethiopia/. Accessed 11 September 2026.
Ophelia Keating. “Only One in Six Emergency Patients Reach Hospital by Ambulance in Conflict-Hit Ethiopia.” Scienmag. September 11, 2026. https://scienmag.com/only-one-in-six-emergency-patients-reach-hospital-by-ambulance-in-conflict-hit-ethiopia/
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Tags: ambulance servicesambulance utilization in conflict zonesarmed conflictbarriers to ambulance use in developing countriescommunity solutionscross-sectional health studies in low-resource settingsdisparities in emergency care accessEast Gojjamemergency medical servicesEmergency medical transport in EthiopiaEthiopiafactors influencing emergency service utilizationGlobal Healthhealth barriershealthcare access in rural Ethiopiahealthcare infrastructure challenges in Ethiopiaimpact of transportation delays on emergency outcomesmixed methodsmixed-methods health research in Ethiopianon-ambulance emergency transportationprehospital careroad infrastructurerole of private and informal transport in emergenciestriage
