Developing emergency medical care policy across Kenya: A framework for policy development

Abstract

Background and objectives

The Kenya Emergency Medical Care (EMC) Policy 2020–2030 was created to guide the advancement of EMC throughout Kenya. This report describes and maps the ongoing EMC policy development process across Kenya's 47 counties, serving as a real-world example of EMC policy development within a decentralized healthcare system in a low—or middle-income country (LMIC).

Methods

This report evaluates the development of county-specific EMC policies using the Kenya Institute for Public Policy Research and Analysis (KIPPRA) six stages for policy development: 1) problem identification, 2) agenda setting, 3) policy design, 4) approval, 5) implementation, and 6) monitoring and evaluation. Meeting minutes, workshop proceedings, and draft and final EMC policy documents were used to analyze the policy development process and provide a snapshot of current EMC policy statuses by county.

Results

As of August 2024, 23 counties have engaged in EMC policy development. Thirteen have finalized and are implementing their EMC policies, while 10 await approval. The remaining 24 counties are still in the planning stages. This process included gathering baseline emergency medical care standards to identify areas for improvement in each county. A core vision, mission, and goal aligned with the national policy were established and tailored to the county's needs. County-specific strategies were developed to address gaps between the existing system and national objectives. EMC policies were drafted, collaboratively reviewed, revised, and finalized before official approval. The next steps will be implementation, monitoring, and evaluation. Growth and improvement will be measured post-implementation based on baseline EMC metrics.

Conclusion

Kenya's strategy for EMC policy development across the 47 counties, utilizing KIPPRA's guidelines for public policy formulation, established a structured approach that included engaging stakeholders, conducting situational analyses, and aligning policy objectives with national goals. It is a comprehensive example of developing EMC policies for LMICs within decentralized healthcare systems.

African relevance

 

• •Timely efforts to strengthen the provision of emergency services as part of universal health coverage were called for under the World Health Assembly resolution 76.2 of 2023.
• •This article details how Kenya has approached emergency medical care policy development in a decentralized healthcare system.
• •Other African countries can use Kenya's example of EMC policy development as a roadmap.

Introduction

Emergency healthcare systems address a great variety of illnesses and injuries that disproportionately result in death and disability in low- and middle-income countries (LMICs) [1]. In 2023, the World Health Assembly Resolution 76.2 called upon member states to strengthen the planning and provision of emergency, critical, and operative care services as part of Universal Health Coverage (UHC) [2]. The World Health Organization (WHO) Emergency Care System Framework is an important tool that maps prehospital and facility-based emergency care and is designed to guide policy development and implementation around the world [3].

While emergency medical conditions impose a substantial burden, emergency medical care (EMC) frequently suffers from insufficient financial and political support, particularly in LMICs [4]. However, there has been momentum in LMICs to follow WHO's mandate in building up EMC, especially in Africa. A recent study assessing the constitutions of 195 nations found that ten LMICs had legal frameworks establishing a right to access emergency medical care, and most of these countries are in Africa [5]. This trend is reflected in a growing body of literature on emergency medicine throughout Africa, which documents the rise of EMC policy creation and the strengthening of emergency systems [6]. Numerous African nations over the past three decades, including Kenya, Rwanda, Botswana, Ethiopia, Nigeria, Uganda, and South Africa, have taken significant strides in developing national policies and infrastructure for EMC [[7], [8], [9], [10], [11], [12], [13]].

Arnold's framework for classifying a country's development of emergency medicine describes a progression of three stages: underdeveloped, developing, and mature. Currently, Kenya's emergency healthcare system, like those of many LMICs, can best be classified as "underdeveloped." [14] One reason for this is that prehospital emergency medical services (EMS) have not yet been established throughout Kenya; critically ill or injured patients often arrive at hospitals in private cars or taxis. Additionally, while some emergency departments (EDs) implement basic triage systems, comprehensive patient care and management protocols remain largely absent. Furthermore, although emergency medicine is recognized as a specialized area of medicine, EDs are generally staffed by healthcare providers without specific training in emergency medicine, and these providers are typically overseen by physicians from other specialities of medicine [7,15].

Over the past decade, Kenya has taken great strides to enhance the capabilities of prehospital and facility-based emergency medical care based on the WHO Emergency Care System Framework [3]. The Constitution of Kenya 2010 guaranteed the right to emergency health care, thus setting forth the trajectory of EMC policy development within the country's larger healthcare infrastructure [16]. The Kenya EMC Policy 2020–2030 launched in 2021 as the roadmap to guide the implementation and advancement of emergency medical care throughout the country [16]. The formulation of this national strategic plan was a successful collaboration led by the Ministry of Health involving active participation from various stakeholders, including county governments, national ministries, government departments and agencies, development partners, academic institutions, non-governmental organizations (NGOs), the private sector, and civil society [16].

However, because healthcare in Kenya is a devolved system of governance with 47 semi-autonomous counties operating under the national government, a large amount of the responsibility for emergency healthcare service delivery ultimately occurs at the county level [17]. This report describes and maps the ongoing EMC policy development process across Kenya's 47 counties in line with the Kenya EMC Policy 2020–2030, providing a framework for policy development to enhance emergency healthcare systems in decentralized healthcare settings.

Methods

Following the Kenya EMC Policy 2020–2030 launch in 2021, the Emergency Medicine Kenya Foundation (EMKF) initiated efforts to support county governments in adapting the national EMC policy to address each county's unique needs and challenges. EMKF is an NGO established in 2015 to support governments and emergency healthcare providers across Kenya in saving lives by strengthening the emergency healthcare system through capacity building, knowledge development, advocacy and research. EMKF played a pivotal role in developing the national Kenya EMC Policy 2020–2030, and its partnerships with all county governments have provided essential momentum for EMC policy development at the county level since 2021 [18].

Initially, EMKF held meetings with county leadership, introducing and outlining the Kenya EMC Policy 2020–2030 and emphasizing the importance of strengthening emergency healthcare services and infrastructure at the community level. Subsequently, EMKF facilitated EMC policy development workshops with county governments and key stakeholders. In every county, these workshops included representatives from multiple levels of national and county government leadership, healthcare professionals, emergency responders, public health officials, and community representatives. Table 1 details the participants present at each county EMC policy development workshop. This collaboration helped identify the county's most pressing challenges in delivering emergency medical care, provided a robust foundation for developing policies tailored to each county's unique needs, and fostered ownership and commitment among county officials, promoting more effective and sustainable policy implementation. The national Kenya EMC Policy 2020–2030 and the international WHO Emergency Care System Framework guided the entire process of policy development [3].

Table 1.

Key stakeholders for county emergency medical care policy development.

EMC policy development meeting participants
County Government Leadership	1. County Executive Committee Member (CECM) of Health 2. Chief Officer of Health 3. County Director of Health 4. Chief Nursing Officer 5. Chief Clinical Officer 6. Public Health Lead 7. County Health Budget Lead 8. County Commissioner 9. Other appropriate members of the County Health Management Team (CHMT)
Clinical Leadership	10. Medical Superintendents and/or in-Charges of specified public and private Emergency Care Centers in the county 11. Community health worker (CHW) lead 12. A representative from each donor/partner/stakeholder organization working in the county relevant to EMC services
First Responders	13. Police lead 14. Fire services lead 15. Ambulance services in-charge
National Government Representatives	16. Ministry of Health (MOH) representative 17. Council of Governors (COG) representative
Consultants	18. Emergency Medicine Kenya Foundation (EMKF)

The Kenya Institute for Public Policy Research and Analysis (KIPPRA) provides general guidelines for Kenyan public policy development, which were used as a framework in this report to evaluate the EMC policy development process [19]. KIPPRA outlines six stages for policy development: 1) problem identification, 2) agenda setting, 3) policy design, 4) approval, 5) implementation, and 6) monitoring and evaluation (Fig. 1).

Fig. 1.

The stages of policy in Kenya [19].

This report utilizes KIPPRA's model to evaluate the EMC policy development process across the 47 counties in Kenya. Meeting minutes, workshop proceedings, and draft and final policy documents from individual counties were used to analyze the policy development process, assess the adaptation of the national policy to county-specific contexts, and provide a snapshot of the current EMC policy status across the counties.

Results

County Emergency Medical Care Policy Development Process

Problem identification

The problem identification stage laid the foundation for policy creation. In the county-specific meetings and workshops, situational analyses were conducted to identify the county's most pressing challenges in delivering emergency medical care, providing a robust foundation for developing policies tailored to each county's unique needs.

The current standard of emergency medical care was evaluated using the WHO Emergency Care System Framework (which was also the framework adopted by the Kenya EMC Policy 2020–2030). The primary objective was to identify areas for county-specific improvements to align with the WHO guidelines. Table 2 reflects the baseline landscape of EMC care—prior to policy creation or implementation—in 23 Kenyan counties that have at least begun drafting policies as of August 2024.

Table 2.

Current phase of EMC policy development and baseline metrics by county.

County	Current policy stage*	Initial meeting date	Baseline metrics prior to EMC policy development
			Total health facilities	Total public emergency health facilities⁎⁎	Total public ambulances	Dispatch center⁎⁎⁎
Baringo	Draft	6 April 2023	279	3	8	None
Bungoma	Draft	19 September 2023	256	7	20	None
Elegeyo-Marakwet	Finalized	14 February 2023	133	4	30	None
Garissa	Draft	24 June 2021	84	7	10	Partially functional, run by 6 EMTS
Kilifi	Finalized	6 June 2023	157	3	14	None
Kisumu	Finalized	25 February 2021	210	9	18	Functional, run by nurses, ICT officer, health promotion officer
Lamu	Finalized	25 May 2022	42	4	8 1 Boat 1 Auto Rickshaw	None
Machakos	Draft	11 March 2021	170	5	75	Partially functional, phone calls answered by a nurse or clinical officer with an EMT background
Makueni	Draft	12 February 2021	355	3	14	Partially functional
Migori	Draft	4 July 2023	159	4	10	None
Mombasa	Finalized	1 July 2021	47	4	10	Partially functional
Murang'a	Draft	1 March 2022	284	9	4	Partially functional
Nakuru	Finalized	10 February 2021	657	20	32	Functional
Nyeri	Finalized	19 February 2021	127	3	12	None
Siaya	Finalized	11 November 2022	256	6	10	None
Taita-Taveta	Finalized	27 May 2021	67	3	7	None
Tana River	Finalized	29 June 2022	55	3	20	None
Trans-Nzoia	Finalized	26 January 2023	84	3	9	None
Turkana	Finalized	4 March 2021	228	6	8	Unused dispatch center from 2016/2017; still has computers and software; was not able to receive multiple calls or identify nearest emergency health facility
Uasin Gishu	Finalized	28 February 2023	138	3	16	Partially functional
Vihiga	Draft	11 May 2022	43	3	6	None
Wajir	Draft	7 November 2022	137	4	20	Partially functional
West Pokot	Draft	17 June 2021	67	2	14	None

^⁎Policy development phase as of August 2024. Counties not listed have not yet begun drafting EMC policies.

^⁎⁎Emergency health facilities are facilities open 24/7 and have a functioning operating theatre.

^⁎⁎⁎Functional dispatch centers CAN handle multiple calls simultaneously and identify the nearest ambulance and emergency health facility. Partially functional dispatch centers CAN NOT handle multiple calls simultaneously or identify the nearest ambulance and emergency health facility.

Across multiple counties, critical challenges in emergency medical care were identified based on the WHO EMC Framework. The recent Covid-19 pandemic also helped to highlight the gaps in emergency care. For example, first responders were usually community health workers, boda-boda (motorcycle taxi) riders, public service vehicle drivers, or the police, all of whom were not trained in emergency response. Additionally, all counties lacked a toll-free emergency number like 911, and most did not have an ambulance dispatch centre, so ambulances were not being utilized despite their availability. The available ambulances were often poorly equipped, below national standards, and operated by drivers without formal training in emergency vehicle operations. The counties did not employ emergency medical technicians (EMTs) or paramedics. Thus, nurses were often reassigned from healthcare facilities to handle inter-hospital transfers, which was the primary use of the ambulances. Many healthcare facilities that could serve as emergency care centers (they operated 24 h a day, 7 days a week and had functional operating theatres) lacked dedicated emergency departments, emergency medical care equipment, and trained emergency medical care personnel. Overall, there was a common lack of community awareness of emergency medical response. Perhaps one of the biggest problems identified was that for most counties, these policy development meetings marked the first attempt at creating an emergency medical care policy, so they lacked a dedicated unit and budget allocation for this essential service within their health departments.

Agenda setting

The agenda-setting stage involved engaging county stakeholders (Table 1) in discussions during the workshops to incorporate diverse perspectives and expertise into the policy development process. A core vision, mission, and goal that aligned with the national EMC Policy were laid out. Similarly, county-specific objectives were crafted by adapting the strategies outlined in the Kenya EMC Policy 2020–2030 and the WHO Emergency Care System Framework. These objectives served as a basis for the county stakeholders to develop clear and measurable EMC targets within their developing EMC policy that addressed the unique challenges identified in the previous section while still aligning with the national framework. Table 3 illustrates how county EMC objectives were mapped to the national objectives. Although each county had the freedom to create a unique vision, mission, goal and objectives tailored to their specific needs, many counties felt that the statements in Table 3 rang true and adopted this version directly. This approach established a consistent foundation for EMC policy development across all counties.

Table 3.

Kenya emergency medical care framework & objectives.

Vision	Universal access to the highest standards of emergency medical care across the county
Mission	To promote the standardization, regulation, coordination, and development of an EMC system in the county
Goal	To ensure that emergency medical care is provided to all who need it as part of the Universal Health Coverage, thereby minimizing the morbidity and mortality caused by medical emergencies.
Six EMC Objectives in Kenya
National Objective			County Objectives
Infrastructure		To establish an integrated county infrastructure to support universal access to emergency medical care	a) Map out and strengthen emergency departments to adhere to minimum national standards. b) Map out ambulance services and enhance ambulance standards at all levels. c) Establish an Emergency Operations and Ambulance Dispatch Center d) Establish an emergency medical care access number.
Quality		To ensure quality service delivery across the EMC system	a) Strengthen capacity for integrated EMC management b) Implement Standard Operating Procedures (SOPs) for Ambulances and Emergency Departments c) Implement Emergency Medical Care Treatment Guidelines d) Provide and enhance standards of Emergency Health Products and Technologies.
Finance		To provide mechanisms for the financing of emergency medical care	a) Strengthen resource mobilization initiatives for emergency medical care services b) Establish an Emergency Medical Treatment fund in the county budget. c) Establish a framework for the administration and utilization of the Emergency Medical Treatment Fund.
Human Resources		To develop a framework for emergency medical care human resource development and management	a) Ensure that an adequate emergency care workforce is appropriate at all levels of the EMC system, including the prehospital system. b) Implement emergency medical care training for all healthcare workers within the EMC system, including the prehospital system.
Monitoring & Evaluation		To strengthen systems for monitoring, evaluation, surveillance, and research on emergency medical care	a) Implement EMC surveillance systems. b) Increase the use of EMC data for decision-making. c) Conduct and facilitate EMC system surveys. d) Facilitate operational research to enhance the county EMC plan.
Leadership & Governance		To provide emergency medical care leadership and governance	a) Align emergency medical care governance and legislation to county mandates and core functions b) Strengthen intergovernmental coordination of emergency medical care. c) Develop norms and standards for emergency medical care in the county.

Policy design

With a solid foundation established in identifying key challenges within existing emergency medical care and providing clear strategic direction, counties were then positioned to design and implement their own emergency medical care policies. Based on the stakeholders' input, the county objectives (Table 3) were used to develop detailed plans and strategies to address the identified problems and achieve the desired outcomes for the specific needs of each county. This involved determining the scope of policy interventions, translating the goals and objectives into actionable measures, allocating resources, and establishing timelines for implementation. These plans became the county's EMC policy.

A key aspect of this process was prioritizing specific areas for the county EMC policy based on factors such as problem severity, potential impact, intervention feasibility, and alignment with broader county healthcare goals. Various factors were considered, including political feasibility, resource constraints, administrative capacity, and stakeholder readiness, to ensure the policy was feasible, coherent, and capable of producing a meaningful impact. Evidence-based approaches and best practices guided decision-making. The policy design process bridged gaps between the current EMC system in each county and the country-wide EMC objectives, all of which were rooted in the WHO Emergency Care System Framework.

Approval

The approval stage of policy development involved several crucial steps to yield a comprehensive, effective, and community-aligned final policy. After discussions and deliberations in county meetings and workshops, the draft EMC policy was presented to all stakeholders involved in its creation. This inclusive approach allowed stakeholders to provide feedback, suggestions, and concerns, which were considered and integrated into the policy document. Stakeholder feedback on the EMC policy draft was incorporated into the first major revision.

Next, the county government officials reviewed the EMC policy document, assessing its alignment with strategic objectives, feasibility of implementation, budgetary considerations, and legal compliance. Budgeting discussions focused on the specific implementation activities outlined in the county EMC policy. The outcomes of these discussions were then integrated into the second major policy revision. After this review was finalized, the county government once again circulated the EMC policy document amongst all stakeholders for their final evaluation. This step aimed to ensure transparency, inclusivity, and validation that stakeholder feedback had been appropriately addressed in the final policy. After the stakeholders' final review, the EMC policy document was formally presented to the county government for official authorization and approval. Upon authorization, the county government officially launched the EMC policy for implementation. This comprehensive process ensured that the policy was thoroughly vetted, inclusive of stakeholder input, and ready for effective implementation to enhance emergency medical care services within the county.

Current state of county emergency medical care policies in Kenya

As of August 2024, 23 counties have engaged in EMC policy development. Thirteen have finalized and begun implementing their EMC policies, while 10 await approval. The remaining 24 counties are still in the planning stages (Fig. 2).

Fig. 2.

National State of Emergency Medical Care Policy Development by County as of 2024.

Next steps: implementation, monitoring and evaluation

As more counties engage in the policy development process and have their finalized policies approved, implementing, monitoring, and evaluation will be the next big step to advance emergency medical care throughout Kenya.

Part of the stakeholder meetings included developing the implementation and associated monitoring and evaluation plans, which were included in the final approved policies. These plans include building up key infrastructure such as emergency dispatch centers, improving the quality of existing emergency medical care, conducting resource mobilization and fundraising, and ensuring adequate training of all healthcare personnel involved in hospital and prehospital emergency medical care. These broader categories are broken down into multiple activities and associated outputs. Expected outputs will be tracked by numeric performance indicators, which will be reviewed in quarterly performance meetings and annual reports. It will be important to monitor the baseline EMC metrics (Table 2) for growth and improvement after implementation.

Numerous counties are still in the planning stage of policy development, so implementation, monitoring, and evaluation are still to come. Even for many of the counties with finalized EMC policies, the implementation stage has not yet begun in most counties. This is largely because counties are still fundraising with partners and donors. A key aspect of successful implementation will be first securing sufficient funding to build infrastructure and increase capacity, as outlined in the budgets created in the planning workshops. Successful implementation will also depend on the continued collaboration of all stakeholders involved in the policy development process.

Discussion

This report describes and maps the ongoing EMC policy development process across the 47 counties in Kenya in line with the Kenya Emergency Medical Care (EMC) Policy 2020–2030 and provides a framework for policy development to enhance emergency healthcare systems in decentralized healthcare settings. As of August 2024, nearly 50 % of the 47 counties had at least a draft EMC policy.

Kenya's strategy for EMC policy development, utilizing the KIPPRA guidelines for public policy formulation, establishes a structured approach that provides a comprehensive roadmap for engaging stakeholders, conducting situational analyses, and aligning policy objectives with national goals [19]. This approach serves as a replicable model for other LMICs with decentralized healthcare systems. Collaboration between local governments and key stakeholders from both local and national levels fosters a participatory policy development process, enhancing the policies' ownership, relevance, and acceptability. The WHO EMC System Framework serves as a robust tool for evaluating current local EMC standards and identifying gaps in existing EMC structures [3]. This enables the development of targeted EMC objectives at the local level, ensuring that policies are relevant and effective.

The development of local EMC policies within a decentralized healthcare system is essential for optimizing the efficiency and responsiveness of emergency services. Evidence from studies conducted in Pakistan, Brazil, and Portugal demonstrates that this approach can significantly enhance EMC financing, governance, and service delivery [20]. Engaging local stakeholders in policy development improves ownership, relevance, and acceptability, thus promoting swift and effective decision-making [21]. This involvement ensures the policies are well-suited to the local context and have the community's support. Implementation by local authorities also enhances flexibility and adaptability, allowing for quick implementation. Additionally, it promotes greater accountability and transparency in the management of EMC services, as local authorities are directly accountable to their communities [22]. This direct accountability can lead to improved oversight and higher standards of care. Ongoing monitoring and evaluation of Kenya's strategy will provide further insights into its effectiveness and impact. Continuous monitoring and evaluation will be especially important for expected challenges, such as ensuring equity and maintaining consistent standards across regions.

Limitations

This structured approach to policy development in Kenya, involving numerous counties, highlights the framework's comprehensiveness and applicability. However, several key limitations have significantly hindered progress. A primary challenge is the initiative's heavy reliance on the political goodwill of each county government, which slows down the pace of developing and implementing EMC policies across all 47 counties. Another barrier is the difficulty of bringing together the various stakeholders for workshops, sometimes caused by insufficient funding to compensate stakeholders for their time, coupled with differing work rates.

Perhaps the biggest limitation is insufficient healthcare funding at the county level, which presents substantial barriers to EMC policy development and implementation. The historical exclusion of emergency care from county budgets has created an absence of cost data, which makes a thorough analysis of the financial implications of these policies difficult, if not impossible. Financial uncertainty diminishes the willingness of county governments to develop and approve necessary policies. Counties must turn to external donors and partners to supplement the government budget to develop emergency healthcare systems, which can further hinder progress.

Finally, there is a limited pool of EMC policy experts to facilitate the workshops in which counties align their needs with the WHO EMC Framework, with only EMKF currently leading this process.

Working around these barriers has significantly slowed the pace of policy creation and implementation at the county government level, contributing to many regions of Kenya still being in the 'planning stage' of emergency medical care policy development (Fig. 2).

Conclusion

Kenya's strategy for EMC policy development, utilizing the KIPPRA guidelines for public policy formulation, establishes a structured approach that provides a comprehensive roadmap for engaging stakeholders, conducting situational analyses, and aligning policy objectives with national goals for LMICs with decentralized healthcare systems. Local EMC policies enhance service efficiency and responsiveness, and the involvement of local stakeholders ensures greater adaptability, accountability, and improved standards of emergency medical care, making it a valuable model for other decentralized systems.

Dissemination of results

Feedback from the work and associated outcomes were provided to the national and county governments and key stakeholders.

Contribution

Authors contributed as follows to the conception or design of the work; the acquisition, analysis, or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content: ZS 30 %, TS: 30 %, EN: 10 %, AA: 15 %, BW: 15 %. All authors approved the version to be published and agreed to be accountable for all aspects of the work.

Declaration of competing interest

None.