Effectiveness of a village emergency care model: a pilot intervention in rural Tanzania

Abstract

Background

Emergency services are essential to comprehensive primary healthcare (PHC) and resilient health systems. Prior to December 2021, such services were largely unavailable at the PHC level in Tanzania. To address this gap, we designed and piloted the village emergency care (VEC) model in a rural Tanzanian village. This study evaluates the VEC model’s effectiveness 1 year after implementation.

Methods

A before-and-after sequential mixed-methods design was used. A community survey assessed changes in emergency care access among 191 participants at baseline and 270 postinterventions. Quantitative data were analysed using descriptive statistics and Pearson’s χ² tests to assess preintervention and postintervention differences at a 5% significance level. Qualitative insights were obtained through three interviews with village leaders and healthcare providers, and one focus group with 10 community members, including members of the village health committee, at each phase. The primary outcome was perceived change in access, encompassing availability, acceptability, accommodation, affordability and physical accessibility. Secondary outcomes included awareness, satisfaction and perceived barriers. Qualitative data were analysed thematically.

Results

Availability of emergency services increased from 61.0% to 84.4% (χ²=22.47, p<0.001), satisfaction from 12.0% to 88.5% (χ²=187.6, p<0.001) and awareness from 90.1% to 97.0% (χ²=9.03, p=0.003). Cultural barriers declined from 17.3% to 5.2% (χ²=18.56, p<0.001). Perceived affordability rose from 9.0% to 51.1% (χ²=56.91, p<0.001), however, cost remained a barrier, rising from 16.0% to 35.5% (χ²=4.81, p=0.028). Qualitative findings underscored greater awareness and trust in services but identified persistent financial barriers, particularly for high-cost treatments like antivenom. Health insurance coverage remained limited, with many relying on out-of-pocket payments.

Conclusion

The VEC model significantly improved awareness, satisfaction and access to emergency care in a rural PHC setting. Expanding insurance literacy and coverage, alongside cost transparency and future cost-effectiveness analyses, is recommended to support equitable national scale-up.

WHAT IS ALREADY KNOWN ON THIS TOPIC.

WHAT THIS STUDY ADDS

• In a rural Tanzanian village, implementing a low-resource village emergency care model at the PHC level led to enhanced emergency service availability, sixfold increased patient satisfaction and improved awareness of emergency conditions.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings offer a practical framework for integrating emergency care into rural PHC systems, inform policies to decentralise and sustainably finance such services and provide implementation lessons for LMICs seeking equitable, community-based emergency care models.

Introduction

Globally, access to timely emergency care remains one of the most neglected but vital components of universal health coverage (UHC). More than half of the 45 million deaths occurring every year in low- and middle-income countries (LMICs) could be avoided through timely emergency and critical care.^1–3 In response, the World Health Assembly (WHA) Resolution 76.2 (2023) declared that emergency, critical and operative care services are an essential part of a comprehensive national primary healthcare (PHC) approach and foundation for health systems to address emergencies effectively.⁴ The WHO Emergency Care Systems Framework (ECSF) requires that emergency care begin at the scene and continue through facility-based stabilisation to definitive management.⁵ Together, these instruments emphasise that emergency care must be integrated within PHC rather than limited to tertiary hospitals.

Despite the global commitments, access to emergency services across sub-Saharan Africa remains highly inequitable. Assessments by the African Federation for Emergency Medicine show that most countries lack organised prehospital care, effective referral linkages and adequately trained providers at the PHC level.^6–8 Rural populations experience the most significant delays due to long distances, poor roads and low health literacy.^{6 9 10} While community-based interventions such as Lay First Responder (LFR) programmes in Uganda, Sierra Leone and Chad have improved prehospital stabilisation and referral, their limited integration with formal health systems limits sustainability.^{11 12} This situation in Africa mirrors the global challenge: the absence of scalable models that bridge community first responders to the well-prepared healthcare facilities at the PHC.

Tanzania, like the global picture, lacks emergency care services at the lowest level, the dispensary, which is the primary entry point for most of the population in rural areas. Furthermore, emergency medicine is a relatively new field in Tanzania, established at Muhimbili National Hospital about 14 years ago.⁹ The PHC system in Tanzania comprises dispensaries, health centres and district hospitals and serves as the first entry point to the health system for about 70% of the population. However, only a few district hospitals have established emergency care units, while the rest lack both equipped emergency units and skilled staff. To address this challenge, the government of Tanzania has prioritised the integration of emergency and critical care through the Health Sector Strategic Plan V (2021–2026) and the National Strategic Plan for Essential Emergency and Critical Care (2023–2026).^13–15 These frameworks advocate decentralising emergency services to PHC facilities and engaging communities in preparedness. However, implementation remains limited, with emergency care concentrated mainly in urban secondary and tertiary hospitals.

We developed and implemented a village emergency care (VEC) model, a locally adaptable, community-embedded intervention that translates WHO and WHA recommendations into the rural Tanzanian context. We implemented VEC in the Bantu village in the Mkinga district of the Tanga region. The model comprises seven components: (1) facility readiness: constructing or renovating a local health facility (in this case, newly built since the village lacked one); (2) human resources: hiring or reallocating staff beyond national PHC guidelines to accommodate emergency duties; (3) emergency preparedness: ensuring essential equipment, supplies and medicines are available; (4) staff training on basic emergency care, using WHO’s Basic Emergency Care curriculum along with a locally adapted version for doctors and nurses, complemented by leadership training for facility heads; (5) community engagement: conducting sensitisation sessions on early recognition of emergencies and prompt care-seeking, including village meetings and basic first aid training for 120 key community members (approximately 9.4% of the village population); (6) referral linkage: strengthening communication and referral systems through collaboratively developed referral protocols with higher-level hospitals; and (7) service coverage: providing 24-hour emergency service availability. This study evaluates the effectiveness of the VEC model 1 year after implementation, focusing on changes in access, awareness, satisfaction and perceived barriers to emergency care in a rural Tanzanian village.

Materials and methods

Study design

This evaluation included two work streams: (1) surveys of service users, disseminated before and after implementation of the VEC model; and (2) qualitative evaluation to explore contextual and implementation factors through in-depth interviews (IDIs) to explore community leaders and provider perspectives explaining the observed results. We carried out a baseline assessment in December 2021, before implementing the VEC model and a follow-up assessment in August–September 2023, 1 year after full implementation of the model. The preparatory and implementation phase occurred between June 2022 and July 2023.

Study settings and context

This study took place in Bantu village, situated in the Mkinga district of the Tanga region in the northeastern part of Tanzania. Bantu village lies in Mapatano Ward, Mkinga District, approximately 60 km north of Tanga city.¹⁶ According to the 2022 Population and Housing Census, the village had 1283 residents (668 males, 615 females), distributed across three hamlets. Most residents are small-scale farmers, fishermen, sisal plantation workers and livestock keepers. Before the intervention, the nearest health facility was Maramba Health Centre, about 9 km away; emergency care was largely unavailable at the PHC level.

The site was purposefully selected based on: (1) a documented lack of emergency services; (2) accessibility for evaluation; and (3) prior engagement of the funder in district-level economic and health infrastructure projects.¹⁷ The VEC model transformed a community-initiated dispensary into Tanzania’s first village-level PHC facility with structured emergency care capacity.

Participants, sampling strategy and sample size

Surveys

The target population comprised adult residents (≥18 years) living in Bantu village. Assuming that 80% would perceive emergency services as available, with a 5% margin of error and 95% confidence level, the minimum baseline sample size was 191 participants. Adjusting for population growth using Tanzania’s annual birth rate (0.37), the minimum postintervention sample was 263; ultimately, 270 participants were surveyed.

A systematic proportionate sampling approach was used to identify residents across the three hamlets of Bantu village. Household lists were obtained from hamlet leaders, and the sampling interval was calculated by dividing the total number of households by the required sample size for each hamlet. The number of participants per hamlet was determined proportionally to its population.

Within each selected household, two adult participants were chosen: the household head and another adult member aged ≥18 years. The household head was operationally defined as the individual responsible for overseeing all household matters, both financial and non-financial, as identified by other household members when asked.

Qualitative

Purposive sampling was used to capture a diverse range of stakeholder perspectives. At each phase, three IDIs were conducted with key informants: the village executive officer, village chairperson and facility in-charge. Additionally, two focus group discussions (FGDs) were held (one per phase), with 10 participants each. FGD participants included village health committee members: hamlet leaders (3), 10-cell leaders (3), community health workers (2) and other community representatives (2). Postintervention FGDs specifically included community members who had accessed emergency care services, ensuring that users’ perspectives were represented alongside those of system managers.

Outcome

The primary outcome was perceived change in access, measured across five dimensions: availability, acceptability, affordability, accommodation (or adequacy) and physical accessibility. Secondary outcomes included awareness, satisfaction, perceived barriers and changes in health expenditure.

Data collection procedure

Quantitative data collection

We disseminated questionnaires at baseline (December 2021, approximately 6 months prior to implementing the VEC model) and postimplementation (August to September 2023, approximately 1–3 months after the intervention period). We designed a survey questionnaire developed from adapted Penchansky and Thomas’ five dimensions of access framework.^{18 19} Each domain was defined as applied in the Tanzanian context as follows:

• Availability: presence of emergency services and resources when needed in Bantu village.

• Accessibility: ease of physically reaching services within the village.

• Acceptability: cultural and social appropriateness of services.

• Adequacy (accommodation): quality and appropriateness of services provided.

• Affordability: cost of services relative to household income and perceived economic burden.

Tools were pretested with 50 community members in Dar es Salaam to assess clarity and reliability and reviewed by emergency care experts for content validity. Data were collected electronically via Research Electronic Data Capture (REDCap) using a 5-point Likert scale (Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree), with real-time quality checks by the data manager. No compensation was provided for participation.

Qualitative data collection

Semistructured guides for IDIs and FGDs were developed based on expert input and a review of relevant literature. Guides were first written in English and then translated into Kiswahili. Interviews lasted 30–45 min and FGDs 60–90 min. Participants received TZS10 000 (∼US$4) to compensate for time and transport. This amount is roughly equivalent to 1–2 days of typical daily income for a resident in rural Tanzania, providing meaningful compensation relative to local earnings. A senior qualitative researcher facilitated all sessions, assisted by a trained research assistant who obtained written consent and demographic data. All sessions were audio-recorded, transcribed verbatim in Kiswahili and translated into English for analysis.

Both data collection tools are included as supplementary materials (online supplemental files 1, 2). The instruments targeted three key components for establishing village-level emergency services in Tanzania: (1) health-seeking behaviour; (2) access to health and emergency care, including availability, acceptability, affordability, appropriateness and approachability; and (3) barriers, facilitators and anticipated challenges to implementation. The same tools were used preintervention and postintervention to ensure comparability. This manuscript focuses specifically on the question and findings related to the VEC model’s effectiveness after implementation.

Data analysis

Quantitative analysis

Quantitative data were exported from REDCap and analysed using Stata V.13. Descriptive statistics, including frequencies, percentages, medians and IQRs, were calculated. Pearson’s χ² tests were used to compare baseline and postintervention proportions, with a 5% significance level. Although data were collected using a 5-point Likert scale (Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree), for visualisation and comparative purposes in tables, only the percentage of participants who ‘Agree’ was highlighted, while ‘Neutral’ and ‘Disagree’ were not shown. This approach simplifies interpretation while retaining the integrity of the underlying analysis.

Qualitative analysis

Audio recordings were transcribed and analysed using Braun and Clarke’s six-phase thematic analysis framework: familiarisation, coding, theme generation, reviewing, defining/naming themes and reporting.²⁰ Interview and FGD transcripts were analysed together to enhance triangulation. Manual coding was conducted in Microsoft Excel. Initial coding was performed in Kiswahili to preserve linguistic nuance, and research team consensus meetings ensured analytical reliability.

Integration of quantitative and qualitative findings

During data collection, researchers used REDCap’s real-time chart and graph features to monitor response patterns and ensure data completeness. Minor refinements to the qualitative tool were made to enhance clarity and ensure that interviews and discussions captured in greater detail the patterns emerging from quantitative data, without altering core content. Actual integration of the quantitative and qualitative components occurred at the interpretation stage. Quantitative results identified trends in access, awareness and satisfaction, while qualitative findings provided contextual explanations for these patterns. This explanatory sequential design enabled a deeper understanding of how and why the VEC model influenced observed changes. Integrated interpretations are presented narratively in the Discussion section.

Ethics approval and consent to participate

Permission to conduct the study was granted by the relevant regional and municipal authorities and the head of the facility where data collection took place. Written informed consent was obtained from each participant before commencing interviews or discussions. The informed consent included details about the participants’ rights, privacy, confidentiality measures, contact information in case of questions or concerns, benefits of participation and the study’s objectives. All study procedures adhered to the ethical standards outlined in the Declaration of Helsinki.

Results

Quantitative

Characteristics of the study participants

A total of 191 participants were enrolled at baseline and 270 postinterventions. The median age at follow-up was 44 years (IQR 30.8–58) compared with 41 years (IQR 31–55) at baseline. Sample composition was broadly similar across survey waves, with no significant differences in sex, age group or educational attainment (table 1). However, the proportion of self-employed respondents declined from 90.1% to 72.5% (χ² = 23.9, p<0.001), while unemployment remained low and stable. Overall, participant characteristics were comparable, supporting the validity of pre–post comparisons of the VEC model’s effects.

Table 1. Sociodemographic characteristics of adult village residents surveyed before and after implementation of the village emergency care model.

Variable	Baseline, n=191 n(%)	Postintervention, n=270 n(%)	Test statistic	P value
Median age, years (IQR)	41 (31–55)	44 (30.8–58)	Z=1.12	0.26
Female sex	105 (55.0)	162 (60.0)	χ² = 1.07	0.30
Primary education or higher	162 (84.8)	224 (82.8)	χ² = 0.38	0.54
Self-employed	172 (90.1)	196 (72.5)	χ² = 23.9	<0.001
Unemployed	14 (7.3)	16 (5.9)	χ² = 0.27	0.60

Values are number (%) unless otherwise stated.

Baseline survey conducted prior to implementation of the village emergency care model; postintervention survey conducted following implementation.

Χ² test used for categorical variables; Wilcoxon rank-sum test used for comparison of median age.

Percentages may not total 100 due to rounding.

Perceived access, awareness and satisfaction

Perceived access to emergency services improved markedly following implementation of the VEC model, with statistically significant gains across all dimensions of availability, acceptability, affordability and satisfaction (all p<0.01). Availability rose from 61.0% to 84.4% (χ² = 22.47, p<0.001), and awareness of emergency conditions from 90.1% to 97.0% (χ² = 9.03, p=0.003). Physical accessibility within the village increased from 50.3% to 98.6% (χ² = 168.32, p<0.001). The perceived availability of essential medicines, diagnostics and 24-hour service coverage also improved significantly. Satisfaction increased from 12.0% to 88.5% (χ² = 187.6, p<0.001), highlighting substantial community endorsement of the new emergency services. (table 2).

Table 2. Self-reported perceptions of access, awareness and satisfaction with emergency care services among adult village residents before and after implementation of the village emergency care model.

Indicator	Baseline, n=191 n(%)	Postintervention, n=270 n(%)	χ²	P value
Availability of emergency services	117 (61.0)	228 (84.4)	22.47	<0.001
Acceptability of emergency care	172 (90.0)	263 (97.4)	9.03	0.003
Affordability of emergency services	17 (9.0)	138 (51.1)	56.91	<0.001
Physical accessibility of services	96 (50.3)	266 (98.6)	168.32	<0.001
Availability of essential medicines	120 (62.8)	245 (90.7)	35.11	<0.001
Diagnostic services readily available	92 (48.2)	223 (82.6)	46.27	<0.001
24-hour service availability at facility	19 (10.1)	270 (100.0)	385.30	<0.001
Awareness of emergency services	172 (90.1)	262 (97.0)	9.03	0.003
Satisfaction with emergency services	23 (12.0)	239 (88.5)	187.60	<0.001

Values are number (%) unless otherwise stated.

Indicators reflect self-reported perceptions of access domains adapted from the Penchansky and Thomas framework.

Baseline survey conducted prior to implementation of the village emergency care model; postintervention survey conducted after implementation.

Χ² tests used for all categorical comparisons

Healthcare expenditure and mode of payment

Annual healthcare expenditure declined significantly after VEC implementation. At baseline, 64.0% reported spending >TZS100 000 per year, compared with 28.1% postimplementation. The proportion spending <TZS50 000 increased from 9.0% to 51.1% (χ² = 63.12, p<0.001).

Although health-insurance coverage remained low, reliance on cash payments persisted. These findings indicate improved affordability despite ongoing vulnerability to out-of-pocket costs. (table 3)

Table 3. Annual out-of-pocket healthcare expenditure and mode of payment among adult village residents before and after implementation of the village emergency care model.

Variable	Category	Baseline, n=95 n(%)	Postintervention, n=270 n (%)	χ²	P value
Annual out-of-pocket healthcare expenditure	<TZS50 000 (<US$20)	9 (9.0)	138 (51.1)	63.12	<0.001
	TZS50 000–100 000 (US$20–41)	25 (26.0)	56 (20.7)
	>TZS100 000 (>US$41)	61 (64.0)	76 (28.1)
Mode of payment	Cash	178 (93.2)	248 (91.9)	1.12	0.29
	Health insurance	9 (4.7)	22 (8.1)

Values are number (%).

Baseline sample for expenditure reflects respondents reporting healthcare costs in the preceding year.

Costs represent annual out-of-pocket expenditure on healthcare.

For context, the World Bank (2022) defines the international extreme poverty line as living on less than US$2.15 per person per day (2022 PPP). In rural Tanzania, this approximates TZS3000–4000 per person per day. At this income range, an annual out-of-pocket healthcare expenditure of TZS50 000 (∼US$20) represents roughly 12–17 days of typical daily income.

Currency conversion rates used: US$1=TZS2455; GBP1=TZS3230.

χ2 test used for categorical comparisons.

Barriers to access

Following implementation of the VEC model, several barriers to accessing emergency care showed significant improvement. Seven indicators demonstrated statistically significant positive change (p<0.05), including reduced waiting times, improved customer care and better availability of medicines and diagnostic equipment (table 4).

Table 4. Self-reported barriers and facilitators to accessing emergency care at baseline and postevaluation.

Indicator	Baseline, n=100 %	Post evaluation, n=72 %*	χ²	P value
Long waiting	21.0	2.7	13.58	<0.001
Failed to pay for health services	16.0	30.5	4.81	0.028
Poor customer care	12.0	1.4	6.32	0.012
Shortage of diagnostic equipment	8.0	6.9	0.06	0.80
Shortage of medicine	21.0	2.7	13.58	<0.001
Cultural barriers to seeking formal care	17.3	5.2	18.56	<0.001
Trust in facility care	54.5	95.6	86.73	<0.001
Others (insurance not accepted, distance to care)	13.0	8.3	0.87	0.35
Did not face any challenge	7.0	47.2	32.9	<0.001

χ² tests assess differences in proportions between baseline and postevaluation samples.

All indicators are self-reported and reflect perceived barriers or facilitators.

Observed differences represent associations and do not imply causation.

^*Postevaluation includes only respondents who reported at least one barrier (N=72).

Cultural barriers declined, and trust in facility staff increased, reflecting strengthened community confidence. Nevertheless, financial constraints remained a recurring barrier, as the inability to pay continued to limit access for some households. The proportion reporting no challenges in accessing care increased from 7.0% to 47.2% (χ² = 32.9, p<0.001), suggesting broad gains in affordability and service acceptability.

Qualitative

Four main themes emerged from FGDs and IDIs.

Enhanced access to emergency care services

1. Enhanced availability of medicines and diagnostics.

Respondents acknowledged that medicines and supplies are now available at the dispensary, enabling effective emergency response. Prior to the intervention, supplies such as oxygen, pulse oximeters, and basic medications were limited or unavailable.

For cases of difficulty in breathing we have oxygen concentrators’ machines which helps with ventilation, a pulse oximetry for oxygen saturation monitoring as seen there. Also, we have emergency medications like aminophylline, working as a team in handling emergency cases we quickly attain patients’ physiological stability. You may go in other places they don’t have nebulizer, but we have it here with us. (IDI-MOI)

2. Availability of services for 24 hours.

Informants emphasised that care was accessible beyond normal working hours through an on-call arrangement.

…So, when a patient arrives seeking emergency services, there are phone numbers set on a noticeboard. When it’s out of work hours, and a villager has an emergency case, they call them, and they come to serve the patient on time because they reside close to the facility. Our Dispensary workers are so friendly and sensitive to villagers’ needs… (IDI-3)

Increasing community awareness of emergency care concept

1. Understanding of emergency conditions.

Participants described greater knowledge of what constitutes an emergency and the importance of seeking professional help.

Before that, there were many strange things that used to happen. Imagine a person cuts himself and urinates to stop the bleeding, creating big problems for himself. Or a person is bitten by a snake, he ties a rope and puts a stone, like that! There were many things, but after the training, many things have changed…. if you get that challenge, the first thing to do is to run to the hospital for emergency checkup and treatment… (FGD-06)

2. Recognition of vulnerable groups.

Respondents acknowledged that compared with baseline, they now could recognise groups most vulnerable to emergencies due to high accident risk. These included young adults. Others mentioned pregnant women, children and elderly adults as groups frequently using emergency services.

For my observation, since this clinic has been opened, many emergency patients attended are in the youth group because of accidents. Many youths here are attended due to accident. (FGD-06)

and

…In my view is that 10% of the elderly get emergency conditions, many falls and get strokes… Thus, in general, the elderly are more likely to get emergency conditions… (FGD-02)

3. Awareness of common emergency conditions.

Respondents were more aware of frequently occurring emergencies in their area, including asthma, bleeding, accidents, hypertensive crises and obstetric complications.

…Most of our emergency patients who come here are asthmatics; some have high blood pressure, and others who have probably cut themselves are also coming. (IDI-1)

4. Proper emergency scene handling.

First-aid training increased community confidence in responding before professional help arrived.

…personally, I received first Aid training in our village, and we were awarded certificates. Therefore, I can offer first aid service anywhere regardless of the environment…for example a child swallowing a coin, maybe two cents or any other coins which can cause blockage of throat, respiratory system… it’s not something to rush into, I ensure proper handling of the patient before seeking professional care at the dispensary … (IDI-2)

Varying perceptions on the cost of health services

1. Reduced cost of emergency services.

Participants reported substantial savings in travel and treatment.

…The services have brought relief in the community, basically for the issue of cost, a patient used to spend a lot of money travelling to hospital, but currently the same amount of money is used to buy medicine, thus it helps a lot … (FGD-08).

2. High cost of some of the available services.

The study informants reported that some services, such as antivenom, remain expensive, posing affordability challenges.

Anti-venom is really costly here, I think it is costly… because we also buy it at a high price, I think it reaches 200,000/= now that is another challenge, you find that someone comes with snake bite and in need of anti-venom but fails to pay that 200,000/=. (IDI-1)

3. Perceived high cost of investigations.

Some informants noted that prior to the introduction of the Bantu dispensary, treatment at other hospitals was largely symptom-driven with few diagnostic tests. Laboratory investigations were perceived as expensive, and some caregivers occasionally avoided them due to financial constraints.

Income varies, and sometimes I struggle to pay. I once brought my child for tests. For a UTI test, I paid about 3,000 TZS, and for malaria testing, I am unsure of the cost, though I believe it is free. The total bill, including drugs, could reach 10,000 TZS, which is beyond my financial capacity. (IDI-2)

4. Perception that donor-supported services are free of charge.

There is a community perception that donor-funded services are free. Thus, confusion existed about the role of donors

…The Government is the one started to build the dispensary and then Abbott came and finish the dispensary infrastructure now the villagers taking for granted that due to conducive infrastructures they thought that Abbott is the one owning the dispensary and every Abbott funded project is free of charge, some were unaware that the service has to be paid for… (IDI-4)

Enhanced trust in emergency care services of emergency care concepts

1. Utilisation of the available emergency care services.

Informants reported increased attendance at the dispensary and a marked reduction in reliance on traditional herbs. Several participants described how, before the dispensary was established, community members depended on herbal remedies and pregnant women often delivered on their way to distant facilities. The availability of local emergency and maternal services has improved timely care-seeking for both emergencies and common ailments.

…I’m thankful to have a dispensary here, in the past it was a challenge, pregnant women used to give birth on the way, a person would be laid down to give birth alongside the road because of the lack of delivery service in the village…Some used herbs as a first remedy for ailments… but now people are motivated to seek proper care from the dispensary. (FGD-05)

2. Emergency care services meet community expectations.

Most participants expressed satisfaction with the quality and responsiveness of services provided at the dispensary. They described improved provider–patient relationships, better customer care and reliable diagnostic capacity, all contributing to higher trust and confidence in the facility.

…The treatments provided here are of better quality compared to other hospitals, at Bantu dispensary there are many diagnostic equipment, other hospitals do not have some of the diagnostic equipment… (FGD-07)

Discussion

This study evaluated the effectiveness of the VEC model in improving access to emergency services within a rural Tanzanian PHC setting, guided by adapted Penchansky and Thomas’s five dimensions of access: availability, accessibility, affordability, acceptability and adequacy. 1 year after implementation, the evaluation observed improvements across all domains. Quantitative data were associated with gains in access, affordability and satisfaction, while qualitative narratives provided insights into factors that may have contributed to these trends, including enhanced facility readiness, staff responsiveness and increased community health literacy. Persistent concerns about cost and insurance were also noted, suggesting that financial barriers, though potentially reduced, remain a significant challenge.

Existing literature describes three broad models of emergency care delivery in low-resource countries: (1) LFR systems, (2) community paramedicine or community emergency health worker models and (3) formal emergency medical services (EMS) or hospital-based prehospital care.^{12 21 22} These models differ in scope, workforce training and level of system integration. For example, lay responder systems, such as those piloted in Sierra Leone, Uganda and Chad, primarily involve non-clinical volunteers trained in basic first aid and stabilisation techniques.²¹ Typically, these are stand-alone interventions with limited integration into the broader health system. Similarly, the eight-domain framework proposed by Nakahara et al¹¹ which outlines essential components of emergency care systems, remains largely untested in rural LMIC settings.

The VEC model implemented in Bantu most closely resembles community-based first responder strategies but diverges in several key aspects. Unlike purely volunteer-led models, VEC is integrated within the existing PHC infrastructure, involving structured training for facility-based health workers, prepositioned emergency supplies and formal referral linkages to higher levels of care. This design aligns with the WHO’s ECSF, which emphasises system integration, workforce capacity and resource readiness.⁵ In contexts such as rural Tanzania, where formal EMS systems are limited, the VEC model appears to be a feasible and potentially scalable approach. Our findings indicate associations between the intervention and improvements in emergency care availability, awareness and patient satisfaction, suggesting that modest, community-rooted innovations may contribute to evolving typologies of decentralised emergency care systems in LMICs.

Assessment of community satisfaction revealed a sixfold increase in perceived service satisfaction, suggesting an association between the intervention and enhanced community confidence in accessing emergency services. Patient satisfaction with healthcare is strongly linked to the ability to access quality care.^{23 24} When patients are satisfied, they are more likely to seek care consistently and recommend services to others.²⁵ Qualitative interviews corroborated this, with community members reporting that services now meet their expectations and are of good quality. Such perceptions of high-quality care foster trust, which in turn encourages timely health-seeking behaviour and amplifies overall access. As previous research has shown, the presence of skilled providers and reliable equipment is central to community perceptions of safety and quality in emergency care.^{26 27}

The availability of emergency equipment and essential drugs in the facility was associated with improved perceptions of reliability and appeared to reinforce public confidence. Nonetheless, shortages and stockouts remain a concern, potentially limiting access and eroding trust.²³ Diagnostic equipment, vital for accurate assessment and treatment, was highly valued by the community, as it ensured patients received appropriate care. The community’s appreciation of these resources highlights the importance of maintaining supply chains and resource availability to sustain gains in trust and service quality. This VEC model also strengthened community capacity through education on emergency conditions and basic first aid. Participants reported that heightened awareness catalysed behavioural changes, suggesting that education is an active, strategic component of improving access rather than a passive outcome. These findings are consistent with other health awareness campaigns, emphasising the potential for targeted community interventions to influence health-seeking behaviour.²⁸

Community perceptions of the affordability of VEC services varied across participants. Some reported that the proximity of the dispensary was associated with reduced travel and transport costs, which made accessing care appear cheaper than before. Others, however, reported that certain life-saving interventions, such as antivenom, antirabies immunoglobulin and specific antidotes, remained prohibitively expensive. These variations likely reflect differences in individual circumstances, the type and urgency of care needed and incomplete coverage under the Tanzanian National Health Insurance scheme. The authors also recognise that as a newly introduced service, some costs may have been perceived as higher due to lack of familiarity or uncertainty about insurance coverage. While geographical and logistical barriers were reduced for most, financial constraints persist as a significant challenge for some community members, suggesting that further efforts to expand insurance integration and transparent communication of costs are necessary to ensure equitable access. The issue of financial barriers to emergency care is well-documented in the literature, where high costs and limited insurance coverage often delay or prevent necessary treatment, especially in low-income settings.^29–31 This issue is particularly severe in low-income areas, where many patients are either uninsured or underinsured, which makes accessing emergency care financially difficult.^{29 31} These financial barriers may lead individuals to delay or skip necessary treatment due to cost concerns.^{6 29 30} Addressing these barriers is crucial for maximising the impact of community-based emergency care models.

Limitation and generalisability

Several limitations should be considered. First, the evaluation was conducted only 1 year after implementation, which may not reflect longer-term trends or sustainability. Second, the presence of a new health facility in Bantu may be associated with some of the observed improvements in access, particularly in physical accessibility, introducing potential bias. Nonetheless, the data suggest that VEC may be linked to changes in acceptability, affordability and service adequacy, though these associations cannot establish causation. Third, contextual factors, such as funder support for medications, equipment, staff housing and staffing levels, may be associated with the observed outcomes and limit generalisability. Fourth, while access was quantitatively measured using a single-item indicator, this limitation is partially mitigated by complementary qualitative data, which provided context and helped support the observed trends. Observed changes may also be associated with the surveys themselves or ongoing government campaigns post-COVID. Despite these limitations, Bantu village shares characteristics with many rural Tanzanian communities, suggesting that the findings may be relevant for informing the design and evaluation of similar interventions in comparable settings.

Impact

This study offers one of the first evaluations of a community-based emergency care model integrated within PHC in rural Tanzania. The results suggest that modest, context-tailored interventions at the village level can meaningfully improve emergency care availability, awareness and patient satisfaction, even in resource-constrained settings. The findings contribute novel evidence to the global discourse on strengthening emergency care at the PHC level and illustrate the potential of community-driven models to reduce access inequities. These insights may inform public health policy and support the case for scaling up decentralised, locally adapted emergency care systems as part of broader efforts to advance UHC and health system resilience in LMICs. Future studies should assess the cost-effectiveness and long-term sustainability of this model to inform national scale-up.

Conclusion

The VEC model in Bantu village was associated with improvements in access, satisfaction and community awareness of emergency services. Quantitative data indicated gains in accessibility, affordability and satisfaction, while qualitative findings provided insights into how enhanced facility readiness, trained staff and community education may have contributed to these observed trends. Financial perceptions varied: some community members reported benefits from reduced travel costs, whereas others noted high expenses for life-saving interventions not covered by insurance.

To support the effectiveness and sustainability of the VEC model, efforts could focus on expanding community education on insurance coverage, ensuring transparent communication about costs and exploring strategies to reduce out-of-pocket expenses for high-cost emergency interventions. These steps may help maximise the potential of community-based emergency care in rural, resource-limited settings, while acknowledging that further research is needed to confirm long-term outcomes and causal relationships.

Data availability statement

Data are available upon reasonable request.