Ambulances often slow care for injured patients in Ghana, Pakistan, Rwanda, and South Africa

The golden hour - that first 60 minutes after a serious injury when rapid treatment can mean the difference between survival and death - is a concept borrowed from military medicine and enshrined in emergency care worldwide. But in Ghana, Pakistan, Rwanda, and South Africa, more than half of seriously injured patients never make it to a hospital within that window. And the vehicle most people associate with emergency rescue, the ambulance, is part of the problem.

A study of 8,331 injured patients across 19 hospitals in four countries, published March 23 in BMJ Global Health, finds that patients transported by ambulance consistently arrived later than those who grabbed a taxi, climbed into a private car, or hitched a ride on a motorbike.

Fifty-seven percent arrive too late

The research team, led by Justine Davies at the University of Birmingham and colleagues at Stellenbosch University, tracked patients admitted with serious injuries from interpersonal violence, road traffic collisions, falls, burns, and cuts. Across all four countries, 57% arrived more than one hour after being injured. A full 34% did not reach care until more than two hours had passed.

Ambulance use varied sharply between countries. In Ghana, only about 20% of injured patients traveled by ambulance. In Pakistan and South Africa, the figure was around 50%. In Rwanda, it reached 65%. But in every setting, ambulance transport was associated with arriving after the golden hour, not before it.

Patients using informal transport - private cars, taxis, motorbikes - got to treatment faster. That finding cuts against the intuition that more ambulances automatically mean better emergency care.

Fragmented referral chains and missed destinations

Part of the problem is that ambulances in these settings do not always take patients directly to the hospital equipped to treat them. Over 50% of patients in the study had not gone directly to the facility capable of providing definitive treatment. About 20% sought care first at a primary care clinic before being redirected to a hospital - a detour that adds precious minutes or hours.

This points to systemic failures in referral pathways. Ambulance crews may lack the information or protocols needed to route patients to the right facility on the first try. Without centralized dispatch systems that match patient needs to hospital capabilities, ambulances become expensive taxis that take the scenic route.

The delays also fell unevenly. Poorer patients, older patients, and those with less education experienced longer waits. Yet despite objectively delayed care, only 19% of patients believed they had experienced a delay. Many who reached the hospital hours after injury still felt they had arrived on time - a perception gap that suggests public understanding of emergency timing remains limited.

The cost of copying high-income models

Many low- and middle-income countries are currently weighing major investments in ambulance services, often modeled on systems from the United Kingdom or the United States. The study's authors urge caution. Building an ambulance fleet requires trained paramedics, medical equipment, data infrastructure, coordinated dispatch centers, road access policies, and maintenance budgets. Simply purchasing vehicles and parking them at hospitals will not replicate the outcomes seen in London or New York.

The researchers argue that the entire pre-hospital system needs attention, not just the ambulance component. Their recommendations include strengthening transport alternatives alongside ambulance services, streamlining referral pathways so patients reach capable hospitals on the first attempt, addressing socioeconomic inequities in access to emergency care, and developing public health messaging that helps people recognize when an injury demands hospital-level treatment.

Software to match patients with hospitals

Davies and her collaborators are not only diagnosing the problem - they are building a tool to address it. Working with IT developers in Rwanda and international partners, the team is creating the 912Rwanda software platform, which automatically recommends the nearest hospital capable of treating a specific patient's condition. The goal is to eliminate the guesswork that currently sends ambulances - and private vehicles - to facilities that cannot provide the care needed.

Backed by more than 3 million pounds from the National Institute for Health and Care Research and nearly $1 million from the US National Institutes of Health, the software could reduce serious disabilities for an estimated 250 million people who suffer injuries annually in low- and middle-income countries. It also targets emergency medical conditions like post-partum hemorrhage, sepsis, malaria, heart attacks, and strokes, which together cause roughly half of all deaths in these settings.

Limitations and what remains unknown

The study analyzed patients who reached hospitals, which means it cannot account for those who died before arriving at any facility. The true burden of delayed care is almost certainly worse than these numbers suggest. The data also come from 19 hospitals in four countries, and conditions vary enormously within and between nations in the Global South. What holds in urban Johannesburg may not apply in rural northern Ghana.

The researchers also note that ambulance services in these countries are at very different stages of development. Comparing ambulance performance in Rwanda, where 65% of injured patients use them, to Ghana, where only 20% do, involves comparing systems with fundamentally different levels of infrastructure and staffing.

Still, the central finding is robust across all four countries: the ambulance, as currently deployed in these settings, is not reliably getting patients to the right hospital within the time frame that matters most. Fixing that will require more than buying more vehicles. It will require rethinking how entire emergency care systems are designed.