Leveraging transportation providers to deploy lay first responder (LFR) programs in three sub-Saharan African countries without formal emergency medical services: Evaluating longitudinal impact and cost-effectiveness

Introduction In 2019, the World Health Assembly declared emergency care essential to achieve the 2030 Sustainable Development Goals. Few sub-Saharan African (SSA) countries have developed robust approaches to sustainably deliver emergency medical services (EMS) at scale, as high-income country models are financially impractical. Innovative reassessment of EMS delivery in resource-limited settings is necessary as timely emergency care access can substantially reduce mortality. Materials and Methods We developed the Lay First Responder (LFR) program by training 1,291 pre-existing motorcycle taxi drivers, a predominant form of short-distance transport in sub-Saharan Africa, to provide trauma care and transport for road traffic injuries. Three pilot programs were launched in staggered fashion between 2016-2019 in West, Central, and East Africa and a 5.5-hour curriculum was iteratively developed to train first responders. Longitudinal data on patient impact (patient demographics, injury characteristics, and treatment rendered), emergency care knowledge acquisition/retention, and social/financial effects of LFR training were collected and pooled across three sites for collective analysis. Novel cost-effectiveness ratios were calculated based on prospective cost data from each site. Previously projected aggregate disability-adjusted life years (DALYs) addressable by LFRs were used to inform cost-effectiveness ratios($USD cost per DALY averted). Cost-effectiveness ratios were then compared against African per capita gross domestic product (GDP), following WHO-CHOICE guidelines, which state ratios less than GDP per capita are "very cost-effective." Results In 2,171 total patient encounters across all three pilot sites, LFRs most frequently provided hemorrhage control in 61% of patient encounters and patient transport by motorcycle in 98.5%. Median pre-/post-test scores improved by 34.1 percentage points (39.5%vs.73.6%, p<0.0001) with significant knowledge retention at six months. 75% of initial participants remain voluntarily involved 3 years post-course, reporting increased local stature and customer acquisition(income 32.0% greater than non-trained counterparts). Locally sourced first-aid materials cost $6.54USD/participant. Cost-effectiveness analysis demonstrated cost per DALY averted=$51.65USD. Conclusion LFR training is highly cost-effective according to WHO-CHOICE guidelines and expands emergency care access. The LFR program may be an alternative approach to formal ambulance-reliant EMS that are cost-prohibitive in resource-limited, sub-Saharan African settings. A novel social/financial mechanism appears to incentivize long-term voluntary LFR involvement, which may sustain programs in resource-limited settings.