When ambulances are not enough: An interview-based needs assessment of governance and accountability gaps in prehospital emergency care in Hawassa, Ethiopia.

BACKGROUND: Effective prehospital emergency care requires functioning infrastructure, trained personnel, reliable communication, and coordinated governance. In low- and middle-income countries, these system components are often fragmented. This study assessed prehospital emergency care delivery in Hawassa, Ethiopia, from the perspectives of regional- and facility-level leaders. METHODS: A qualitative, interview-based needs assessment was conducted during February 10-20, 2025, at Hawassa University Comprehensive Specialized Hospital and Motite Furra Hospital, Sidama National Regional State, Ethiopia. The World Health Organization Prehospital Emergency Care Assessment Tool guided interview development. Fifteen interviews were conducted with emergency medical service leaders, hospital administrators, and coordinators from the Hawassa City Health Bureau and Sidama Regional Health Bureau. Transcripts were analyzed thematically in NVivo 15 (Lumivero, LLC, Denver, CO). RESULTS: Interviews identified 6 recurring barriers: infrastructure constraints, shortages of essential medicines and equipment, communication gaps, community perceptions of emergency care, workforce limitations, and structural weaknesses. Governance emerged as a central cross-cutting barrier. Participants described unclear ownership of dispatch and prehospital care, limited accountability, fragmented coordination, and inadequate budget authority. These governance gaps shaped otherwise familiar constraints, including nonfunctional emergency communication, poorly equipped ambulances, procurement delays, training interruptions, and limited workforce retention. CONCLUSION: Prehospital emergency care in Hawassa is constrained not only by limited resources but also by unclear responsibility for organizing, financing, and sustaining the system. Participants described services that often function more as interfacility transport than true prehospital care. Strengthening prehospital care will require clearer institutional ownership and accountability alongside restoration of emergency communication, improved ambulance readiness, reliable medicine and supply availability, and sustained workforce training.