Performance of an Emergency Road Ambulance Service in Bhutan: Response Time, Utilization, and Outcomes.

Background: An efficient ambulance service is a vital component of emergency medical services. We determined the emergency ambulance response and transport times and ambulance exit outcomes in Bhutan. Methods: A cross-sectional study involving real-time monitoring of emergency ambulance deployments managed by a central toll-free (112) hotline (20 October 2021 to 20 January 2022) was carried out. Results: Of 5092 ambulance deployments, 4291 (84%) were inter-facility transfers, and 801 (16%) were for emergencies. Of the latter, 703 (88%) were for non-pregnancy-related emergencies (i.e., medical, surgical, and accidents), while 98 (12%) were for pregnancy-related emergencies. The median ambulance response and patient transport times were 42 (IQR 3-271) and 41 (IQR 2-272) minutes, respectively. The median round-trip distance travelled by ambulances was 18 km (range 1-186 km). For ambulance exit outcomes that were pregnancy-related (n = 98), 89 (91%) reached the health facility successfully, 8 delivered prior to ambulance arrival at the scene or in the ambulance during transport, and 1 had no outcome record. For the remaining 703 non-pregnancy deployments, 29 (4.1%) deployments were deemed not required or refusals, and 656 (93.3%) reached the health facility successfully; 16 (2.3%) died before the ambulance's arrival at the scene, and 2 (0.3%) were not recorded. Conclusions: This first countrywide real-time operational research showed acceptable ambulance exit outcomes. Improving ambulance response and transport times might reduce morbidities and mortalities further.

Assessing Sustainability Factors for Rural Household Sanitation Coverage in Bhutan, Kenya, Nepal, and Zambia: A Qualitative Analysis.

BACKGROUND: Few countries are likely to achieve universal sanitation within the next decade as sustaining household sanitation coverage remains a critical challenge. This study aimed to investigate factors that may have supported or hindered sustainability of sanitation coverage 1-2 years after the completion of an integrated, area-wide sanitation program in 4 countries. METHODS: We conducted qualitative analyses to identify factors related to the sustainability of sanitation coverage in Bhutan, Kenya, Nepal, and Zambia, 2 years after completion of the Sustainable Sanitation and Hygiene for All program. From November 2019 to March 2020, we conducted focus group discussions and key informant interviews with community members, project implementers, and decision makers. We triangulated the qualitative findings with data from household surveys to characterize subnational sanitation coverage throughout implementation and 1-2 years after. RESULTS: Our data revealed behavioral, contextual, and service delivery factors that were related to the sustainability of sanitation improvements. Service delivery factors included follow-up hygiene promotion, access to construction materials, local government commitment postimplementation, functioning monitoring systems, private sector uptake of supply chain improvements, and capacity for innovation. Contextual and behavioral factors included poverty, soil type, road networks, social cohesion, desire for improved latrines, maintenance and cleaning, and knowledge of sanitation benefits. CONCLUSION: The presence or absence of sustainability factors identified through this research may have implications on where certain programmatic approaches will work and where adaptations may be required. By comparing sustainability factors with subnational slippage rates, we were able to illustrate how local service delivery systems may respond to barriers and enablers. Understanding the programmatic and contextual factors that either drive or hinder long-term sanitation coverage may allow for greater program impact through adapting implementation based on existing challenges in service delivery and context.

Analyses of the performance of the Ebola virus disease alert management system in South Sudan: August 2018 to November 2019.

South Sudan implemented Ebola virus disease preparedness interventions aiming at preventing and rapidly containing any importation of the virus from the Democratic Republic of Congo starting from August 2018. One of these interventions was a surveillance system which included an Ebola alert management system. This study analyzed the performance of this system. A descriptive cross-sectional study of the Ebola virus disease alerts which were reported in South Sudan from August 2018 to November 2019 was conducted using both quantitative and qualitative methods. As of 30 November 2019, a total of 107 alerts had been detected in the country out of which 51 (47.7%) met the case definition and were investigated with blood samples collected for laboratory confirmation. Most (81%) of the investigated alerts were South Sudanese nationals. The alerts were identified by health workers (53.1%) at health facilities, at the community (20.4%) and by screeners at the points of entry (12.2%). Most of the investigated alerts were detected from the high-risk states of Gbudwe (46.9%), Jubek (16.3%) and Torit (10.2%). The investigated alerts commonly presented with fever, bleeding, headache and vomiting. The median timeliness for deployment of Rapid Response Team was less than one day and significantly different between the 6-month time periods (K-W = 7.7567; df = 2; p = 0.0024) from 2018 to 2019. Strengths of the alert management system included existence of a dedicated national alert hotline, case definition for alerts and rapid response teams while the weaknesses were occasional inability to access the alert toll-free hotline and lack of transport for deployment of the rapid response teams which often constrain quick response. This study demonstrates that the Ebola virus disease alert management system in South Sudan was fully functional despite the associated challenges and provides evidence to further improve Ebola preparedness in the country.