title: Population-level Spatial Access to Prehospital Care by the National Ambulance Service in Ghana.
abstract: Conditions requiring emergency treatment disproportionately affect low- and middle-income countries (LMICs), where there is often insufficient prehospital care capacity. To inform targeted prehospital care development in Ghana, we aimed to describe spatial access to formal prehospital care services and identify ambulance stations for capacity expansion.
  
  
  
  Cost distance methods were used to evaluate areal and population-level access to prehospital care within 30 and 60 minutes of each of the 128 ambulance stations in Ghana. With network analysis methods, a two-step floating catchment area model was created to identify district-level variability in access. Districts without NAS stations within their catchment areas were identified as candidates for an additional NAS station. Additionally, five candidate stations for capacity expansion (e.g., addition of an ambulance) were then identified through iterative simulations that were designed to identify the stations that had the greatest influence on the access scores of the ten lowest access districts.
  
  
  
  Following NAS inception, the proportion of Ghana's landmass serviceable within 60 minutes of a station increased from 8.7 to 59.4% from 2004 to 2014, respectively. Over the same time period, the proportion of the population with access to the NAS within 60-minutes increased from 48% to 79%. The two-step floating catchment area model identified considerable variation in district-level access scores, which ranged from 0.05 to 2.43 ambulances per 100,000 persons (median 0.45; interquartile range 0.23-0.63). Seven candidate districts for NAS station addition and five candidate NAS stations for capacity expansion were identified. The addition of one ambulance to each of the five candidate stations improved access scores in the ten lowest access districts by a total 0.22 ambulances per 100,000 persons.
  
  
  
  The NAS in Ghana has expanded its population-level spatial access to the majority of the population; however, access inequality exists in both rural and urban areas that can be improved by increasing station capacity or adding additional stations. Geospatial methods to identify access inequities and inform service expansion might serve as a model for other LMICs attempting to understand and improve formal prehospital care services.
authors.forename: Gavin
authors.initials: G
authors.lastname: Tansley
authors.forename: Barclay
authors.initials: B
authors.lastname: Stewart
authors.forename: Ahmed
authors.initials: A
authors.lastname: Zakariah
authors.forename: Edmund
authors.initials: E
authors.lastname: Boateng
authors.forename: Christiana
authors.initials: C
authors.lastname: Achena
authors.forename: Daniel
authors.initials: D
authors.lastname: Lewis
authors.forename: Charles
authors.initials: C
authors.lastname: Mock
mesh_terms: D000552:Ambulances / Q000706:statistics & numerical data*; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D040362:Geographic Information Systems / Q000706:statistics & numerical data*; D005869:Ghana; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D012424:Rural Population
keywords: Geographic Information Systems; developing countries; emergency medical services; health services accessibility