Emergency medical services infrastructure development and operations in low- and middle-income countries: Community fi rst responder-driven (Tier-1) emergency medical services systems

Low- and middle-income countries face unique challenges in delivering prehospital emergency care, often requiring context-appropriate emergency medical services development focused on community- driven solutions (tier 1 systems). Replicating high-income country tier 2 systems in low- and middle- income countries is not financially feasible in resource-limited settings. Instead, tier 1 systems composed of trained layperson first responders use locally available vehicles and involve local communities and stakeholders in their design and implementation to address specific local needs and emergencies. Community engagement is crucial for establishing sustainable and inclusive emergency medical services systems. This article focuses on the development and operation of tier 1 systems in low- and middle-income countries, covering technology integration, local appropriateness and co-operation, training curricula, trainee recruitment and selection, volunteer incentivization, monitoring and evaluation, and coordination with tier 2 systems. Layperson first responder programs are essential to address the global injury burden that disproportionately affects low- and middle-income countries and to evolve into, or coordinate with, tier 2 systems in resource-limited settings, but this requires community involvement to increase local ownership, drive sustainable solutions, and respect local values and cultures.