Emergency Medicine in South Africa: Progress, challenges, and future directions from a qualitative inquiry.

Introduction: In South Africa (SA), Emergency Medicine (EM) has rapidly evolved from an unstructured service to a recognised speciality since 2004. Specialists in EM now lead many Emergency Departments (EDs) in SA, and the impact that the speciality has made is hard to measure against a resource-constrained system and growing healthcare needs. This study aims to explore these aspects through the perspectives of key stakeholders, providing insights into the speciality's progress and its future trajectory. Methods: A qualitative study was used to examine the experiences and perceptions of local EM leaders. Semi-structured one-on-one interviews were conducted with a purposive convenience sample from hospitals across SA. An appreciative inquiry framework was used to explore positive aspects of EM alongside its challenges and analysed using inductive thematic analysis. Results: Ten primary interviews, followed by a further three secondary interviews were conducted across four provinces of SA. Four primary themes emerged: EM has changed everything, systems in the chaos; the EM team goes the extra mile - the people in EM; the ED is the hub and heart of the hospital; and a team of EM specialists can innovate and change beyond the ED. Each theme encapsulated distinct perspectives on the achievements and challenges faced by EM professionals, highlighting the complex and evolving role of the speciality within SA healthcare. Conclusion: EM has evolved into a crucial speciality, providing essential acute care, improving patient flow, and mitigating access barriers. The findings emphasise EM's function as both a frontline responder and a system stabiliser, compensating for gaps in primary and inpatient care. Strong EM leadership, training and teamwork are central to the accomplishments, although many challenges remain. Strengthening EM leadership, integrating EM into broader healthcare strategies, and fostering multidisciplinary collaboration are key to ensuring the speciality's continued growth and impact. Lessons from SA's experience offer valuable insights for other African systems.