Emergency medical services in low- and middle-income countries: a systematic review of systemic barriers and integration challenges.

Objective: To assess the status of emergency medical services (EMS) in low- and middle-income countries (LMICs) and identify key barriers to effective service delivery. Methods: A systematic review was conducted following PRISMA guidelines. PubMed, Scopus, Embase, and Cochrane Library were searched in March 2025 for studies on emergency medical service systems in low- and middle-income countries published between 2009 and 2023. Seventeen peer-reviewed studies were included. Thematic analysis was applied to synthesize findings and identify recurring challenges across EMS systems. Results: EMS systems in LMICs ranged from fragmented and informal arrangements to partially integrated national systems. Key barriers included weak governance, inadequate financing, workforce shortages, poor communication and coordination, and limited infrastructure. Findings suggest that EMS underperformance is driven not only by resource constraints but also by fragmentation and limited integration of community-based emergency networks. Informal responders, such as community volunteers, frequently fill gaps in formal EMS but remain largely absent from policy frameworks. Conclusions: Strengthening EMS in LMICs requires integrated approaches that bridge formal and informal systems, alongside improved workforce capacity and coordination, to enhance emergency care outcomes.