A community-based ambulance model: lessons for Emergency Medical Services (EMS) and everyday health systems resilience from South Africa.

The role of Emergency Medical Services (EMS) is changing globally as ambulance crews respond to a shifting burden of disease as well as societal stressors such as violence and inequality. New ways of thinking about how to provide emergency care are required to shift EMS from a role primarily focused on clinical care and transporting patients to hospital. In this paper, we present the experience of the Philippi Project (PP), an innovative community-based model of care developed by front-line ambulance crews in a low-income neighborhood in Cape Town, South Africa. Our insights were developed through observational, interview and document review work, within an overall embedded research approach. Our analysis draws on the Everyday Health Systems Resilience framework, which sees resilience as an emergent process that may be stimulated through response to stress and shock. Responses take the form of absorptive, adaptive or transformative strategies and are underpinned by system capacities (cognitive, behavioral and contextual). We consider the PP as a potentially transformative resilience strategy, defined as a new way of working that offered the promise of long-term health system gains. We found that the PP's initial development was supported by a range of system capacity attributes (such as the intentional development of relationships, a sense of collective purpose, and creating spaces for constructive sensemaking). However, the PP was hard to sustain over time because emergent ways of working were undermined both by other capacity attributes rooted in pre-existing organizational routines, and two contextual shocks (Covid-19 and a violent incident). The paper adds a new empirical contribution to the still-small EHSR literature. In addition, the PP experience offers globally relevant lessons for developing community-based models of EMS care. It demonstrates that frontline staff can develop creative solutions to their stressful daily realities, but only if space is created and protected.