Emergency Medical Care and the Law in Nigeria: Towards Protection of Patients' Rights. (2024)

I. Introduction

The rights of individuals to the highest attainable standard of health, established in international legal instruments, connotes that medical attention should be available to everyone when required, without any form of denial on the basis of religion, age, origin, gender, or medical status. (1) The right to health cannot be fully realized when medical emergencies are not efficiently handled by States and when sick or injured persons are deprived of access to urgent care and treatment. (2)

A medical emergency is an unexpected situation which could affect the wellbeing of persons to the extent of causing death or serious damage when prompt attention and care is not received. (3) The World Health Organization (WHO) classifies emergencies to include: non-communicable diseases, such as diarrhea, malaria, heart diseases, cerebrovascular disease, asthma and diabetes. (4) Also included, are injuries whether intentional through self-inflicted harm, interpersonal violence, armed conflict and non-intentional injuries from transport or non-transport and with forces of nature. (5) In recent times, communicable diseases like the Ebola virus and Coronavirus Disease (COVID-19) have also caused emergencies globally, and as these incidents have indeed made obvious, poor response mechanisms to health emergencies exist in several countries. (6)

Emergency Medical Services "EMS" refers to "a comprehensive system which provides the arrangements of personnel, facilities and equipment for the effective, coordinated and timely delivery of health and safety services to victims of sudden illness or injury." (7) EMS can also been defined as rapid and efficient health care services rendered to persons with various life-threatening ailments or conditions. (8) Emergency care is an important aspect of healthcare delivery, as better results are achieved in health systems which promptly and efficiently attend to people with life-threatening health issues. (9)

EMS reduces delays in accessing hospital care, thereby promoting the health of the population. (10) Apart from contributing significantly to untimely deaths and disabilities, inefficient EMS systems affect societal development, as members expend unnecessary time and resources on medical conditions that could have been appropriately handled before patients' conditions deteriorated. (11) In low- and middle-income countries, ("LMIC") quality EMS has been estimated to reduce mortality rates by forty-five percent and disability rates by thirty-six percent. (12)

The quality of EMS differs from one country to another, and may even vary between regions within countries. (13) Emergency care systems have received little attention in LMICs, mostly due to the reluctance in investing the funding necessary to establish a formal and high-quality system. (14) These countries instead mostly focus on using scarce resources to deliver affordable health services to citizens without much attention paid to the quality of these services. (15) Developed countries on the other hand have well-developed, structured, and high-quality EMS. (16) Some of these systems operate at very advanced levels, using telemedicine to promote speedy professional medical care remotely to patients who are far away from specialists. (17) Apart from the benefit to patients, telemedicine improves the skills of the less-experienced distant practitioners who receive instructions from more experienced practitioners. (18) Store and forward technology, where electronic information can be stored and transferred to obtain the opinion of specialists, in addition to mobile health, where mobile phones are the means of communication and used for the continuous observation of the patient after they have been discharged, are also used by developed countries to access critical care during emergencies. (19) Despite the fact that Nigeria has been reported to be the second-highest country in the world in terms of traffic accidents and other emergencies, EMS delivery remains sub-standard. (20) The situation is worse in rural communities, as development lags behind urban settings. (21)

This Article is organized into eight parts. Section One introduces the work, and section Two examines the components of emergency systems. Section Three analyses the accessibility to Nigerians of both pre-hospital and hospital-based emergency care. Domestic and international legal instruments regulating emergency care are discussed in Section Four, while liabilities of both medical practitioners and good Samaritans are explored in Sections Five and Six, respectively. Strategies that could improve access to emergency care in Nigeria are explored in Section Seven, while Section Eight concludes.

II. Components of Emergency Medical Systems

An emergency medical system includes pre-hospital care and hospital-based care. (22) Both components are important in promoting the health of persons who need emergency care as poor quality in either level of care is bound to negatively affect the lives of populations. (23)

A. Pre-Hospital Emergency Medical Services

Pre-hospital care is the medical attention received by ill or injured persons from the location of an emergency incident until they arrive at hospitals capable of providing care. (24) The pre-hospital period is a crucial and time-sensitive phase, where actions and decisions must be made quickly to prevent the patient's condition from worsening. (25) According to the American Association of Orthopaedic Surgeons, persons undergoing a medical emergency who receive the required medical attention before arriving at the hospital are more likely to survive than persons who have no such opportunity. (26) One report has stated that about 54 percent of an estimated 45 million deaths which occur in LMICs annually would have been preventable with quality pre-hospital care. (27)

The strategy used for the pre-hospital system of care depends on the availability of resources. (28) Under the formal system, treatment is administered at the scene of the emergency by technicians who use advanced procedures and equipment to provide medical attention, until the patient reaches the hospital. (29) However, due to inadequate availability of personnel and resources, emergency technicians are usually not accessible to all persons in LMICs. (30)

Because of the time-sensitive nature of medical emergencies, the response time of a pre-hospital EMS is an important criterion in measuring the quality of care. (31) "Response time" refers to the period between the call for medical assistance and the arrival of the emergency medical team at the location of the incident. (32) Timely intervention in emergency care achieves more positive outcomes, such as increasing the survival rates of sick and injured persons. (33) For example, a U.S. study discovered that prolonged EMS response times increased mortality rates of victims of motor vehicle crashes. (34) In contrast, a recent study in the US on transportation for trauma patients who contracted COVID-19, revealed that arriving at a hospital within 60 minutes increases the survival rate of the patients who are treated. (35) The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation ("CPR") and Emergency Cardiovascular Care ("ECC") recommended a response time of between eight to ten minutes for medical intervention from the time a patient collapses to the time paramedics arrive. (36) Additionally, providers should delay no more than five minutes in performing CPR and defibrillation. (37) Similar standards of response time have been adopted in EMS systems of various countries. (38)

Blanchard notes however, that it is challenging to expect the same response time for emergency situations all over the world. (39) Inadequate resources, congested traffic, and unsuitable roads, which are peculiar to some environments, affect EMS response time and produce less effective results. (40) The number of paramedics available in a particular city, compared to the size of the population, will also determine response time in periods of emergencies. (41) For example, it has been reported that the suggested proportion of one team of paramedics to 50,000 people results in a response time of four to six minutes. (42) Conversely, in Monterrey, Mexico, an average response time of ten minutes was documented for a ratio of one team to 100,000 people, while in Hanoi, Viet Nam, one paramedic team per 600,000 people responded to emergencies in thirty minutes on average. (43)

B. Hospital-Based Care

It is expected that persons who have been transported to hospitals receive adequate medical attention. However, the reality is that many persons with treatable illness do not have access to emergency care and end up losing their lives or becoming disabled, even after arriving at the hospital.

According to Eastman and others, the survival of persons in need of urgent medical attention depends on whether the hospital they are transported to is able to provide the required services in a timely manner. (44) Emergency departments ("EDs") within hospitals should be accessible throughout the day and should serve as the point of entry for persons without a previous hospital appointment. (45) Visits to this department require urgent attention, which may include the need to conduct rapid tests, make proper diagnoses and treatments, and even make rapid transfers to specialist hospitals once it is clear that the patient's condition is beyond the capacity and resources of the hospital. (46) It is, however, important that the receiving hospital accept the referred patient and be aware of appropriate details, so as to make adequate preparations for transfer. (47) Mortality rates are high in EDs that fail to promptly attend to patients, lack adequate resources, practice late referrals, and prescribe improper medications. (48) Discriminatory practices against vulnerable persons and inadequate training in emergency care among health workers also constitute challenges to emergency care in hospitals. (49)

The International Federation of Emergency Medicine ("IFEM") (50) notes that EDs of good quality must have adequate facilities; adequate staff who are qualified in handling emergencies; data support; a safe and clean environment; good administrative process; prompt and timely investigation and assessment processes; patient-centered care approaches; a good support system after leaving the emergency ward; and a mechanism for the monitoring and compliance of the standard of care in emergencies. (51) An ED set to achieve positive should also have "space, medications, supplies and specialized equipment." (52)

III. Emergency Medical Services in Nigeria

A. Pre-Hospital Based EMS in Nigeria

Road traffic accidents ("RTAs") constitute one of the highest number of emergencies leading to mortalities in Nigeria. (53) A study on ambulance services in Lagos states that between 2001 and 2006 RTAs constituted 35 percent of the total number of cases attended to by these services. The second highest cohort involved injuries arising from large crowds including "political and non-political rallies, mass protests/demonstrations, sports festivals, traditional/religious festivals" (32.2%), followed by gas or bomb explosions and drowning (8.8%), and finally, home accidents (0.1%). (54)

Nigeria, like most LMICs, does not have a formal and organized pre-hospital EMS. (55) Factors such as the type and severity of injuries and distance to a hospital are often considered when determining whether a pre-hospital emergency system is efficient. (56) Several studies also consider the number of people who died before reaching the hospital as an additional determinant. (57) For example, a research study conducted over two years in a tertiary hospital in Enugu state reported that 88 people were Brought in Dead ("BID") out of 382 emergency patients brought to the hospital. (58) Similarly, an eight-month long study that took place in a teaching hospital in Lagos, Nigeria, had a total of 144 BID cases. This statistic is higher than other countries, indicating that the pre-hospital EMS in Nigeria is inefficient and fraught with challenges. (59)

The need for the prioritization of quality EMS in Nigeria came to the forefront when six medical practitioners were involved in an RTA in April 2016. (60) The Federal Road Safety officers who assisted them were not trained as first responders and packed the patients into a car and transported them to the hospital without rendering any form of life-saving care. Their conditions worsened and led to death. (61) Additionally, the hospital that received them was not prepared for an emergency and could not offer sufficient help. (62)

At the federal level, the National Emergency Management Agency ("NEMA") was established to prevent and manage disasters in Nigeria. (63) NEMA also improves the living conditions in the country after a catastrophe and educates people in terms of new disasters. (64) NEMA operates offices in six geo-political zones of the country. (65) NEMA handles a wide range of emergencies, not just emergencies specific to medical conditions. (66) Hereinafter, the Nigerian Federal Road Safety Corps, ("FRSC") a paramilitary structure, was created in 1988. (67) One of the responsibilities of the FRSC is 'giving prompt attention and care to victims of accidents and providing roadside and mobile clinics for the treatment of accident victims free of charge'. (68) The FRSC has thus been involved in the pre-hospital care of accident victims but with little or no training to render effective services.

In 2001, the Lagos State Government, in collaboration with a foreign firm, attempted to establish an EMS system. (69) Subsequently, the Rivers State Government-owned EMS kicked off in 2002, followed by other states including Enugu, Ondo, Ogun, Delta, Akwa Ibom and the Federal Capital Territory. (70) These attempts have been marred by the unwillingness of these governments to contribute funds into a project that does not generate revenue. (71) Reports support that Lagos State has the most efficient state-run EMS system in Nigeria. (72)

Agencies carrying out EMS in Lagos state include the Lagos State Emergency Management Agency ("LASEMA"), which manages emergency responses in the state, and Lagos Response Unit ("LRU"), which strives to make both human and material resources available for effective response to emergencies. (73) The emergency services of Lagos state consist of two trauma centers, which initially had ambulance services available at those centers. (74) However, for greater efficiency, the ambulance services were detached from the trauma centers in March 2001, to exist independently as the Lagos State Ambulance Services ("LASAMBUS"). (75) In a bid to provide a formal and standardized hospital-based EMS they lacked, Lagos State established LASEMS in 1998. (76) Upon establishment, health professionals employed in LASAMBUS were trained on emergency medicine in France and Israel. (77) Lagos State adopted the models of both countries to form a pre-hospital EMS system, which translated to staff simultaneously having the capacity to handle urgent cases at the emergency scene, perform first-aid treatments and transport patients to the hospital. (78) In 2011, the Lagos State government established ambulance stations in strategically selected locations across the state, each equipped with an ambulance.. (79) As of 2020, twenty-five stations were managed by LASAMBUS in the state. (80) By operating throughout the day and week, LASAMBUS improved emergency services significantly with regard to response time and quality of care, all resulting in lower mortality rates. (81)

However, Lagos State is recently experiencing some challenges in providing pre-hospital care to individuals who have a medical emergency and strengthen hospital-based medical care. (82) Reports state emergency stations managed by LASAMBUS are insufficient, with about one million persons depending on one ambulance for urgent transportation, while few existing stations have sufficient facilities to carry out their duties. (83) Reports of neglect and dilapidating structures also exist. People living on the streets occupy some of these stations, and the desire for further development has led to the demolition of others (84) Healthcare professionals working in LASAMBUS have not maintained their formal certifications in training programs, or courses like Basic Life Support ("BLS"), Advanced Cardiovascular Life Support skills, and International Trauma and Life Support ("ITLS"). (85)

Poor administration, poor staff welfare, lack of funds, dangerous locations used as stations, and lack of facilities are among some of the reasons quoted by members of staff for the inefficiency of LASAMBUS. (86) Others include traffic congestion, failure of drivers to give ambulances the right of way, thereby leading to delays in arriving at emergency scenes, remoteness between the location of the emergency, emergency centers, and the hospital, difficulty in accessing emergency locations due to inadequate rescue equipment, for example, seas, buildings under fire and collapsed buildings, inadequate ambulances, and confusion regarding whom to call for assistance. (87)

These challenges take a toll on the performance of the program, for example, research to determine the performance of LASAMBUS found that the average response time was seventeen minutes, a time described as poor compared to standards in other countries. (88) Similarly, a study found that out of a total of 23,537 patients treated at the ED of the Lagos State University Teaching Hospital (LASUTH) from 2012 to 2014, only about 24% arrived at the hospital within an hour after injury, while one-third waited one to six hours before arrival. (89)

Private organizations have also established EMS systems due to the inefficiencies in various states in Nigeria, for example, private organizations in the Federal Capital Territory, Abuja, own almost all EMS. (90) While this is good, several systems do not meet standard requirements. Some only provide ambulance services without including paramedics, who perform first aid techniques until the patient arrives at the hospital. While some private EMS may be of good quality, standard requirements are not met in several of these systems, as some companies only provide ambulance services without paramedics. (91) Most private systems employ a fee-for-service model, which is difficult for some individuals to afford. (92) Examples of these private EMS organizations include Critical Rescue International ("CRI"), which was founded in 2001 and recorded to be the first advanced EMS provider in Nigeria with qualified and experienced paramedics. (93) With offices in Ikeja and Lekki, Lagos, CRI has expanded their scope from merely EMS to now providing healthcare services to patients. (94) Other private EMS companies include Flying Doctors Nigeria Ltd., First Assistance Medical Rescue Services, Ambulance Services, Ambulance Nigeria, Braingrace Medical Services, and Medevac Nigeria Limited. (95)

B. Hospital-Based EMS in Nigeria

Recent migration of medical practitioners from Nigeria to other countries has worsened Nigeria's lack of adequate healthcare workers. (96) The available practitioners thus work under the pressure and stress of the heavy workload, which limits their efficiency in the workplace. (97)

Medications, supplies, and equipment are also in short supply, and family members are often asked to buy their own supplies before they are attended to. (98) This situation creates a lot of problems for EDs, especially in public or government-owned hospitals. (99) Urgent diagnostic tests are often delayed due to the high case load. (100)

Limited space and facilities have led to crowded EDs, further affecting care of patients. (101) According to a 2021 study, patients in Nigerian hospitals were turned away due to lack of bed space and available facilities. (102) The LASUTH Head of the Public Affairs Department, states that the hospital, with a 750-bed capacity and only thirty-six beds for emergencies, lacks adequate bed spaces compared to what is needed by the Lagos state population. (103) A study that explored twenty-four EDs in Abuja reported that even though EDs were open to the public for twenty-four hours for the whole week, only 21% of EDs ensured that medical practitioners were available throughout the day within the department, while 67% had to summon medical practitioners working in other departments within the hospital. (104) Additionally, only 4% of the EDs had a CT scanner to be used solely in the departments, only 38% had ventilators despite their claim of handling trauma cases, 75% had cardiac monitors, while none had 'negative-pressure rooms' notwithstanding the high prevalence of tuberculosis in Nigeria. (105) Also, some toxicological and cardiac emergencies could not be treated because specialists in those areas were not available. (106)

C. Domestic and International Legal Instruments for Emergency Care in Nigeria

1. International Legal Framework Regulating Emergency Care

Access to healthcare is a human right, clearly expressed in international legal frameworks and at least one of these treaties has been ratified by all nations. (107) While the applicability of these laws require domestication by the Nigerian legislature, which limits their enforcement, these laws a guide to the standard expected from the country. (108)

The 1948 Universal Declaration of Human Rights ("UDHR"), although not binding on parties, recognises the rights of individuals to a "standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services." (109) The 1966 International Covenant on Economic, Social and Cultural Rights ("ICESCR") also identifies the rights of persons to the "highest attainable standard of physical and mental health." (110) The ICESCR further encourages States to reduce infant mortality rates and ensure that children develop in a healthy manner, improve the environment to prevent degradation, prevent, treat and control epidemics and other diseases, and guarantee access to required medical services. (111) Other Conventions also emphasize access to healthcare for vulnerable and marginalized persons highlighting the lack of basis for discrimination on the grounds of gender, race and economic status.. (112)

Similar provisions safeguarding the right to health also exist in African regional instruments like the African Charter on Human and Peoples' Rights (African Charter) 1986, (113) African Charter on the Rights and Welfare of the Child (African Children's Charter) 1999, and the Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa 2003 (African Women's Protocol). (114)

Existing Resolutions and General Comments also contain provisions relevant to emergency care. Resolutions are not legally binding but serve as an essential background to changes made by governments and other relevant stakeholders. (115) In a general comment authored by the Committee on Economic, Social and Cultural Rights ("CESCR"), the organization notes that the right to be treated for diseases includes "the creation of a system of urgent medical care in cases of accidents, epidemics and similar health hazards, and the provision of disaster relief and humanitarian assistance in emergency situations." (116)

According to the CESCR, the availability, accessibility, acceptability, and quality of healthcare goods and services characterizes the right to health. (117) EMS is an essential part of healthcare services, and thus, it is included in the right to health. Therefore, the availability of emergency care in the form of services, drugs, and trained personnel, in pre-hospital and hospital based settings, is essential to achieving the overall right to health.. (118) However, the CESCR notes that the specific nature of the health facilities and services available to populations will differ based on the development level of the state in which the facilities are located and the resources available to that state. (119)

Accessibility for persons who require urgent medical attention, including vulnerable and marginalized groups, means that no one would be denied access to emergency health services on discriminatory grounds. (120) Accessibility in emergency situations includes ease of physical and financial access to ensure equitable distribution of healthcare across socioeconomic lines. (121) Lastly, accessibility also includes the right to access information about emergency healthcare. (122) Accessibility of healthcare services is critical in emergencies because of the "time-dependent nature" associated with such conditions.1 (23)

Acceptability translates to respecting the culture of persons, their gender, and life-cycle requirements in addition to adherence to the principles of medical ethics. (124) Many ethical decisions are involved in emergency situations, which puts healthcare professionals under a lot of pressure because of the unpredictable circ*mstances, the urgency required, and the life-threatening nature of these cases. (125) In making ethical decisions during the daily performance of their duties, emergency care providers usually consider established professional principles, specific rules set out by the organizations where they work, and the legal consequences of their actions. (126) Some of these ethical issues have been addressed by regulatory frameworks of some countries, which makes it easier for services to be rendered without fear.

For instance, observing the principle of confidentiality in emergencies could be quite challenging due to space constraints and the presence of other patients and family members. (127) Patients who are seriously ill may need to be undressed for immediate intervention, and personal questions may need to be asked. (128) According to Kasule, some information concerning the patient, for example, medical history, might have to be disclosed to family members during treatment, especially in circ*mstances where the patient is unconscious or unable to converse. (129) Also, obtaining informed consent expressly, either through verbal or written means, is not feasible in all emergency cases due to the critical condition of the patient and the need to save lives without wasting time. (130) Without an advanced directive or a family member's consent, a patient is cared for based on implied consent as it is assumed that the patient would want their life to be saved. (131)

Medical emergency facilities and services should be of good quality, which entails having "skilled medical personnel, scientifically approved and unexpired drugs and hospital equipment, safe and potable water, and adequate sanitation." (132) Thus, emergency care must be designed to stabilize patients and improve their condition. (133)

The CESCR also notes that States are responsible for respecting, protecting, and fulfilling the right to health. (134) Thus, the right to health is not respected when State actions, laws and policies do not meet international standards to the extent that mortality rates increase in persons who need urgent care. (135) States do not protect the right to health when they fail to take adequate measures in protecting persons from third parties who may want to hinder their use of emergency services. (136) Also, States do not fulfil this right when they fail to apportion enough resources to the health sector; misappropriate public funds that would have been used to provide health services; fail to identify the appropriate indicators for proper monitoring of State responsibilities and set benchmarks for achievement; and fail to equitably distribute health facilities to meet the emergency care needs of all populations. (137)

The United Nations General Assembly in its 2018 Resolution, while recognizing the urgency in reducing deaths and injuries from RTAs, encourages States to "strengthen pre-hospital care, including emergency health services and the immediate post-crash response, hospital and ambulatory guidelines for trauma care and rehabilitation services." (138) The WHO should support states in achieving these healthcare objectives. (139)

The World Health Assembly ("WHA") is the governing body of the WHO and is comprised of all Ministers of Health in the 194 WHO Member States. (140) The WHA converges yearly to deliberate on diverse subjects related to health and agree on actions to bring about needed changes, which are subsequently documented as Resolutions. (141)

To improve EMS in LMICs, the WHA adopted Resolution 60.22 in 2017, which was the first item to be published by them on this matter. (142) This Resolution estimates that globally, one hundred million injuries occur annually and more than five million deaths occur as a result of violence, while 90% of these deaths occur in LMICs. (143) The WHA encourages governments to improve their pre-hospital and emergency trauma care systems by ensuring that services are timely and effective. (144) Member States should assess and identify unfulfilled needs of EMS. (145) States should further ensure that they collaborate with ministries of health to evaluate and improve the delivery of trauma and emergency services. (146) In places where the establishment of formal EMS systems is not feasible, States are to establish capacity for pre-hospital care using "informal systems and community resources." (147)

Thus, first aid training is necessary for first responders to effectively offer basic care to patients before they reach the hospital in the absence of formal ambulance services. (148) States with formal emergency systems are expected to establish monitoring mechanisms to ensure that minimum standards in respect of "training, equipment, infrastructure and communication" are met. (149) A universal-access telephone number, which is extensively disseminated to the public, is to be made available in formal emergency systems or where such formal systems are being established. (150) The WHA also urges states to improve their working conditions and provide training and continuing education for trauma and emergency care personnel. (151)

Moreover, in 2011, the WHA adopted Resolution 64.10, and reaffirms in its preamble that "the resilience and self-reliance of the health system" is key to curtailing health threats and providing effective medical response and care in situations of emergencies and disasters. (152) The WHA recognizes that other sectors and professions have a significant role in protecting the health of people in danger of emergencies. (153) WHA also expresses concern as to the inadequate capacity of several countries in handling major emergencies and disasters, particularly in the areas of communications and logistics. (154) The WHA therefore urges states to take certain actions which include: integrating emergency programs into national or subnational health plans and developing programs that guarantee that new hospitals are built to survive local threats, with adequate capacity to handle internal and external emergencies. States are also to collaborate with regional and subregional bodies. (155)

In 2015, the WHA adopted Resolution 68.15, which notes that the availability of "emergency and essential surgical care and anaesthesia" lowers the rate of deaths and reduces the negative effects that could arise from injuries and noncommunicable diseases. (156) It also expresses concern that the advancement of EMS in several countries has been stunted In Resolution 68.15, the WHA also expresses concern that the advancement of EMS in several countries has been stunted due to insufficient investment in health system infrastructure, inadequate training of health professionals, and inadequate surgical equipment. (157) The WHA therefore urges States to, "identify and prioritize a core set of emergency and essential surgery and anaesthesia services at the primary health care and first-referral hospital level." (158)

In 2019, the WHA adopted Resolution 72.16. In its preamble, the Resolution, emphasizes the importance of urgently attending to critical medical situations. (159) The Resolution acknowledges that emergency care is vital to the achievement of several targets under SDGs 3, 11 and 16, which focus on, respectively: (1) ensuring the health and wellbeing of all persons; (2) guaranteeing inclusive, safe and resilient cities; promoting "peaceful and inclusive societies for sustainable development;" and (3) promoting "access to justice for all and build effective, accountable and inclusive institutions at all levels." (160) The WHA also notes that quality EMS reduces the effects of disasters and limits the number of deaths as well as sustains the availability of care in fragile situations and places affected by conflict. (161)

To guarantee prompt and efficient health services for populations, the WHA calls upon States to take additional steps in strengthening the delivery of emergency services as part of UHC, as well as adopt policies that would encourage an EMS system that is sustainably-funded and appropriately-managed. (162) This EMS system would provide safe and quality services without discrimination against sociocultural and socioeconomic factors, such as the inability to pay before treatment. (163) Pre-hospital and facility-based emergency care should be included or promoted in health strategies and plans at suitable stages of governance. (164) The WHA recognizes that some countries may be restricted in running their EMS due to a lack of resources; to remedy this, the WHA advocates that, depending on the available resources, either formal or informal systems may be used to promote access to urgent medical care for all. (165) This recommendation includes the provision of "toll-free universal access numbers that meet international standards." (166) Health providers should also be appropriately trained in administering EMS. (167) Training should include (1) the integration of emergency care modules into the undergraduate medical and nursing curricula; (2) post-graduate studies on emergency training for medical practitioners and nurses; and (3) courses on basic emergency care for frontline personnel. (168) Through campaigns and training, awareness and capacity building can be implemented in communities to enable better responses during emergencies. (169)

In 2005, the WHO published two articles about trauma care: "Guideline of Essential Trauma Care 2004" and "Pre-hospital Trauma Care System 2005". (170) The WHO Guidelines for Essential Trauma Care, specifies the services that should be made available to injured persons in a bid to improve trauma care globally. (171) These guidelines recommend that healthcare works have specific knowledge and skills about elements of trauma care such as human resources; physical resources such as infrastructure, equipment and supplies; and lack of organizational and administrative skills. (172) Alternatively, the Pre-Hospital Trauma Care System guidelines focus on pre-hospital EMS and set the standards for providers. (173) The guidelines include the required knowledge, skills and equipment, which should be at the disposal of pre-hospital care providers. (174) Furthermore, the guidelines include essential components relevant to trauma care, including "organization and oversight, coordination, documentation of care, and ethical and legal issues". (175)

The Thirteenth General Programme of Work ("GPW 13"), which outlines WHO's strategy for the period between 2019 to 2023, and with the mission to "promote health--keep the world safe--serve the vulnerable," focuses on three targets; one target is to ensure that by 2030, "one billion more people are better protected from health emergencies." (176) Through this initiative, WHO seeks to ensure that people have access to urgent medical attention, while also providing countries with the capacity to alleviate infectious health threats. (177) Countries will also be able to assess and address the gaps evident in their EMS through support received from WHO. (178) The above interventions will particularly improve the availability of services to persons that are disadvantaged, marginalized, and living in remote areas, so that ultimately, "no one is left behind." (179) WHO's initiative emphasizes the need for quality EMS in countries that have not yet achieved this desired and required outcome.

2. Domestic Legal Framework Regulating Emergency Care in Nigeria

The 1999 Constitution of the Federal Republic of Nigeria ("CFRN") specifies the responsibility foisted on the government to make healthcare services available for all individuals in the country. (180)

The 2014 National Health Act ("NHA"), is the "first and principal national legislation enacted to regulate healthcare delivery in Nigeria." (181) It prohibits the refusal to treat persons who need emergency care in health establishments for any reason. (182) A violator of this provision can be punished with a fine of N100,000, a maximum of six months imprisonment, or both. (183) The NHA also established the Basic Health Care Provision Fund ("BHCPF"), and dedicated five percent of the fund to emergency medical care. (184) The BHCPF aims to improve access to medical care by providing funds to the primary health care sector in Nigeria. (185) The funds are obtained from a minimum of one percent grant received from the Consolidated Revenue Fund (CRF) of the Federal government, grants by international donors, and other sources, including private organisations. (186) It has, however, been reported that the BHCPF, implemented in 2018, has been shrinking due to the "dwindling government revenue and shrinkage in the overall size of the CRF thus reducing the population covered by BHCPF." (187)

Furthermore, the Compulsory Treatment and Care for Victims of Gunshots Act (CTCVGA) was enacted in 2017 to protect victims of gunshot wounds and enable them to receive urgent treatment. (188) Thus, public and private hospitals in Nigeria must give immediate medical attention to gunshot victims whether or not the victims have police clearance reports with them. (189) Medical practitioners must then report the incident to the nearest police station within two hours after beginning treatment to enable necessary investigations. (190) A hospital's failure to make this report subjects them, and the medical practitioner directly involved with the patient's care, to the risk of a fine of N100,000 or potential jail time, if they are found guilty. (191) The CTCVGA also mandates that all persons, including security agents, render assistance to persons with gunshot wounds by taking them to the hospital closest to the scene of injury. (192) The CTCVGA, in a bid to encourage the rescue or assistance of victims of gunshot wounds by bystanders or volunteers, provides that persons who render assistance must not be disrespected or interrogated unnecessarily. (193) The CTCVGA also prohibits the police from taking a person with gunshot wounds from the hospital to investigate the incident until such patient has been certified fit and no longer requires medical care. (194) This prohibition ensures that patients are not deprived of treatment on the basis of investigations, as all persons are entitled to health services when required, even if they are suspected of committing a crime. Furthermore, the CTCVGA provides that treatment procedures of the gunshot wound patient must be well-documented by the hospital. (195) Patients who have been shot must be urgently and adequately treated whether the patient deposits cash or not. (196) This provision is similar to Section 20 of the NHA, which mandates the treatment of persons in emergencies "for any reason." (197)

However, in Nigeria, patients generally struggle to pay their hospital bills while seeking emergency care. (198) Often, hospitals demand deposit payment before stabilizing patients, which puts a lot of pressure on their family members. (199) Due to the time-sensitive nature of emergencies, many patients suffer more harm or lose their lives. (200) The World Bank estimates that prior to the COVID-19 outbreak, 82.9% of Nigerians lived in poverty, which could worsen in 2022. (201) Unfortunately, universal health coverage ("UHC") is far from a reality because only an estimated 3% of Nigerians have access to health insurance, while others rely on out-of-pocket payments. (202) Some organizations like the Health Emergency Initiative ("HEI") assist people experiencing medical emergencies who cannot afford to pay. (203) However, these efforts are not sufficient, and many Nigerians still suffer setbacks in receiving emergency healthcare due to their inability to pay. (204) The 1986 Emergency Medical Treatment and Active Labor Act (EMTALA), was enacted to regulate emergency care in the United States. The EMTALA Act mandates all hospitals that receive federal funds such as Medicare or are exempted from tax, to stabilize patients and treat them despite their insurance status or ability to afford hospital bills. (205) Olumese opines that even though the above provision is laudable, it is wrong for the government to place such a huge responsibility of providing emergency care at all costs on private hospitals without providing support or funding. (206)

When a gunshot wound patient dies as a result of the failure of an individual or hospital to carry out his obligations, that individual or hospital would have committed a crime and would face a possible punishment of five years imprisonment, a fine of N500,000, or both. (207) However, the CTCVGA is limited to victims with gunshot wounds and does not extend to other forms of emergencies. (208)

The 2004 Code of Medical Ethics ("CME") is a Code of Conduct prepared by the Medical and Dental Council of Nigeria ("MDCN") to guide the medical and dental professions in Nigeria. (209) The CME specifies the responsibilities of medical professionals to the sick and one of these duties is to "give emergency care as a humanitarian duty unless he is assured that others are willing and able to give such care." (2)10 Furthermore, the CME provides that, during emergencies, medical practitioners must provide quality medical care to patients and attend to them without discrimination. (211) Rule 12 provides that healthcare facilities, are expected to have emergency and accident units. (212) The CME also states that medical practitioners who happen to be at the scene of an emergency are not under any obligation to give medical attention to the victim of that emergency. (213) However, if the practitioner decides to assist, he or she must provide reasonable care, in that the practitioners actions must align with a competent and reasonable qualified practitioner would do in a similar situation. (214) The CME also notes that failure to meet the required standard will give rise to liability for professional negligence, despite the limitations outside the control of the practitioner in an emergency situation. (215) According to the CME, it constitutes professional negligence when a medical practitioner who is in a position to attend to a patient who needs urgent medical attention fails to promptly do so. (216) These provisions of the CME mean that emergency care must be given to a patient when it is within the duty of the practitioner in the hospital. (217) This duty, however, will not extend to settings outside the hospital. (218)

D. Liability of Medical Practitioners in Emergencies

In emergency situations, stabilizing medical conditions and saving lives is considered a priority, and providers may not fully adhere to formal processes due to the emergency. (219) The necessity of making quick decision, together with the fact that the medical history of the patient might not be available, means medical practitioners are more prone to making mistakes. (220) In such cases, courts do not completely accept emergencies as excuses for negligence but nevertheless take such circ*mstances into account when determining the liability of the professional and the resulting penalty. (221)

Claims against medical practitioners in emergency situations usually arise under the law of torts as a form of negligence because providers do not have intent to cause harm to the patient. (222) For such claims to be successful, the plaintiff must prove that the medical practitioner owed a duty of care to the patient, whether written, verbal, or implied. Furthermore, the plaintiff must also prove that the provider breached this duty of care. (223) Providers who meet the standard of care will not be held liable for negligence. (224) The standard of care is determined by the type of care provided by a reasonable professional with similar training and skill in the same circ*mstance (225). Where, however, the practitioner is uncertain about a patient's condition and fails to promptly make a referral to a specialist hospital, he may be held liable for negligence. (226) For a negligence claim to be sustained in emergency cases, it must be established that the patient suffered harm or injury taken as a result of the actions or inactions by the professional. (227)

E. Liability of Good Samaritans in Emergencies

In Nigeria, bystanders or good Samaritans play an important role in rescuing persons in need of emergency care and transporting them to the hospital. (228) The assistance rendered to these distressed persons save lives due to the timely intervention. (229) The question that arises is whether good Samaritans will be liable if they perform a negligent act leading to accidental harm or loss of life while trying to assist a sick or injured person.

The term "good Samaritan" originates from a parable in the Bible, which discusses who qualifies as one's neighbour. (230) In that parable, a man from Samaria helps a robbery victim left for dead, despite differences in their religion and ethnicity. (231) The parable thus portrays a good Samaritan as "an individual who intervenes to assist another without a previous responsibility and without compensation." (232) Good Samaritan Laws ("GSLs") differ between countries and specify who is protected from liability and the extent of this protection. (233)

A Good Samaritans' bill proposed in 2015, is being considered by the legislative arm of the Nigerian government. (234) The bill aims to remove legal obstacles encountered by bystanders in the course of saving lives, so that bystanders would be encouraged to assist without fear of liability. (235) The bill, which is only applicable to emergencies that occur outside hospital premises specifies that persons who assist those in need of urgent medical attention will not be liable for their actions or omissions. (236) The bill notes that the good Samaritan is duty-bound to treat the emergency patient cautiously and carefully, as acting in an unreasonable, reckless, or negligent manner will incur liability. (237) It also states that immunity from liability does not apply to persons who intervene in the normal course of their workplace obligations, nor does it apply to those who receive financial reward for the assistance they rendered. (238) Those who intentionally cause or worsen the emergency are also not immune from liability. (239) It remains unclear whether the Bill protects medical practitioners who assist at the scene of emergencies. (240)

Good Samaritans must obtain the consent of the ill or injured before assisting, with the exception that if the ill or injured person is unconscious or unable to approve, implied consent will be presumed. (241) Minors who need urgent medical intervention, on the other hand, are not required to give their consent before assistance is rendered to them. (242)

GSLs are established in every state in the United States of America ("USA"), including the District of Columbia. (243) These laws vary by state with respect to the range of guaranteed protections, the amount of immunity from liability, and whether there is a legal duty to assist at the scene of an emergency. (244) Nevertheless, a similar provision in U.S. GSLs, is the immunity from liability granted to good Samaritans who assist ill or injured people at the scene of an emergen232cy; however, the exemption does not extend to aid that was carried out in a reckless or grossly negligent manner. (245) This immunity usually covers healthcare providers who in good faith, intervene in medical emergencies that occur outside hospital settings without receiving compensation. (246) To be considered a good Samaritan, a pre-existing relationship and duty of care must not exist; therefore, immunity does not apply to healthcare professionals assisting in emergencies while performing their regular duties in clinical settings. (247) Other laws may protect these health professionals, but a higher degree of care is required from professionals than from laymen. (248)

Furthermore, only a few States in the United States, including Vermont, Minnesota and Rhode Island impose a duty on bystanders to assist people in distress, with minor penalties for violators who do not assist others. (249) The laws specify that bystanders are only compelled to offer assistance where the distressed individual is at risk of, or has experienced "grave physical harm" and where it is certain that the good Samaritans will not incur harm on themselves or others in the process. (250) In states like Vermont and Wisconsin, the duty to assist does not arise when the distressed person is already receiving assistance or when the bystander has sought help on the person's behalf. (251) The type of help rendered also differs. (252) For most states in the U.S., the volunteer could assist personally or contact the appropriate authorities for assistance. (253) The same position applies in Belgium and the Netherlands, while in countries like Italy, only notification of the appropriate authorities is required. (254)

States like Hawaii, Wisconsin, Colorado, Massachusetts, and Ohio, limit the duty to assist to victims of crimes and solely emergency situations like illness or accidents. (255) More restrictive duties are specified for bystanders in Texas and Nevada, as bystanders are only mandated to assist child victims being subjected to sexual abuse. (256) This restrictive rule aims to better protect sexual abuse victims due to their vulnerability and the likelihood that they may not be able to make such reports themselves. (257) Furthermore, the perpetrators are usually known to the victim, thus increasing the risk of repetitive abuse. (258) In another example, Nigeria's duty to assist rule is restricted to victims of gunshot wounds. (259) To encourage assistance, it is stated that good Samaritans must not be unduly interrogated and disrespected. (260)

Some scholars and members of the public believe that being forced to rescue distressed persons is a moral decision that should not be compelled by law, since it is contrary to the rights of individual autonomy and personal liberty. (261) Kathleen Ridolfi, a professor at Santa Clara University Law School, claims that performing an act of kindness is both a personal and private decision, as well a moral duty that should only be mandatory for someone who shares a relationship with the distressed. (262) Others also oppose the duty to assist law because it would be challenging to enforce, since detection of violators would be difficult due to third parties wanting to avoid similar liability for failing to rescue, including being accused of snitching. (263) On the other hand, proponents of the duty to rescue laws argue that bystanders who violate the law by failing to assist would be easily identified in an investigation, especially with the through technological devices like cell phones and the Closed-Circuit Television (CCTV). Supporters also add that if law enforcement officers detect offenders who have committed other crimes, detecting violators of the duty to rescue should be no different. (264) These supporters stress that duty to rescue laws would help educate and remind people of their moral obligation to those who require help. Supporters also berate opponents for not considering that the laws would be beneficial to society, as well as for ignoring the fact that other laws also limit actions and choices that people would have otherwise. (265)

Almost all states in the U.S. have taken further steps in enacting GSLs to reduce the surge of drug overdose mortality rates in the country, which are driven by opioids and which is a challenge that has been recognised as a "national public health issue." (266) As such, these GSLs grant legal protection to victims of opioid overdose and bystanders who assist them by calling 911 or by administering first aid. (267) The extent of legal protection varies across states and may extend to reduced charges or total immunity from arrests and prosecution. (268) Urgent medical assistance that saves lives is thus prioritized over arrests and sentencing. (269)

Virtually all European countries with civil law jurisdiction, including Portugal, Italy, France, Germany, Poland, and Russia, impose a duty on bystanders to rescue those in danger or peril. (270) The penalties for violators range from fines to community service, and some are as high as a 5-year imprisonment. (271) These laws are contrary to the position in common law European countries where there is no duty to rescue persons in danger unless an existing relationship exists between the bystander and the person in need of urgent care. (272)

IV. Strategies for Improving EMS Systems in Nigeria

The following strategies will be useful in ensuring that Nigerians who need urgent medical care have better access to such care.

A. Strengthening of National Legislation

Under the Nigerian Constitution, (273) the right to health established does not explicitly encompass the right to access emergency care. Conversely, countries like Egypt, Kenya, Somalia, South Africa, South Sudan, Sudan and Zimbabwe, specifically include emergency care as a right in their Constitutions. (274) For example, Section 43(2) of the Constitution of Kenya provides that "[a] person shall not be denied emergency medical treatment." (275) While it may be argued that the term "adequate medical and health facilities," as stated in the Nigerian Constitution, automatically includes emergency care, it has been reasoned that the specific mention of emergency care as a human right in the supreme laws of other countries, have contributed to the implementation of this right through favorable judicial pronouncements. (276)

Furthermore, the NHA, which establishes the right to emergency care, should include more comprehensive provisions that define health emergencies, outline the components of an emergency system, highlight the responsibilities of the main stakeholders delivering healthcare, and establish penalties for violators. (277) For instance, the NHA establishes emergency care as one of the duties of healthcare providers in both public and private hospitals operating in Kenya. (278) The Kenyan Health Act defines medical emergencies and describes the components of such care, including pre-hospital care, stabilizing the patient's condition, and referral to another facility in the absence of sufficient capacity. (279) When health facilities with the capacity to provide emergency care fail to provide required care, they commit an offense that may result in a fine of up to three million shillings upon conviction. (280) The Ministry of Health is tasked with implementing the right to emergency care. (281) The above provisions, if incorporated into the NHA, would provide a legal foundation to support claims for a violation of the right to emergency care. (282) Such provisions would also encourage prompt action to be taken by both government and health facilities. Colombia tried this approach by establishing national legislation on emergency care, which ultimately led to an improvement. (283)

The duty to save lives should be prioritized by health practitioners above all else, including the payment of hospital bills. (284) Guaranteeing access to emergency care would require implementation of laws prohibiting hospitals from demanding payments without first assessing and stabilizing patients. Such laws must also establish adequate penalties for violations of these provisions. (285) However, because private hospitals need money to operate, the rule should be restricted to stabilization. (286) Once their condition is stable, the patient can be referred to government hospitals where health services can be accessed more affordably. (287) Although the NHA prohibits refusal of emergency care "for any reason," it should be amended to expressly include the "stabilisation before insistence on payment" rule, with penalties attached for violators.

The CTCVGA contains laudable provisions, including the "stabilisation before payment" rule, priority on treatment before the involvement of the police, encouragement of bystanders to assist by ensuring they are not victimized, among others. (288) The CTCVGA is limited in scope, however, to victims of gunshot wounds, whereas it is clear that other ill and injured persons requiring emergency care would benefit from its provisions. (289) It is thus recommended that the CTCVGA be expanded to an emergency care law that would regulate all forms of emergencies and all issues relating to emergency care, including the provisions contained in the Nationwide Toll-Free Emergency Number (Establishment) Bill, 2021 and the Good Samaritan Bill.

Nigerian legislators should adopt the model of the United States and protect medical practitioners who intervene in medical emergencies that occur outside the hospital. (290) They deserve protection because of the difficult circ*mstances under which they attend to distressed persons in an emergency. (291) These difficult circ*mstances include the severity of the person's condition, lack of required equipment at the emergency scene, and the lack of sufficient information about the distressed person. Medical practitioners have a higher potential to help due to their medical training and would render assistance more effectively than a layperson, hence the need to encourage medical practitioners to render assistance in emergencies.

Regarding the duty to assist rule, Nigerians are reluctant to assist for cogent reasons. (292) The usual restraining factor is that hospitals ask good Samaritans for police reports detailing the incident and process of rescue, thereby discouraging individuals who want to avoid police involvement from taking the initiative to help in emergencies. (293) Some good Samaritans are even wrongly detained or imprisoned. (294) Aside from these issues, the average Nigerian is not hesitant on helping people, especially when the circ*mstances do not spell danger for the volunteer, such as when the incident happens in daytime and in areas accessible to the public. (295) Therefore, a mandatory rule to assist as seen in some states in the USA, is unnecessary in Nigeria if the above-mentioned challenges can be resolved.

Besides, enforcement of such a law would be a challenge in Nigeria, where technology like CCTVs is mostly unavailable. (296) The Good Samaritan Bill already protects good Samaritans from liability when harm is caused to the patient, while the CTCVGA protects them from unnecessary interrogation. (297) The inclusion of these provisions in the recommended Emergency Care Act with due enforcement would encourage assistance and make the mandatory rule to assist unnecessary. However, penalties could be established for "engaged spectators," that is individuals who have the capacity to assist yet instead take pictures of distressed persons, steal from them, or cause further harm. (298)

To assist practitioners with ethical decision making and to reduce errors that could endanger the lives of patients, guidelines should be included in the recommended Emergency Care Legislation. (299) Personnel handling emergencies must be mindful of all ethical principles and adhere to them as much as the urgent circ*mstances permit. (300) Barriers to effective implementation of the laws protecting the right of patients to emergency care should be addressed. One major barrier is the lack of knowledge of existing laws. (301) A study by William M. Garneau on Good Samaritan behavior by physicians in North Carolina found that practitioners knowledgeable of GSLs are more likely to respond to a call for assistance. (302) There should thus be an awareness of the existing laws governing EMS in Nigeria. (303)

B. Alternatives to Formal EMS

To establish a formal EMS system which would be effective in improving emergency care in both rural and urban areas in Nigeria, infrastructural development is paramount. (304) Thus, an increased availability of functional and well-equipped ambulances and ambulance stations should be made available to result in more lives saved. (305) To effectively utilize the knowledge and skills of healthcare workers, EDs require sufficient equipment. (306) EDs also require more highly skilled healthcare professionals experienced in providing EMS. (307)

Furthermore, a formal EMS system requires a good communications system that allows for easier access to patients and permits paramedics to request additional resources, including the opinion of medical practitioners. (308) To confirm their suitability and availability to handle the case, hospitals require a good communications system to aid connections with hospitals where a patient is headed for treatment. (309) The Nigerian Communications Commission recently established Emergency Communications Centres in eighteen states of the federation with plans to extend to all thirty-six states. (310) The Commission also created a toll-free emergency rescue number to be used by the public to reach all emergency agencies when urgent assistance is required, including during medical emergencies. (311) Such distress calls are then redirected to the appropriate Emergency Response Agency ("ERA") within states for prompt action. (312) These efforts are steps in the right direction, however these new structures will not work when other aspects of a formal EMS, like ambulances and trained paramedics, are still not in place.

Additionally, research directed at improving pre-hospital care contributes to an efficient EMS, and this research is an important requirement for a formal emergency system. (313) This aspect of research is often neglected in LMICs, especially since funding is limited and expertise in the field of emergency care is inadequate. (314) This is contrary to the approach in developed countries where research on EMS is prioritized. (315) A study noted that sixty-four research projects on ambulance care organizations were conducted in the Netherlands between 2012 and 2014. (316) There is a need to organize an EMS system, link its components to function together as a unit and establish adequate monitoring systems. (317)

The above requirements for a formal, quality EMS system, make it clear that a substantial amount of funds must be invested into the health sector. Such an investment depends on the availability of resources, making it challenging to establish a 'uniform policy prescription' in that regard. (318) A challenge to the right to accessing emergency care in Nigeria is the problem of limited resources. (319) Success from duplicating developed countries' models is unlikely. Studying the unique circ*mstances of the Nigerian environment is vital to formulate appropriate strategies to develop Nigeria's EMS system. (320) The CESCR specifies the feasibility of practicing progressive fulfilment of the right to health in countries with limited resources. (321) However, the proposed gradual efforts should not translate to neglecting obligations, and States must take committed and adequate measures to achieve the needed changes. (322)

Thus, while Nigeria strives to establish a formal EMS system for better access to healthcare services during emergencies, considering and employing alternative methods to a formal emergency care system is essential. (323)

In Ghana, for instance, commercial vehicles have helped significantly in transporting injured persons to the hospitals through the drivers hired by the victim's relatives or drivers acting as good Samaritans. (324) Bicycle ambulances have been employed for transportation to hospitals in Malawi, and in Niger, solar-panel-powered radios have been used to connect health centers to other hospitals.. (325) The WHO has recommended bystanders and laypersons be used as first responders; however, this requires funding, proper management, and training programs. (326)

C. Training Programs

Non-medical professionals and medical practitioners benefit from standard training programs on emergency care. Relatives and bystanders are relied upon to transport patients to hospitals in Nigeria via private cars or commercial vehicles because of the lack of a formal pre-hospital system (.327) However, there are limitations to the effectiveness of the assistance provided by good Samaritans who lack training. (328) First, there is the risk that they worsen the condition of the victims. (329) For example, putting victims with spinal cord injuries in a sitting position, transporting them in dilapidated vehicles, or handling them roughly is not good practice. (330) Second, good Samaritans do not have sufficient professional expertise to do a proper triage. Triage processes are methods for determining the level of urgency a patient's condition requires, which influences the priority given to transportation and the appropriate facility where treatment will be received. (331)

These lay persons, which include traditional birth attendants, commercial drivers, students, federal road safety officials, fire service operators, should thus be able to recognize conditions that are life-threatening, notify the appropriate persons and pending the period trained personnel arrives, and deliver basic care. (332) Several countries have recorded improvements in the survival rates of distressed persons who were assisted by persons trained to act as first responders. (333) In Ghana, 61% of 335 commercial drivers who were trained in rendering medical assistance to accident victims were effective in providing some form of first aid to these victims. (334)

The National First Aid Trainer for Nigeria Red Cross Society, Bashir Umar, has emphasized the importance of basic knowledge of life-saving skills, stating that the rise in Nigeria's population to over 200 million people will increase the likelihood of accidents and disease-related emergencies. (335) The Nigerian Red Cross Society and other humanitarian organizations organize these trainings at their offices and encourage all individuals to register. (336) Umar, however, notes the lack of awareness of the need for training, as well as the procedures required to obtain such training. (337) It has also been suggested that first aid knowledge be included in primary and secondary school curricula. (338) Agencies involved in emergencies like the FRSC, Nigeria Security and Civil Defense Corps ("NSCDC"), the police, NEMA, and the armed forces should also be trained in basic life-saving skills. (339)

The second category of persons who require training are health workers. (340) The WHA recognizes that in many countries, frontline healthcare workers attend to persons needing urgent care without receiving specific and targeted training in managing emergency health issues. (341) Such training would enable them to achieve better outcomes in providing emergency care for patients. (342) Training programs should also educate health workers on ethical principles, including autonomy, consent, confidentiality, liabilities in emergencies, and the laws regulating situations of emergencies. (343)

The Advanced Trauma Life Support course, a course designed by the American College of Surgeons, has been found to improve the clinical skills of medical practitioners and has enhanced patient outcomes in some locations. (344) Also, the Emergency Triage Assessment and Treatment ("ETAT") training organized by WHO has improved the urgent care provided for pediatric conditions. (345) Several countries in Africa, including Botswana, Ethiopia, Ghana, Kenya, Rwanda, South Africa, Tanzania, and Uganda, have become more aware of the importance of training medical personnel in emergency care, and have made efforts to establish such programs. (346) This interest has extended to Nigeria, and several efforts have been made over the years to train medical personnel. In 2012, medical practitioners from University Teaching Hospitals to Tel Aviv participated in a two-week training. (347) The period of training was however found to be inadequate to properly equip practitioners with the required knowledge. (348) The Australasian Registry of Emergency Medical Technicians also now exists in Nigeria for experienced health workers who are interested in undertaking an accelerated training program. (349) The Institute of Health Technology ("IHT") in the University of Benin Teaching Hospital ("UBTH") established the first paramedic training school in 2008 and has graduated several students who mostly work within UBTH. (350)

Refresher training courses are required to maintain and upgrade the skills of practitioners and laypersons. (351) Monitoring mechanisms should be put in place to analyze instances when first aid has been rendered, and identify areas in need of more focused training (.352) As recommended by the WHA in Resolution 72.16, emergency care modules should be incorporated into the undergraduate and post-graduate medical and nursing curricula. (353) This improvement would encourage medical students to choose EMS as a career path. (354) The Nigerian populace should be enlightened on the need to receive first aid trainings and its significance on the health of persons. (355)

D. Prevention

Nigeria should prioritize preventative measures that would reduce medical emergencies. (356) For example, in reducing accidents, which contribute to a high number of medical emergencies in Nigeria, more efforts must be geared towards improving road networks, including safe designs and structures, enforcing traffic regulations, and prohibiting vehicles that are not roadworthy from driving on Nigerian roads. (357) Drivers should also be counselled on the need to avoid fast driving. (358) Emergency care providers can serve as advocates against drunk driving by screening drivers who have accidents and counselling those who drive while drunk. (359)

Also, WHO has emphasized an increase in deaths resulting from non-communicable diseases. (360) Thus, to reduce disease-related health emergencies, Nigeria should organize national screening programs, covered by health insurance plans, to reduce disease-related health emergencies" (361) Health care centers should encourage people to conduct regular medical checks, visit the hospital at the onset of symptoms of diseases, and change lifestyles that have negative health consequences. (362)

V. Conclusion

The World Health Assembly Resolution 60.22 emphasized the role of an effective EMS in reducing ailments on a global scale. Individuals who require urgent medical attention have a right to receive such care, as espoused in national and international regulations.

Several countries have made progress in improving EMS, reducing mortality rates. Emergency care has also received some attention in Nigeria, but efforts have not sufficiently met the needs of people who need emergency care in the country, despite the importance of EMS to the overall health care system. An organized and quality pre-hospital EMS is necessary in Nigeria to reduce mortality rates. Thus, more efforts must be made to improve the services provided to Nigerians who need assistance in emergency situations.

An effective EMS should provide universal access to emergency care without discriminating on the grounds of status or ability to pay. Nigeria should allocate/budget money to establish a formal EMS system The government is not capable of performing these responsibilities alone and should collaborate with private organizations to achieve these objectives. In the meantime, individual states should establish alternatives to a formal system An Emergency Care Act would build a good foundation for relevant stakeholders to know their responsibilities, rights and solutions to ethical issues.

Olaitan Olusegun (*)

(*) Senior Lecturer, Faculty of Law, Obafemi Awolowo University, Ile-Ife, Nigeria. Email: [emailprotected]

(1) Human Rights, WORLD HEALTH ORG. (2022), https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health [https://perma.cc/L8CT-C5A5].

(2) See The Right to Health, OFFICE OF U.N. HIGH COMM'R FOR HUMAN RIGHTS & WORLD HEALTH ORG., https://www.ohchr.org/sites/default/files/Documents/Publications/Factsheet31.pdf [https://perma.cc/N7KB-7PFD] (stating that the right to health contains entitlements which include "equal timely access to basic health services").

(3) "Both public and private hospitals have a duty to administer medical care to a person experiencing an emergency. If a hospital has emergency facilities, it is legally required to provide appropriate treatment to a person experiencing an emergency." See Patients' Rights: Right to Treatment, AM. L. & LEGAL INFO., https://law.jrank.org/pages/9111/Patients-Rights-Right-Treatment.html [https://perma.cc/JV78-6FT2].

(4) WHO Methods and Data Sources for Country-Level Causes of Death 2000-2019, WORLD HEALTH ORG. (2020), https://cdn.who.int/media/docs/default-source/gho-documents/global-health-estimates/ghe2019_cod_methods.pdf?sfvrsn=37bcfacc_5 [https://perma.cc/F55V-5QYC].

(5) Id.

(6) See Abdoulaye Bousso, Health Emergency Operation Centers Implementation Challenges in Africa, 33 PAN AFR. MED. J. 171, 171 (2019), https://doi.org/10.11604%2Fpamj.2019.33.171.17890 [https://perma.cc/RE7F-SG9H].

(7) Sultan Al-Shaqsi, Models of International Emergency Medical Service (EMS) Systems, 25 OMAN MED. J. 320, 320 (2010), http://www.omjournal.org/fultext_PDF.aspx?DetailsID=37&type=fultext [https://perma.cc/VL6R-D8B5].

(8) See Paul O. Ouma et al., Access to Emergency Hospital Care Provided by the Public Sector in Sub-Saharan Africa in 2015: A Geocoded Inventory and Spatial Analysis, 6 LANCET GLOB. HEALTH, 342, 343 (2018), https://doi.org/10.1016/s2214-109x(17)30488-6 [https://perma.cc/J3ZY-ECD2].

(9) See Ricardo Martinez & Brendan Carr, Creating Integrated Networks of ECF Emergency Care: From Vision to Value, 32 HEALTH AFF. 2082, 2082 (2013), https://doi.org/10.1377/hlthaff.2013.0884 [https://perma.cc/MPJ9-G5YR]. See Strengthening Health Systems to Improve Health Outcomes, WORLD HEALTH ORG. (2007), http://apps.who.int/iris/bitstream/handle/10665/43918/9789241596077_eng.pdf;jsessionid=2734A1E249CEF8B5C16B10CA287574A4?sequence=1 [https://perma.cc/55ZM-KLUV] (describing how "service delivery in emergencies" strengthen health systems and improve health outcomes).

(10) Tae-Hun Lee et al., A Sustainable Ambulance Operation Model in a Low-Resource Country (the Democratic Republic of Congo), EMERGENCY MED. INT'L 1, 2 (2018), https://doi.org/10.1155/2018/8701957 [https://perma.cc/2Y4V-U687].

(11) See Taylor W. Burkholder et al., Governing Access to Emergency Care in Africa, 10 AFR. J. EMERGENCY MED. 2, 2 (2020), https://doi.org/10.1016/j.afjem.2020.07.003, [https://perma.cc/FZT2-ESBQ].

(12) See Ouma et al., supra note 8, at 343.

(13) See Amber Mehmood et al., Assessment of Pre-Hospital Emergency Medical Services in Low-Income Settings Using a Health Systems Approach, 11 INT'L J. EMERG. MED. 1, 2 (2018).

(14) See Philip D. Anderson et al., World Health Assembly Resolution 60.22 and Its Importance as a Health Care Policy Tool for Improving Emergency Care Access and Availability Globally, 60 ANN. EMERG. MED. 35, 35 (2012).

(15) See Hunniya Waseem et al., Establishing a Successful Pre-hospital Emergency Service in a Developing Country: Experience from Rescue 122 Service in Pakistan, 288 EMERG. MED. J. 513, 513-14 (2011).

(16) I.O. Adewole et al., Ambulance Services of Lagos State, Nigeria: A Six-Year (2001-2006) Audit, 31 WEST AF. J. MED. 3, 4 (2012).

(17) Jessica Schoen et al., Advancing Telemedicine through Medical Simulation in Emergency Medicine, MODSIM WORLD (2019), http://www.modsimworld.org/papers/2019/MODSIM_2019_paper_51.pdf [https://perma.cc/S3D6-GX5X].

(18) See id; Wei Xiong et al., Implementing Telemedicine in Medical Emergency Response: Concept of Operation for a Regional Telemedicine Hub, 36 J. OF MED. SYST. 1651, 1651 (2012).

(19) See The Emergency Care System in the United States, in EMERGENCY CARE AND THE PUBLIC'S HEALTH 4 (Jesse M. Pines et al., eds., 2014).

(20) See Peter Asaga et al., Needs Assessment of Emergency Medical and Rescue Services in Abuja/Nigeria and Environs, 19.1 BMC EMERGENCY MED. 1, 1 (2019).

(21) Id. at 6.

(22) See Olive C. Kobusingye et al., Emergency Medical Systems in Low-and Middle-Income Countries: Recommendations for Action, 83 BULL. WORLD HEALTH ORG. 626, 627 (2005).

(23) Id. at 627.

(24) Id.

(25) See Mark H Wilson et al., Pre-hospital Emergency Medicine, 386 LANCET 2526, 2526 (2015).

(26) See DAVID SCHOTTKE, EMERGENCY MEDICAL RESPONDER: YOUR FIRST RESPONSE IN EMERGENCY CARE, 29 (Andrew N. Pollak ed., 6th ed. 2018).

(27) See AMARDEEP THIND ET AL., Prehospital and Emergency Care, in ESSENTIAL SURGERY: DISEASE CONTROL PRIORITIES 245, 246 (Haile T. Debas et al. eds., 3rd ed., 2015).

(28) See Kobusingye, et al., supra note 22, at 628.

(29) See Bahman S. Roudsari et al., Emergency Medical Service (EMS) Systems in Developed and Developing Countries, 38 INJ., INT'L. J. CARE INJURED 1001-03 (2007) (emphasizing the advanced nature of the formal EMS system available in developed countries unlike LMICs where resources and medical personnel are usually not sufficient).

(30) See Thind et al., supra note 27, at 248 (describing lack of resources to train lay first responders).

(31) See M A. Bahrami et al., Pre-Hospital Emergency Medical Services in Developing Countries: A Case Study about EMS Response Time in Yazd, Iran, 13 IRAN RED CRESCENT MED. J. 735-38 (2011) (highlighting EMS medics are evaluated by their response time).

(32) See Richard P. Gonzalez et al., Does Increased Emergency Medical Services Prehospital Time affect Patient Mortality in Rural Motor Vehicle Crashes? A State-Wide Analysis, 197 AM. J. SURGERY 1-33 (2009) (defining response time).

(33) See Ian E. Blanchard et al., Emergency Medical Services Response Time and Mortality in an Urban Setting, 16 PREHOSPICE EMERGENCY CARE 142-43 (2012); AMK Harmsen et al., The Influence of Prehospital Time on Trauma Patients Outcome: A Systematic Review, 46 INJURY: INT'L. J. CARE INJURED 602 (2015); Sneha R. Vanga et al., EMS Response Time for Patients Critically-Injured from Automobile Accidents Using Regression Analysis, 9 CURRENT URB. STUD. 581 (2021). Having early EMS response times, "generally leads to stabilization of [patient's] with life threatening injuries... and lower probability of loss of life." Id.

(34) See James P. Byrne et al., Association between Emergency Medical Service Response Time and Motor Vehicle Crash Mortality in the United States, 154 J. AM. MED. ASS'N SURGERY 286 (2019); Vanga, supra note 33, at 581.

(35) See Stephanie Jarvis et al., Examining Emergency Medical Services' Prehospital Transport Times for Trauma Patients during COVID- 19, 44 AM. J. EMERGENCY MED. 30 (2021) (describing how prolonged EMS treatment resulted in higher survival rates).

(36) See Thomas H. Blackwell & Jay S. Kaufman, Response time Effectiveness Comparison of Response Time and Survival in an Emergency Medical Services System, 9 ACAD. EMERGENCY MED. 288-89 (2002).

(37) See Tomas Barry et al., Community first responders for out-of-hospital cardiac arrest in adults and children, THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 7 (2019). Cardiopulmonary resuscitation (CPR) is a technique where a bystander can compress and release the chest of a person who has suffered cardiac arrest, thus artificially pumping blood throughout the body. Id. CPR can keep a cardiac arrest victim alive until a defibrillator arrives, but again it is effective only if started very soon after cardiac arrest occurs. A safe, portable, and affordable device called a 'defibrillator' can be used to terminate ('defibrillate') the abnormal rhythm causing cardiac arrest, allowing the heart to restart. A defibrillator can be used by almost anyone, even without training. To be effective, a defibrillator must be used within minutes of a cardiac arrest. Id.

(38) See Peter T. Pons & Vincent J. Markovchick, Eight Minutes or Less: Does the Ambulance Response Time Guideline Impact Trauma Patient Outcome?, EMERGENCY MED. 43-48 (2002).

(39) See Blanchard et al., supra note 33, at 288.

(40) See Blackwell & Kaufman, supra note 36, at 627.

(41) See Kobusingye et al., supra note 22.

(42) See id.

(43) See Charles N. Mock et al., Trauma Mortality Patterns in Three Nations at Different Economic Levels: Implications for Global Trauma System Development, 44 J. TRAUMA, INJURY, INFECTION, & CRITICAL CARE 804, 804 (1998).

(44) See Brent A. Eastman et al., Sustaining a Coordinated, Regional Approach to Trauma and Emergency Care is Critical to Patient Health Care Needs, 32 HEALTH AFFAIRS 2091, 2091 (2013).

(45) See Arthur L. Kellermann et al., Emergency Care: Then, Now, and Next, 32 Health Affairs, HEALTH AFFAIRS 2069-2074 (2013); see AD Olusegun-Joseph et al., Medical Mortality in an Emergency Department in Nigeria: The Transition is Obvious 21 AFR. HEALTH SCI. 1, 172 (2021).

(46) See Martinez & Carr, supra note 9, at 2082; Martinez & Carr, supra note 9; see Michael J. Reilly, Improving Trauma System Preparedness for Disasters and Public Health Emergencies, in HEALTH CARE EMERGENCY MANAGEMENT: PRINCIPLES AND PRACTICE 47, 56 (2011) (describing patient transfer to better-suited facility where resources are too low at initial treating facility).

(46) Adekunle Yusuf, Understanding Emergency Care in Hospitals, NATION (Jan. 10, 2020), https://thenationonlineng.net/understanding-emergency-care-in-hospitals/ [https://perma.cc/JE9K-UVH9].

(47) Id.

(48) See, e.g., Terry Nolan et al., Quality of Hospital Care for Seriously Ill Children in Less-Developed Countries, 357 LANCET 106, 106 (2001) (describing hospitals with inadequate, improper, and delayed treatment).

(49) See Luk Cannoodt et al., Identifying Barriers to Emergency Care Services, 27 INT'L J. HEALTH PLAN. & MGMT. 104, 105-06 (2012) (describing vulnerabilities include financial struggle and old age).

(50) IFEM was established in 1991 as part of the collaborative efforts by countries which recognized emergency medicine as a specialty, to improve emergency care globally. See Anderson et al., supra note 14. IFEM is a "federation of national emergency medicine professional societies," with the aim to promote the importance of emergency medical care. Id.

(51) Fiona Lecky et al., The International Federation for Emergency Medicine Framework for Quality and Safety in the Emergency Department, 31 EMERGENCY MED. J. 926, 928 (2014).

(52) See Junaid A. Razzak & Arthur L. Kellermann, Emergency Medical Care in Developing Countries: Is It Worthwhile?, 80 BULL. WORLD HEALTH ORG. 900, 902 (2002) (describing an ED's capacity for care as judged upon such structural factors).

(53) Ndubuisi O.C. Onyemaechi & Uchenna R. Ofoma, The Public Health Threat of Road Traffic Accidents in Nigeria: A Call to Action, 6 ANNALS MED. & HEALTH SCIS. RSCH 199, 199 (2016).

(54) Adewole et al., supra note 16, at 5-6.

(55) See Low-and Middle-Income Countries, WELLCOME, https://wellcome.org/grant-funding/guidance/low-and-middle-income-countries [https://perma.cc/PD26-G83Y] (last visited Feb. 25, 2023) (describing Nigeria as an LMIC); see also Thind et al., supra note 27, at 248 (describing lack of emergency medical personnel employment and utilization in LMICs).

(56) See H.G. Burkitt et al., Essential Surgery: Problems, Diagnosis and Management, 95 BR. J. SURG. 535 (2007).

(57) See Mobolai Oludara et al., Emergency Medical Services Outcome Assessment in Lagos, Nigeria: Review of Cases of "Brought in Dead" Patients, 7 OPEN ACCESS MACED. J. MED. SCI. 253, 253 (2014).

(58) See AJ Edeh et al., Cases of Brought In Dead (BID) In The Accident And Emergency Department Of A Tertiary Hospital In Enugu, Nigeria: A Retrospective Study, 6 J. EXPERIMENTAL RSCH. 71, 72 (2018).

(59) See Oludara et al., supra note 57, at 254.

(60) See Abiodun Oyinpreye Jasper et al., Pre-Hospital Care of Road Traffic Accident Victims in the Niger Delta: a Private Initiative and Experience, 11 OPEN ACCESS EMERG. MED. 51, 55 (2019).

(61) Id

(62) Id.

(63) Id.

(64) Id.

(65) See About NEMA, NATIONAL EMERG. MGMT. AGENCY, https://nema.gov.ng/about-nema/ (last visited Feb. 26, 2023).

(66) See Davies Adeloye, Prehospital Trauma Care Systems: Potential Role Toward Reducing Morbidities and Mortalities from Road Traffic Injuries in Nigeria, 27 PREHOSP. DISASTER MED. 536, 536 (2012). See generally About NEMA, supra note 65.

(67) See About FRSC, FEDERAL ROAD SAFETY COMMISSION, https://frsc.gov.ng/about-us/ (last visited Feb. 26, 2023).

(68) See id.

(69) See Nnamdi Nwauwa, Improving Care and Response in Nigeria, J. EMERG. MED. SERVICES (May 31, 2017), https://www.jems.com/operations/ambulances-vehicle-ops/improving-care-response-in-nigeria/ [https://perma.cc/N2S3-6XPG].

(70) See id.

(71) See id.

(72) Helen Zidon, Nigerian Ambulance Services: For the Dead or the Living?, BUSINESS DAY (Dec. 19, 2020), https://businessday.ng/bd-weekender/article/nigerian-ambulance-services-for-the-dead-or-the-living/ [https://perma.cc/WW4G-9FW7].

(73) Abiodun Awoyemi, EMS Around the World: Bare Bones--EMS in Nigeria, EMSWORLD (Sept. 2019), https://www.hmpgloballearningnetwork.com/site/emsworld/article/1223146/ems-around-world-bare-bones-ems-nigeria https://www.hmpgloballearningnetwork.com/site/emsworld/article/1223146/ems-around-world-bare-bones-ems-nigeria [https://perma.cc/Y5L2-WHYK].

(74) Chinmayee Venkatraman et al., Lagos State Ambulance Service: A Performance Evaluation, 47 EUR J. TRAUMA EMERG. SURG. 1591, 1592 (2020).

(75) Adewole et al., supra note 16.

(76) Awoyemi, supra note 73.

(77) Adewole et al., supra note 16, at 4.

(78) Id.

(79) Gbenga Salau, With depleting Lagos ambulance points, vehicles, accident victims now at higher risk, THE GUARDIAN (Aug. 1, 2021, 4:13 AM), https://guardian.ng/sunday-magazine/with-depleting-lagos-ambulance-points-vehicles-accident-victims-now-at-higher-risk/ [https://perma.cc/UX6X-EYNS].

(80) Venkatraman et al., supra note 74, at 1592.

(81) Emergency Medical Services, LASEMS and LASAMBUS, LAGOS STATE: MINISTRY OF HEALTH (May 10, 2022, 12:10PM), https://health.lagosstate.gov.ng/emergency-medical-services-lasems-and-lasambus/ [https://perma.cc/4NWD-B3M2].

(82) Nahimah Ajikanle Nurudeen, LASAMBUS: Ambulance Points Without Ambulances, DAILY TRUST, (Apr. 27, 2016), https://dailytrust.com/lasambus-ambulance-points-without-ambulances [https://perma.cc/E8HM-HNXM].

(83) Awoyemi, supra note 73.

(84) Salau, supra note 79.

(85) Awoyemi, supra note 73; Nwauwa, supra note 69.

(86) Nurudeen, supra note 82.

(87) Adewole et al., supra note 16, at 4; Zidon, supra note 72.

(88) Venkatraman et al., supra note 74, at 1592.

(89) Nasiru A. Ibrahim et al., Road Traffic Injury in Lagos, Nigeria: Assessing Prehospital Care, 32 PREHOSPITAL AND DISASTER MED. 424, 424 (2017).

(90) Zidon, supra note 72.

(91) Venkatraman et al., supra note 74, at 1592.

(92) Nee-Kofi Mould-Millman et al., The State of Emergency Medical Services (EMS) Systems in Africa, 32 PREHOSPITAL AND DISASTER MED. 273, 278 (2017).

(93) C. L. Okpalla et al., Review of Emergency Health Care Delivery System in Nigeria, 37 J. ADVANCES IN MATHEMATICS & COMPUTER SCIENCE 68, 69 (2022).

(94) Id.

(95) See Flying Doctors Nigeria (last visited May 5, 2023), https://www.flyingdoctorsnigeria.com/ [https://perma.cc/E5XQ-8R7U].

(96) Cosmas Kenan Onah et al., Physician Emigration from Nigeria and the Associated Factors: The Implications to Safeguarding the Nigeria Health System, 20 HUM. RESOUR. HEALTH 1, 12 (2022).

(97) Id.

(98) See Emmanuel Nwachukwu, Nigeria: A Health Sector in Crisis, PREMIUM TIMES NIGERIA (Aug. 6, 2021), https://www.premiumtimesng.com/opinion/477854-nigeria-a-health-sector-in-crisis-by-emmanuel-nwachukwu.html [https://perma.cc/66L5-ZZZW]; see Gunilla Backman et al., Health Systems and the Right to Health: An Assessment of 194 Countries, 372 LANCET 2047, 2085 (2008) (describing challenges in obtaining care in EDs in Nigeria, which in this case, is insufficient resources within the hospital environment).

(99) See Agnes Usoro et al., Perspectives on the Current State of Nigeria's Emergency Care System among Participants of an Emergency Medicine Symposium: A Qualitative Appraisal, 11 BMJ Open, e043869, e0433872 (2021).

(100) Id.

(101) Id.

(102) Id.

(103) See Oluwaseyi Adewale, Rejection of Patients: The LASUTH Perspective, BLUEPRINT (Feb. 2, 2022), https://www.blueprint.ng/rejection-of-patients-the-lasuth-perspective/ [https://perma.cc/LW8D-3KTE].

(104) See Leana S. Wen et al., Characteristics and Capabilities of Emergency Departments in Abuja, Nigeria, 29 EMERGENCY MED. J. 798, 800 (2012).

(105) Id.

(106) Id.

(107) See Backman, supra note 98.

(108) See CONST. OF NIGERIA (1999), [section]12(1).

(109) G.A. Res. 217 (III) A, Universal Declaration of Human Rights art. 25 (Dec. 10, 1948).

(110) G.A. Res. 2200A (XXI) art. 12(1) (Dec. 16, 1966).

(111) Id. at art. 12(2).

(112) See United Nations Convention on the Elimination of All Forms of Discrimination against Women (CEDAW art. 12(1), art. 14(2)(b)) (Sept. 3, 1981) (ensuring access to healthcare for women, including those living in rural areas); see also United Nations International Convention on the Elimination of All Forms of Racial Discrimination (ICERD) art. 5(e)(iv) (Oct. 13, 1966) (protecting access to public health and medical care for all races); United Nations Convention on the Rights of Persons with Disabilities (CRPD), art 25, Mar. 30, 2007. "Provide persons with disabilities the same range, quality and standard of free or affordable health care and programmes as provided to other persons." United Nations Int'l Convention on the Protection of the Rights of All Migrant Workers and Members of their Families art. 28, Dec. 18,1990. This guarantees the right of these persons to receive urgent medical care required to preserve their life, on the same basis with nationals and regardless of conditions of their stay and employment. Id. United Nations Standard Minimum Rules for the Treatment of Prisoners (The Nelson Mandela Rules) Rule 27(1) (Dec. 17, 2015). This declares that prisoners are to be given prompt medical attention in cases of emergencies and correctional facilities who have their own hospitals, should employ adequate staff and equip them appropriately. Id.

(113) African [Banjul] Charter on Human and Peoples' Rights, art 16(1)(2), Jun. 27, 1981, OAU Doc. CAB/LEG/67/3 rev. 5, 21 I.L.M. 58 (1982).

(114) See id. at art. 14(1)(2). African Union, Protocol to the African Charter of Human and People's Rights on the Rights of Women in Africa, UNITED NATIONS (July 11, 2003), at 16-17, https://www.un.org/shestandsforpeace/sites/www.un.org.shestandsforpeace/files/protocolontherightsofwomen.pdf [https://perma.cc/QJ2A-UC6K] [hereinafter Protocol to the African Charter] (explaining women's rights to health).

(115) See Charles Mock, WHO Update, WHA resolution on Trauma and Emergency Care Services, NAT'L LIBR. MED., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2598340/pdf/285.pdf [https://perma.cc/6MJD-TB68] [hereinafter WHO Update] (last visited Feb. 23, 2023) (explaining impact of WHA resolution on healthcare).

(116) See U.N. ECON. & SOC. COUNCIL, Comm. on Econ, Soc, & Cultural Rights, Substantive Issues Arising in the Implementation of the International Covenant on Economic, Social and Cultural Rights, General Comment No. 14 (2000), The Right to the Highest Attainable Standard of Health (Article 12 of the International Covenant on Economic, Social and Cultural Rights), [paragraph] 16, U.N. Doc. E/C.12/2000/4 (Aug. 11, 2000) [hereinafter General Comment No. 14].

(117) See id. at [paragraph] 12.

(118) See id. at [paragraph] 12(a); OFFICE OF U.N. HIGH COMM'R FOR HUMAN RIGHTS & WORLD HEALTH ORG, supra note 2. (Explaining the importance of emergency care in achieving the right to health).

(119) See U.N. ECON. & SOC. COUNCIL, Comm. on Econ, Soc, & Cultural Rights, supra note 116.

(120) Id.

(121) See id. at [paragraph] 12(b)(ii)-(iii).

(122) See id. at [paragraph] 12(b)(iv).

(123) See Burkholder et al, supra note 11, at S2 (discussing limited accessibility to emergency care leading to worse outcomes).

(124) See Gen. Comment 14, supra note 116, [paragraph] 12(c); see also Jean-Frederic Levesque et al, Patient-Centered Access to Health care; Conceptualising Access at the Interface of Health Systems and Populations, 12 INTL J. EQUITY HEALTH 18 (2013) (discussing how acceptability relates to factors determining acceptance of care); Burkholder et al, supra note 11 (discussing five dimensions of accessibility to emergency care: approachability, acceptability, availability and accommodation, affordability and appropriateness).

(125) See Mohammad Torabi et al. Experiences of Pre-hospital Emergency Medical Personnel in Ethical Decision-Making: A Qualitative Study, 19 BMC MEDICAL ETHICS 1,1 (2018) (comparing exacerbated stress in emergencies due to distance to resources and other variables).

(126) See generally id.

(127) See generally Omar Hasan Kasule, Ethical Issues in Emergency Care and Research, 6 J. OF TUMS 77 (2011).

(128) Id.

(129) See id. at 80-81 (discussing effect of emergency on patient autonomy).

(130) Id at 80.

(131) See CME, Rule 39(d); see also SPYROS D. MENTZELOPOULOS, PATIENTS AND TEAMS CARING FOR THEM: PARALLELS BETWEEN CRITICAL CARE AND EMERGENCY MEDICINE 15-18; COMPELLING ETHICAL CHALLENGES IN CRITICAL CASE AND EMERGENCY CARE 16, 18 (Andrej Michalsen & Nicholas Sadovnikoff eds., 2020); Spyros D. Mentzelopoulos et al., Ethical Challenges in Resuscitation, 44 INTENSIVE CARE MED., 703 (2018).

(132) General Comment No. 14, supra note 116: The Right to the Highest Attainable Standard of Health (Art. 12), [paragraph] 12(d), U.N. Doc. E/C.12/2000/4 (Aug. 11, 2000).

(133) See id.

(134) See id.

(135) See id. at [paragraph] 50 (providing examples of violations of a state's obligation to respect the right to health). For example, a state may violate their obligation to respect the right to health by adopting practices that are discriminatory against certain individuals' or groups of individuals' access to healthcare. Id.

(136) See id. at [paragraph] 51 (providing examples of violations of a state's obligation to protect the right to health). A state may violate the obligation to protect by failing to regulate the marketing and production of products that are harmful to human health. Id.

(137) Comment No. 14, supra note 116: The Right to the Highest Attainable Standard of Health (Art. 12), [paragraph] 51, U.N. Doc. E/C.12/2000/4 (Aug. 11, 2000).

(138) G.A. Res. 72/271, Improving Global Road Safety (Apr. 12, 2018), [paragraph] 16.

(139) Id.

(140) See Tsion Firew, The World Health Assembly Adopts an Emergency Care Resolution, ACEP NOW (Dec. 20, 2019), https://www.acepnow.com/article/the-world-health-assembly-adopts-an-emergency-care-resolution/?singlepage=1&theme=print-friendly [https://perma.cc/5HTR-3W9Y].

(141) See id.

(142) Sixtieth World Health Assembly, Health systems: emergency-care systems, U.N. Doc. A60/22 (May 23, 2007).

(143) Id. at 1.

(144) See id. at 1.

(145) See id. at 2.

(146) See id. at 2.

(147) Id. at 2.

(148) See WHO Update, WHA Resolution on Trauma and Emergency Care Services, INJURY PREVENTION (June 12, 2022, 4.10PM), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2598340/pdf/285.pdf [perma.cc/5ZTX-AN3J].

(149) See id. at 285.

(150) See id.

(151) See id.

(152) See Sixty-Fourth World Health Assembly, Strengthening National Health Emergency and Disaster Management Capacities and Resilience of Health Systems, U.N. Doc. A64/10 (May 24, 2011).

(153) See id.

(154) See id.

(155) Disaster Management, Strengthening National Health Emergency and Disaster Management Capacities and Resilience of Health Systems, supra note 132.

(156) See Sixty-Eighth World Health Assembly, Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage, U.N. Doc. A68/15 (May 26, 2015) (describing how 'more than 100 million people sustain injuries globally' and would require surgical care to prevent loss of lives).

(157) See id. at 3. (This situation is more rampant in Low- and Middle-Income Countries and would cause harm to citizens if not promptly handled).

(158) See id. at 4. States are also to promote access to surgical care and anaesthesia, carry out regular monitoring and evaluation, compile data, strengthen infection prevention and control and ensure that health workers are competent to perform their duties. Id.

(159) See Seventy-Second World Health Assembly, Emergency Care Systems for Universal Health Coverage: Ensuring Timely Care for the Acutely Ill and Injured, U.N. Doc. A72/16 (May 28, 2019). WHA emphasises that millions of deaths and long-term disabilities and complicated health conditions would be avoided if there is access to quality and urgent medical care. Id.

(160) See id. at 1-2. Emergency care is vital to ensuring the health of persons by preventing the loss of life. Access to emergency care enable people participate in the development of their societies because unhealthy and deceased persons do not have such liberties. Id.

(161) See id. at 2 (lives are saved when people who require urgent medical attention are promptly attended to and receive the care they require).

(162) See Emergency Care Systems for Universal Health Coverage: Ensuring Timely Care for the Acutely Ill and Injured, supra note 159, at 3. Emergency services can be strenghtened when states provide quality pre-hospital and hospital based services without discriminating agaisnt certain individuals or groups. Id.

(163) See id. Social determinants of health restrict access to healthcare services for some individuals and these include: education, unemployment and job insecurity, food insecurity, housing and basic amenities and the environment. Id.

(164) See id.

(165) According to Usoro, Health facilities are poorly resourced and understaffed, especially in rural areas. Despite having the largest economy in Africa, Nigeria has 0.5 hospital beds per 1000 people, which falls below the average of 1.0 hospital bed per 1000 people in other sub-Saharan African countries. See Usoro et al., supra note 99, at 2; Health systems: emergency-care systems, supra note 142, at 4.

(166) Id.

(167) See id.

(168) See id.

(169) See Health systems: emergency-care systems, supra note 142, at 2.

(170) See Waseem et al., supra note 15, at 514.

(171) See Guidelines for Essential Trauma Care, WORLD HEALTH ORG. (Feb. 23, 2023, 9:30 PM), https://www.who.int/publications/i/item/guidelines-for-essential-trauma-care [https://perma.cc/K48S-9XG9].

(172) See id.

(173) See Mehmood, supra note 13, at 57.

(174) See id

(175) See id.

(176) See Thirteenth General Programme of Work 2019-2023, WORLD HEALTH ORG.

(Feb. 23, 2023, 10:01 PM), https://www.who.int/about/what-we-do/thirteenth-general-programme-of-work-2019---2023 [https://perma.cc/9LG3-Z83].

(177) See id.

(178) See id.

(179) See Seventy-Second World Health Assembly, Emergency Care Systems For Universal Health Coverage: Ensuring Timely Care for the Acutely Ill and Injured, U.N. Doc. A72/31 (May 28, 2019).

(180) Constitution of the Federal Republic of Nigeria, 1999, [section] 17(3)(d).

(181) OLAITAN O. OLUSEGUN & OLUDAMILOLA A. ADEJUMO, LEGAL PRESCRIPTIONS FOR MEDICAL PRACTITIONERS: A HANDBOOK OF MEDICO-LEGAL ISSUES AND RIGHTS PROTECTION IN NIGERIA 14 (Krafts Publishers, 2023).

(182) National Health Act, 2014, [section] 20(1).

(183) Id. at [section] 20(2).

(184) Id. at [section] 11(3)(e).

(185) See id. at [section] 11(3)(d); NATIONAL PRIMARY HEALTHCARE DEVELOPMENT AGENCY, About Basic Health Care Provision Fund, https://nphcda.gov.ng/bhcpf/ (last visited Feb. 23, 2023).

(186) See id.

(187) See Implementation of the Basic Health Care Provision Fund (BHCPF) in Nigeria, HUMAN DEV. NETWORK (June 14, 2022, 6:07 AM), https://options.co.uk/sites/default/files/bhcpf_advocacy_brief.pdf.

(188) See Compulsory Treatment and Care for Victims of Gunshot Act (2017) [section] 1 (Nigeria).

(189) See id (describing purpose of statute). The refusal of medical practitioners to treat gunshot victims without police reports arose from the enactment of the Robbery and Firearms (Special Provisions) Act, which mandated that medical practitioners report such incidents to the police in order to reduce the proliferation of firearms and armed robbery cases in Nigeria that arose after the civil war. See Percy Ani, Police Report: Families of Gunshot, Accident Victims in Tears amid Rising Cases of Needless Deaths, THE PUNCH (Sept 5, 2021) https://punchng.com/police-report-families-of-gunshot-accident-victims-in-tears-amid-rising-cases-of-needless-deaths/ [https://perma.cc/7J2C-JYZ6].

(190) Id. at [section] 3.

(191) Id. at [section] 5. Nigeria uses Naira (common acronyms "NGN" and "N") as its currency. A recent estimate by the Forbes Currency Converter states that 1 USD is the equivalent of 460.44 NGN. See 1 USD to NGN Convert United States Dollar to Nigerian Naira, Forbes (Feb. 24, 2023, 15:45 UTC), https://www.forbes.com/advisor/money-transfer/currency-converter/usd-ngn/ [https://perma.cc/XQT5-CRSL].

(192) Id. at [section] 2(1) (explaining procedure for bringing gunshot victims medical care).

(193) See id. at [section] 8 (explaining protections for those rendering assistance to gunshot victims); Chinyere Nwali-Chukwu, Nigeria: Compulsory Treatment and Care For Victims Of Gunshot Act 2017: How Effective?, MONDAQ (2021), https://www.mondaq.com/nigeria/healthcare/1082822/compulsory-treatment-and-care-for-victims-of-gunshot-act-2017-how-effective [https://perma.cc/VH7E-PB8C].

(194) Id. at [section] 4.

(195) See Compulsory Treatment and Care for Victims of Gunshot Act (2017) [section] 12 (Nigeria) (describing medical care provision regardless of economic status).

(196) Id. [section] 2(2a).

(197) Id. [section] 20.

(198) Usoro et al., supra note 99, at 6.

(199) See id; Nicholas Ibekwe & Ifeoluwa Adediran, Health Emergency Initiative--Lagos Organisation Paying Hospital Bills of Poor Nigerians, PREMIUM TIMES (Mar. 23, 2020).

(200) See generally Taylor W. Burkholder et al., Developing Emergency Care Systems: A Human Rights-Based Approach, 97 BULL. WHO 612, 615 (2019) (describing provision of emergency care internationally).

(201) See The World Bank, Nigeria Poverty Assessment 2022: A Better Future for All Nigerians, WASHINGTON DC: INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT 13 (2022).

(202) See Ode Uduu, Health Insurance in Nigeria - Only 3% of Nigerians are Covered, DATAPHYTE (Nov. 28, 2022), https://www.dataphyte.com/latest-reports/development/health-insurance-in-nigeria-only-3-of-nigerians-are-covered/ [https://perma.cc/87X9-4G6A].

(203) See Ibekwe & Adediran, supra note 199.

(204) See id.

(205) See L Yount, Patients' Rights in the Age of Managed Health Care, FACTS ON FILE INC (2001).

(206) See O Olumese, Duty without Liability: The Impact of Article 12 of the International Covenant on Economic, Social and Cultural Rights on the Right to Health Care in Nigeria, 21 AHRLJ 1112-1134 (2021).

(207) See CTCVGA, [section] 11.

(208) See CTCVGA.

(209) See OLUSEGUN & ADEJUMO, supra note 181, at 17.

(210) See Medical and Dental Council of Nigeria, Code of Medical Ethics (2016).

(211) See id.

(212) See id.

(213) Id.

(214) Id.

(215) Medical and Dental Council of Nigeria, supra note 210

(216) See id.

(217) See id.

(218) See id.

(219) See Kasule, supra note 127.

(220) Id.

(221) Id.

(222) See Wes Ogilvie & Hawnwan Moy, EMS Legal and Ethical Issues, STATPEARLS (June 14, 2022, 9.20AM), https://www.statpearls.com/ArticleLibrary/viewarticle/31761 [https://perma.cc/E7B3-VTGJ].

(223) See id.

(224) Id.

(225) Id.

(226) See Oludamilola Adebola Adejumo & Oluseyi Ademola Adejumo, Legal Perspectives on Liability for Medical Negligence and Malpractices in Nigeria, PAN AFR. MED. J. 34, 35 (2020).

(227) See Ogilvie & Moy, supra note 222.

(228) B.A. Solagberu et al., Re-Hospital Care in Nigeria: A Country Without Emergency Medical Services, 12 NIGER J. CLINICAL PRAC. 29, 31 (2009).

(229) Id.

(230) See Luke 10:25-37; Damien Schiff, Samaritans: Good, Bad and Ugly: A Comparative Law Analysis, 11 ROGER WILLIAMS UNIV. L. REV. 77, 78 (2005).

(231) Id.

(232) See William M. Garneau et al., Cross-Sectional Survey of Good Samaritan Behaviour by Physicians in North Carolina, 10 BMJ OPEN 1, 1 (2016).

(233) Brian West & Matthew Varacallo Good Samaritan Laws (2019), https://www.ncbi.nlm.nih.gov/books/NBK542176/ [https://perma.cc/4EKR-4EVG].

(234) See Dare Odufowokan, House in Move to Protect Good Samaritans, Youths, THE NATION (June 26, 2016), https://thenationonlineng.net/house-move-protect-good-samaritans-youths/ [https://perma.cc/BEH3-6MAF].

(235) See id.

(236) See Good Samaritan's Bill, [section] 2 (2019).

(237) See id. at [section] 1.

(238) See id.

(239) See Good Samaritan's Bill, [section] 1 (2019).

(240) See id.

(241) See id. at [section] 3.

(242) Id. at [section] 4(2).

(243) See Patricia G. Montana, Watch or Report? Livestream or Help? Good Samaritan Laws Revisited: The Need to Create a Duty to Report, 66 CLEV. ST. L. REV. 533, 537 (2018).

(244) See Garneau et al., supra note 232.

(245) See Nancy Levit, The Kindness of Strangers: Interdisciplinary Foundations of a Duty to Act, 40 WASHBURN L. J. 463, 476 (2001).

(246) See Montana, supra note 243, at 537. See generally Illinois Good Samaritan Act, 745 ILL. COMP. STAT. 49/25; N.C. GEN. STAT. [section] 90-21.14; ARK. CODE ANN. [section] 17-95-101 (2017).

(247) See Brian West & Matthew Varacallo, Good Samaritan Laws, STATPEARLS (Sept. 12, 2022), https://www.ncbi.nlm.nih.gov/books/NBK542176/ [https://perma.cc/J88Z-SGJK].

(248) See Montana, supra note 243, at 537; see also Ark. Volunteer Immunity Act for Healthcare Prof. [section] 202 (2022) https://www.healthy.arkansas.gov/images/uploads/rules/Volunteer_Licensed_Health_Care_Immunity_Act.pdf [https://perma.cc/75RC-EN8Y].

(249) See VT. STAT. ANN. tit. 12 [section] 519(a) (2022); MINN. STAT. ANN. [section] 604A.01(1) (West, Westlaw through 2023 Reg. Sess.); 11 R.I. GEN. LAWS Ann. [section] 11-56-1 (West, Westlaw through 2022 Reg. Sess.) For example, in Minnesota, a violation of the Statute translates to a petty misdemeanour and the violator would have to pay a maximum fine of $300. [section] 604A.01(1) Violators of the Rhode Island Statute are subjected to a slightly higher punishment of six months imprisonment and a maximum fine of $500, or both. [section] 11-56-1. See generally Schiff, supra note 230.

(250) See generally Schiff, supra note 230.

(251) 1967 Vt. Acts & Resolves 309, Adj. Sess, 2-4, codified at VT. STAT. ANN. tit. 12, [section] 519 (West, Westlaw through 2021-22 Vt. Gen. Assemb.); 1983 Wis. Laws 198, 1, codified at WIS. STAT. ANN. [section] 940.34 (West, Westlaw 2021 Act 267); Man Yee Karen Lee, The Role of Law in Addressing the Good Samaritan's Dilemma: A Chinese Model?, 2 ASIAN J. L. SOC'Y 55, 70 (2015).

(252) Lee, supra note 251, at 70.

(253) Id.

(254) Id.

(255) See COLO. REV. STAT. ANN. [section] 18-8-115 (West, Westlaw through 2d Reg. Sess, 73rd Gen. Assemb. 2022); HAW. REV. STAT. ANN. 663-1.6(a); MASS. GEN. LAWS ch. 268 [section] 40 (West, Westlaw through 2022 2d Annual Sess.); OHIO REV. CODE ANN. [section] 2921.22(A)(1) (West, Westlaw through 134th Gen. Assemb. 2021-2022); [section][section] 940.34(2)(a).

(256) 2008 TEX. PENAL CODE. [section] 38.17(a)(1) (West, Westlaw through 2021 Reg. and Called Sess. Of 87th Legis.), NEV. STAT. ANN. [section] 202.882(1)(2) (West, Westlaw through 33rd Spec. Sess. 2021); Montana, supra 243, at 544.

(257) See Montana, supra note 243, at 546 (explaining how reporting crimes prevents further abuse).

(258) Id.

(259) See generally the Compulsory Treatment and Care for Victims of Gunshots Act (2017).

(260) See Compulsory Treatment and Care for Victims of Gunshots Act (2017) Cap. [section] 2(1), 8 (Nigeria). "Every volunteer or helper of a victim of gunshots shall be treated with respect and shall not be subjected to unnecessary and embarrassing interrogation in their genuine attempt to save life." Id.

(261) See Lee, supra note 251, at 69.

(262) Kathleen M. Ridolfi, Law, Ethics, and the Good Samaritan: Should There Be a Duty to Rescue?, 40 SANTA CLARA L. REV. 957, 960 (2000) (introducing historical, moral debate surrounding helping those in medical distress).

(263) See Montana, supra note 243, at 549.

(264) See id.

(265) See Angela Hayden, Imposing Criminal and Civil Penalties for Failing to Help Another: Are "Good Samaritan" Laws Good Ideas?, 6 NEW ENG. J. INT'L. & COMPAR. L. 27-31 (2000) (highlighting historical foundation supporting current duty to rescue laws).

(266) See Nasim S. Sabounchi et al., Assessing the impact of the Good Samaritan Law in the state of Connecticut: a system dynamics approach, 20 HEALTH RSCH. POLICY AND SYS. 5 (2022).

(267) See Watson DP et al., Lay responder naloxone access and Good Samaritan Law compliance: postcard survey results from 20 Indiana counties, 15 HARM REDUCTION J. 18, 19 (2018).

(268) See Amanda D. Latimore & Rachel S. Bergstein, "Caught with a Body" Yet Protected by Law? Calling 911 For Opioid Overdose in The Context of the Good Samaritan Law, 50 INT'L J. DRUG POLICY 82, 83 (2017).

(269) See id.

(270) See Lee, supra note 251.

(271) See Hayden, supra note 265. For example, the French Criminal Code, Article 223-6[2], imposes a penalty of five years of misdemeanour imprisonment and a fine of 500,000 francs for offenders. Id.

(272) Lee, supra note 251, at 72.

(273) CONSTITUTION OF NIGERIA (1999), [section] 17(3)(d). "The State shall direct its policy towards ensuring that... there are adequate medical and health facilities for all persons...." Id.

(274) Burkholder et al., supra note 11, at S4.

(275) CONSTITUTION [section] 43(2) (2010) (Kenya).

(276) See CONSTITUTION OF NIGERIA (1999), [section] 17(3)(d). See generally Hans V. Hogerzeil et al., Is Access to Essential Medicines As Part of the Fulfilment of the Right to Health Enforceable Through the Courts?, 368 LANCET 305-1, 11 (2006) (describing court decisions reinforcing constitutional and treaty-based guarantees to emergency care); Burkholder et al., supra note 11, at S4 (describing right to emergency care in national constitutions).

(277) See, e.g., Burkholder et al., supra note 11, at S4 (describing policy in need of such factors).

(278) See The Health Act, No. 21 [section] 12(2)(b) (2017) KENYA GAZETTE SUPPLEMENT No. 101.

(279) See The Health Act, No. 21 [section]21 [section] 7(2) (2017).

(280) See The Health Act, No. 21 [section]21 [section] 7(3) (2017).

(281) See The Health Act, No. 21 [section]21 [section] 15(1) (2017).

(282) See Thind et al., supra note 27 (describing how the inclusion of emergency care in national Constitutions increased accessibility to healthcare in some countries).

(283) See id.

(284) See Burkholder et al., supra note 11.

(285) See id.

(286) See Karl Brooks & Susan Hedman, Medicare Program; Emergency Medical Treatment and Labor Act (EMTALA): Applicability to Hospital Inpatients and Hospitals with Specialized Capabilities, 77 FED. REG. 5213- 5214 (2012).

(287) See id.

(288) See generally CTCVGA Act.

(289) Id.

(290) See for example, Illinois Good Samaritan Act, 745 ILL. COMP. STAT. 49/25; N.C. GEN. STAT. [section] 90-21.14; ARK. CODE ANN. [section] 17-95-101 (2017).

(291) Cameron DeGuerre, Good Samaritan Statutes: Are Medical Volunteers Protected? 6 Virtual Mentor 181 (2004).

(292) See Tessy Igomu, How Hospitals Aid Deaths of Gunshot Victims (Aug 2, 2019) https://sunnewsonline.com/how-hospitals-aid-deaths-of-gunshot-victims/ [https://perma.cc/2FRQ-E6H4].

(293) Id.

(294) Id.

(295) See, Health Emergency Initiative, Good Samaritan Law in Nigeria (2019) https://hei.org.ng/good-samaritan-law-in-nigeria/.

(296) See By Ibanga Isine, High-level corruption rocks $470million CCTV project that could secure Abuja (June 27, 2014) https://www.premiumtimesng.com/news/163975-high-level-corruption-rocks-470million-cctv-project-secure-abuja.html?tztc=1 [https://perma.cc/H48H-Z2QK].

(297) See the Good Samaritan's Bill, [section] 2 (2019); CTCVGA at [section] 8.

(298) See Montana, supra note 243, at 533.

(299) Kasule, supra note 127, at 83; Wilson et al., supra note 25, at 2530.

(300) See Kasule, supra note 127, at 83.

(301) See Garneau et al., supra note 232, at 454.

(302) Id.

(303) See id.

(304) Salau, supra note 79.

(305) Id.

(306) Kobusingye et al., supra note 22, at 627.

(307) Id.

(308) JOSEPH J. MISTOVICH ET AL., PREHOSPITAL EMERGENCY CARE 81(10th ed. 2014).

(309) Kobusingye et al., supra note 22, at 628.

(310) See Nigeria Launches 112 Toll-free Telephone Number for Emergencies, PREMIUM TIMES (June 14, 2022), https://www.premiumtimesng.com/news/top-news/367273-nigeria-launches-112-toll-free-telephone-number-for-emergencies.html [https://perma.cc/V9LY-H8P7].

(311) Id.

(312) Zidon, supra note 72.

(313) Van de Glind et al., A National Research Agenda for Pre-Hospital Emergency Medical Services in the Netherlands: a Delphi-study, Resuscitation and Emergency Medicine, 24 SCANDINAVIAN J. TRAUMA, RESUSCITATION, EMERGENCY MED. 1, 1 (2016).

(314) Thind et al., supra note 27, at 257.

(315) Jan L. Jensen et al., The Canadian National EMS Research Agenda: A Mixed Methods Consensus Study, 15 CAN, J. EMERGENCY MED. 73, 73-82 (2013).

(316) Van de Glind, supra note 314, at 2.

(317) Kobusingye et al., supra note 22, at 629.

(318) Thind et al., supra note 27, at 257; Lee et al., supra note 10, at 1-7.

(319) Usoro et al., supra note 99, at 6.

(320) Anderson et al., supra note 14, at 35.

(321) CESCR, supra note 132, [paragraph] 30.

(322) Id. [paragraph] 51.

(323) See Charles Mock et al., Trauma Care in Africa: The Way Forward, 33 AFR. J. TRAUMA, 313, 5 (2014)

(324) Id (detailing examples of prehospital care issues including transportation).

(325) See Thind et al., supra note 27.

(326) See Adeloye, supra note 66, at 251-52.

(327) See Katie Nielsen et al., Assessment of the Status of Prehospital Care in 13 Low- and Middle-Income Countries, 16 PREHOSP. EMERGENCY CARE 381, 387 (2012).

(328) See Oluwadiya KS et al., Pre-hospital care of the injured in South Western Nigeria: A Hospital-Based study of Four Tertiary Level Hospitals in Three States, 49 ASS'N. ADV. OF AUTO. MED. 93, 98 (2005); Usoro et al., supra note 99, at 3.

(329) See id. (finding victims of emergencies were handled and treated in unsuitable and dangerous manners by bystanders).

(330) B.A. Solagberu et al., supra note 228, at 31.

(331) Lidal et al., Triage Systems for Pre-Hospital Emergency Medical Services - A Systematic Review, 21 SJTREM 1, 4 (2013).

(332) Thind et al., supra note 27, at 249.

(333) Razzak & Kellerman, supra note 52, at 905.

(334) Mock C et al., Improvements in Prehospital Trauma Care in an African Country with no Formal Emergency Medical Services, 53 J. TRAUMA 90, 90 (2002); Akande AT, Accident Emergency and Road Safety, AFRICANWOMENINMEDIA (June 14, 2022, 9.20AM), http://www.iq4news.com/?q5conteent/emergroad [https://perma.cc/5N8T-T2QP].

(335) The Nation, Good Samaritan Act (June 14, 2022, 9.20AM), https://thenationonlineng.net/good-samaritan-act/ [https://perma.cc/F4PE-JYV].

(336) Id.

(337) Id.

(338) Id.

(339) Edeh et al., supra note 58, at 75.

(340) See Emergency Care Systems for Universal Health Coverage: Ensuring Timely Care for the Acutely Ill and Injured, supra note 179.

(341) Id.

(342) See id.

(343) See Kasule, supra note 127, at 83.

(344) See Kobusingye et al., supra note 22, at 629 (discussing improved outcomes with financial and logistical considerations of training program in low-middle income countries).

(345) See Christopher Hands et al., Emergency Triage Assessment and Treatment Plus (ETAT+): Adapting Training to Strengthen Quality Improvement and Task-sharing in Emergency Paediatric care in Sierra Leone 11 J Glob. Health., 04069-04079 (2021);, Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for Care at the First-referral Level in Developing Countries, WORLD HEALTH ORGANIZATION (2000), https://apps.who.int/iris/bitstream/handle/10665/42335/WHO_FCH_CAH_00.1.pdf;jsessionid=B3E4B177C1C71E6D132239999F7FB70B?sequence=1 [https://perma.cc/8WAX-SGU8] (detailing protocol of assessment and treatment of children).

(346) See Teri A. Reynolds et al., Emergency Care Capacity in Africa: A Clinical and Educational Initiative in Tanzania, 33(S1) J. PUB. HEALTH POL'Y 126, 129 (2012), https://www.researchgate.net/publication/260100546_Open_Emergency_care_capacity_in_Africa_A_clinical_and_educational_initiative_in_Tanzania [https://perma.cc/7TQG-SA24].

(347) Nwauwa, supra note 69.

(348) Id. (describing two-week training process in Tel Aviv). The training program was a partnership between the Federal Ministry of Health and the Israeli government, with the goal of fostering the development of emergency medical services in Nigeria. Id. See generally Usoro et al., supra note 99 (describing ongoing deficiencies in Nigerian emergency medical training). See generally House in Move to Protect Good Samaritans Youths, THE NATION (June 26, 2016), thenationonlineng.net/house-move-protect-good-samaritans-youths/ [https://perma.cc/RN48-AJPV] (describing new law to protect volunteers rendering aid). The Good Samaritan Bill passed unanimously, reflecting a need for more widespread access to emergency aid. Id.

(349) Jasper et al., supra note 60. The Australasian Registry of EMT's fast track programs are intended to provide support for existing personnel until federal government sponsored paramedics become available. Id.

(350) UBTH @ 50, UBTH Paramedic Program (2023) https://ubth.org/clinical-departments/ubth-paramedic-program/#:~:text=As%20the%20first%20and%20only,are%20presently%20working%20in%20UBTH [https://perma.cc/J7Z9-UHQS].

(351) See Adesola O Sangowawa & Eme T Owoaje, Building Capacity of Drivers in Nigeria to Provide First aid for Road Crash Victims, NAT'L LIBR. OF MED. (Jan. 19, 2012), https://pubmed.ncbi.nlm.nih.gov/22157207/ [https://perma.cc/PQ4K-7UP4] (suggesting periodic training to sustain first aid skills).

(352) See Thind et al., supra note 27, at 249. Monitoring the effectiveness of training programs can provide a way to analyse costs and benefits. Id.

(353) World Health Assembly Res. 72/16, [paragraph] 2(9) (May 28, 2019).

(354) Scott Lancaster et al., Defining Priorities for Emergency Medical Services Education Research: A Modified Delphi Study 4 J. AM. COLL. EMERG. PHY. OP., 12882-12992 (2023).

(355) Nkechi Clara Nwosu et al., Awareness, Knowledge of First Aid and First Emergency Behavioral Perception of Medical Students in a University in Southeastern Nigeria, 20 AJMAH 67, 71 (2022).

(356) See Oludara et al., supra note 57, at 255.

(357) See id.

(358) See Donald A. Redelmeier & Allan S. Detsky, Clinical Action against Drunk Driving 14 PLos Med, 1,4 (2017).

(359) See id.

(360) See Noncommunicable Diseases, WORLD HEALTH ORG. (Nov. 12, 2022, 6::00 AM), https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases [https://perma.cc/X6SB-N43A].

(361) See Edeh et al., supra note 53, at 75.

(362) See id.