Operationalising the WHO call for integrated emergency care through a national ambulance alliance network: implementation experience and lessons from Addis Ababa, Ethiopia (PRECOS-1)

Prehospital emergency care in many African cities is constrained not by ambulance scarcity but by fragmentation: multiple uncoordinated provider types operating parallel dispatch systems, with no shared data and no capacity to measure system performance. Despite the World Health Assembly's 2023 resolution on integrated emergency care (WHA 76.2) and Ethiopia's Health Sector Transformation Plan II (HSTP-II), prehospital coordination has remained a critical missing link. In response, Ethiopia developed the Hospital Emergency Assistance and Response Tracking System (HEARTS) under the Ethiopian Ambulance Alliance Network (EAAN), a governed, multi-provider federation established through consultation with the Network for Perioperative and Critical Care (N4PCc), Federal Ministry of Health, the Addis Ababa city administration fire and disaster response team, a humanitarian NGO provider, and dedicated private ambulance providers. HEARTS provides real-time fleet tracking, unified call processing, community access via a dedicated mobile application, and performance dashboards disaggregated by sub-city and provider type. This paper reports the first phase of the Prehospital Care Outcome Study (PRECOS-1), a programmatic research platform established to generate longitudinal evidence on prehospital coordination in Ethiopia and to inform replication across Africa. During the first operational phase in Addis Ababa (December 2025 to June 2026), HEARTS coordinated 1,403 trips across four provider types and 59 response units. The majority of trips were high- or critical-acuity (63.3%), with maternal and obstetric presentations forming the largest clinical category (44.3%). Median response time was 14.5 minutes (IQR 5.8 to 27.0; 90th percentile 75.0 minutes), the first unified prehospital performance baseline for this city. These findings demonstrate that a coordination-first approach to prehospital system strengthening is feasible in a fragmented low- and middle-income country setting, generate the measurement infrastructure for future improvement studies (PRECOS-2 onward), and offer a replicable model for African cities pursuing integrated emergency care.