Managing medical assets post-deployment: a critical review of equipment leave-behind and retrieval in international EMT operations

Abstract Background While the deployment of international Emergency Medical Teams (EMTs) is increasingly characterized by professionalization and standardization, the critical mission closure or ‘exit phase’ remains an unevenly codified and ethically fraught domain, with relevant guidance emerging in some surge frameworks but without a consistently harmonized and operationalized approach across EMT-related deployments. This significant gap between a monitored entry and an improvised exit results in operational and ethical questions. The most documented consequence is the phenomenon of "equipment graveyards," a symptom of a more intrinsic issue where humanitarian interventions risk perpetuating dependency rather than building sustainable, local resilience. This challenge is underscored by landmark findings that approximately 40% of all medical equipment in developing countries is non-functional at any given time, often due to unsustainable donation practices. Objectives This study aims to bridge this critical knowledge gap by comprehensively mapping and analyzing the ethical, operational, and strategic domains that shape decision-making around equipment, infrastructure, and related post-deployment asset management at the end of an Emergency Medical Team (EMT) deployment. By undertaking this analysis, the study seeks to advance both the conceptual understanding and practical enhancement of this critical, yet persistently underexamined, phase of the humanitarian mission lifecycle. Methods This study employed a structured scoping literature review methodology. A multi-channel search strategy-encompassing academic databases and citation chaining (i.e., snowballing)—identified 510 potential sources. Through a systematic screening process guided by PRISMA principles, a final corpus of 92 sources was selected for inclusion. The resulting corpus was subjected to an in-depth thematic analysis organized around three principal analytical dimensions: ethical considerations, operational and sustainability factors, strategic frameworks, and we provide case-based empirical evidence behind this. Results The analysis identifies patterns of a nexus of interconnected failures that define the mission exit phase. On the ethical axis, the findings show that decisions about retaining or withdrawing equipment are often distorted by systemic power imbalances and the exclusion of local stakeholders. On the operational and sustainability front, the literature documents a recurring pattern where a technological mismatch precipitates an inability to maintain donated equipment, culminating in non-functional devices and a lack of clinical continuity-a failure driven not only by recipient-side challenges but also by the donor's own logistical and strategic dilemmas. The strategic analysis of key case studies illustrates an evolution in field practice, showing how lessons learned from early responses have led to the development of more adaptive, partnership-based strategies, such as the 'Hybrid Model' and pre-planned withdrawals, as emerging best practices. Conclusions A mission's exit is not merely a logistical task but a defining strategic and ethical act that shapes its long-term legacy. The findings lead to three primary conclusions: 1) Mission closure must be reframed as a core strategic objective planned from the outset. 2) Deep, early, and continuous collaboration with local stakeholders is the single most critical determinant of a successful and responsible exit. 3) The more sustainable long-term solution to the "exit dilemma" requires a paradigm shift from external aid to building national resilience, in line with the principles of localization and decolonization. The study concludes with a recommendation for international governing bodies to strengthen, harmonize, and operationalize exit-related standards across EMT and related surge frameworks, while addressing persistent gaps in implementation, accountability, and contextual adaptation.