Transportation as a determinant of equitable access to emergency critical and operative care in Africa

Abstract Background Transportation barriers are a pressing yet overlooked challenge facing emergency, critical, and operative care (ECO) across Africa. Despite World Health Assembly Resolution 76.2 (2023) urging integrated approaches to ECO, transport remains peripheral to healthcare planning. With five billion people worldwide lacking access to safe, affordable surgical care and an estimated143 million procedures needed each year, and with Africa bearing a disproportionate share of this unmet need, unreliable medical transport shapes outcomes for millions requiring time-sensitive care. Main text This Perspective examines how transport barriers affect every dimension of access: availability, accessibility, affordability, acceptability, and accommodation, across Africa’s diverse landscapes. Framed against the “three delays” model, transport barriers act principally through the second delay, reaching an appropriate facility, converting survivable, time-sensitive conditions into death or disability. Urban centres struggle with the reliability and affordability of informal transport networks such as matatus, boda-bodas, okadas, and taxis, while rural regions often lack formal transport infrastructure. Emergency care suffers from the absence of dedicated medical transport and prolonged response times; critical care transfers are compromised by underdeveloped referral pathways and a lack of in-transit monitoring; surgical services face delayed presentations, interfacility obstacles, and disrupted postoperative follow-up. These barriers disproportionately burden rural populations, women, children, the elderly, and people living in poverty, deepening health inequity. Conclusion Innovative responses are emerging, including Rwanda’s nationally coordinated ambulance dispatch system (SAMU/912), mobile surgical units in Tanzania and Ethiopia, motorcycle ambulances in Uganda, and drone-based medical logistics in Ghana, illustrating the continent’s capacity to adapt and, at times, leapfrog conventional infrastructure, even as questions of cost, scale, and sustainability remain. We argue for integrated transport–health planning, investment in dedicated medical transport, formalisation of informal transport systems, community-driven solutions, and geospatial research to inform evidence-based policy. Addressing transport barriers is essential to achieving equitable access to ECO and the United Nations 2030 Sustainable Development Goals.