Pay or perish: Inside Kenya's broken ambulance system

On a chilly evening in Zimmerman estate, Nairobi the boda boda stage was alive with its usual rhythm; engines idling, riders swapping banter, the occasional customer hopping on for a quick ride home.

 James Moi was right in the middle of it, as he often is. As chairman of the Zebra Stage Boda Boda Association, he is not just another rider; he is a mobiliser, first point of contact, and leader in a space where urgency is part of daily life.

 Then his phone rang. The tone on the other end was frantic. Less than ten minutes earlier, one of his colleagues had picked up a customer. It was supposed to be a routine trip — the kind that makes up hundreds of daily boda boda runs across the city.

 But now, the rider had been involved in a serious road accident somewhere near the city centre. James did not hesitate. Leadership, in that moment, meant action.

 He jumped onto his bike, alerted other riders at the stage and within seconds, a small convoy was racing towards the scene. No sirens, no official dispatch; just instinct, adrenaline and the unspoken code among riders to show up when one of their own is in trouble.  When they arrived, reality hit hard. A small crowd had already gathered. Among the first responders were a matatu tout and several passengers who had been in a nearby vehicle. They had tried to help, but there was little they could do.

 The matatu had no proper first aid kit. Just cotton wool. No bandages to stop the bleeding. No antiseptic to clean wounds. No trained personnel to stabilise the victim. The injured rider lay there, bleeding, as time slipped away.

 Calls for an ambulance began almost immediately. But what followed exposed a harsh reality about emergency response in Kenya.

 In one of the calls, James says, the response from an ambulance service was not a reassurance — it was a condition. Payment first.

 “In that moment, you don’t even know what to say,” he recalls. “Someone is lying there fighting for their life and the conversation is about money.”

 As the calls dragged on and confusion mounted, a Good Samaritan stepped forward. Unable to wait any longer, they offered to ferry the injured rider to a nearby hospital in a private vehicle.

 It was a desperate decision and it was too late. The rider succumbed to excessive bleeding before he could receive proper medical attention.

 For James, the memory remains raw.

 “This is an experience I will never forget,” he says. “We normally assume that getting an ambulance is an easy task, but I found out the hard way. Many of these ambulances are privately owned and charge exorbitant fees. For us who rely on government services, we are at a disadvantage.”

 His experience is not unique. It is, in many ways, a reflection of a wider, systemic failure that continues to play out across Kenya’s roads, estates and hospitals.

 A system many only discover in crisis

 For most Kenyans, emergency medical care is an abstract concept; something you assume exists, something you believe will be there when needed. Until it is not.

 Random calls to emergency care providers, particularly in the capital city, reveal a pattern that is as troubling as it is consistent. Many ambulance services operate on a “pay first” model, where dispatch is contingent on upfront payment or proof of ability to pay.

 Public ambulances, on the other hand, are often overstretched, under-resourced and  slow to respond. The result is a dangerous gap; one where critical minutes are lost in negotiations, delays and uncertainty.

 It is this gap that a recent audit by Auditor General Nancy Gathungu sought to examine, and what it uncovered paints a grim picture of emergency medical care in the country.

 The audit, which assessed the effectiveness of emergency medical services between the financial years 2021/2022 and 2024/2025, underscores a simple but critical reality: in emergencies, time is everything.

 When every minute counts and is lost

 Yet across the country, that time is being lost. Ambulance response times, the report notes, can stretch to as long as 60 minutes. In medical terms, that is an eternity.

 The concept of the “golden hour”; the crucial window within which prompt medical intervention can prevent death or irreversible damage — is effectively rendered meaningless when response systems fail. According to the audit, delays are not isolated incidents. They are symptomatic of deeper structural challenges that span both national and county governments.

 At the centre of the problem is coordination — or the lack of it.

 Kenya does not have a national ambulance dispatch centre. There is no single, centralised system to receive emergency calls, track available ambulances in real time and deploy them efficiently based on proximity and urgency.

 Instead, what exists is a fragmented system, where counties operate independently, often with limited capacity and varying levels of preparedness.

 The audit sampled 16 counties, including Nairobi, Mombasa, Kisumu, Nakuru, Isiolo, Narok, Kisii, Busia, Machakos, Kirinyaga, Uasin Gishu, Tana River, Garissa, Tharaka Nithi and Nyandarua.

 Even within this sample, disparities were evident.

 While 12 of the 16 counties had some form of ambulance dispatch centres, their effectiveness was severely limited. Many lacked real-time ambulance tracking systems, meaning dispatchers had no clear visibility of where vehicles were or how quickly they could respond.

Communication systems were inadequate, with insufficient gadgets to coordinate teams on the ground. Internet connectivity issues further hampered operations, while the absence of backup generators meant that even existing systems could fail during power outages.

 In the four counties without dispatch centres, the situation was even more dire. Ambulances were managed at the sub-county or facility level, where priority was often given to hospital referrals rather than emergency response at the community level.

 This meant that a patient needing transfer between facilities could take precedence over a victim bleeding at an accident scene.

 The consequences are predictable — and deadly. The numbers behind the crisis.

 Beyond coordination, the audit highlights a severe shortage of functional ambulances.  Out of 269 ambulances sampled across the 16 counties, 92 — representing 34 per cent — were non-functional.

 Some had broken down and were awaiting repair. Others lacked essential medical equipment. Many were not adequately fuelled. In some cases, there was no trained personnel to operate them.

 Even among the operational ambulances, a great number were classified as Basic Life Support (BLS) units, which offer limited capabilities compared to Advanced Life Support (ALS) ambulances that can provide critical care interventions.

 Interviews and physical verification revealed that nine of the 16 counties had limited numbers of advanced trauma life support or advanced cardiac life support ambulances, further constraining their ability to respond effectively to severe emergencies.

 In contrast, counties that had outsourced ambulance services to private providers; such as Narok, Garissa and Kiambu — reported better outcomes. Through partnerships with Emergency Plus Medical Services (EPlus), these counties had access to well-maintained, fuelled ambulances staffed by trained personnel.

 However, even in these counties, government-owned ambulances continued to operate alongside the subcontracted ones, often with varying levels of efficiency.

 Funding: The silent constraint

  One of the more critical findings of the audit is lack of prioritisation of emergency medical services at the county level.

 Unlike other sectors, emergency care does not always receive dedicated funding. Instead, it competes with other health services for limited resources.

 This, the Auditor General notes, is problematic given the unpredictable nature of emergencies.

 Gathungu has called on counties to ring-fence funds specifically for emergency medical care — covering everything from ambulance maintenance and fuel to staffing, equipment and training.

 Without such financial commitment, the system remains vulnerable to collapse under pressure.

 The challenges do not end with ambulance response. For those who make it to hospital, the situation is often just as precarious.

 The audit found that infrastructure for emergency care is severely lacking, particularly in lower-level facilities.

 Only three out of 33 sampled Level 4 hospitals had operational accident and emergency departments. None had separate units dedicated to paediatric emergencies.

 At Level 5, 11 out of 15 hospitals had accident and emergency departments, but most lacked specialised sections for children.  Even where departments exist, staffing is inadequate.

 Seven out of 14 Level 4 and Level 5 facilities with emergency departments did not meet the minimum requirement of at least 10 accident and emergency nurses. Some had as few as one to four.  As a result, emergency patients are often attended to by general nurses who lack specialised training in handling critical cases.

 The strain is evident in nurse-to-patient ratios. In some Level 4 facilities, ratios ranged from 1:5 to as high as 1:100 within a 24-hour period. In Level 5 facilities, the range was between 1:8 and 1:122.  These figures far exceed the World Health Organisation’s recommended ratio of 1:4 for emergency departments.

 Compounding the staffing crisis is a severe shortage of essential medical equipment.

 Emergency departments are expected to have dedicated diagnostic tools and life-saving equipment to handle critical cases promptly. However, the audit found huge gaps across the board.

 Up to 90 per cent of Level 4 hospitals and 46 per cent of Level 5 hospitals lacked piped oxygen — a basic requirement for treating patients with respiratory distress.

 Ventilators were also scarce, with 84 per cent of Level 4 and 80 per cent of Level 5 hospitals lacking these critical machines.

 Lower-level facilities were even worse off. All sampled Level 2 and Level 3 facilities lacked piped oxygen, while a majority did not have oxygen cylinders.

 The absence of such equipment leads to delayed or missed diagnoses, increased referrals to higher-level facilities and ultimately, poorer patient outcomes.

 “Shortage of essential equipment leads to missed or delayed diagnosis that can result in adverse outcomes, including increased risk of complications, permanent disability or fatalities,” Gathungu notes in her report.

 At the grassroots level, the audit reveals another critical gap — public awareness and preparedness.

 Many Kenyans are unaware of the presence of community health promoters in their areas and few have basic training in first aid.

 This means that in the immediate aftermath of an accident, victims are often attended to by bystanders with little or no medical knowledge. People like James. People like the matatu tout and passengers who tried to help his colleague.They are willing to step in, but they lack the tools and training to make a meaningful difference.

 To address this, the Auditor General has recommended that county governments invest in training community members in basic first aid — including how to recognise emergencies, call for help and stabilise patients until professional care arrives.  Such training, she suggests, should be integrated into county annual work plans.

 In Nairobi County, the challenges are stark. According to Nairobi City County Chief Officer for Disaster Management, Bramwel Simiyu, the county currently operates only three working ambulances. Plans are underway to upgrade these into Advanced Life Support units — described as “mobile ICUs” capable of delivering hospital-level care at the scene and during transport.

 “These are highly sophisticated emergency vehicles,” Simuyu explains. “They represent a significant upgrade from Basic Life Support units, enabling paramedics to perform complex, life-saving interventions.”

 But with a population of close to five million, three ambulances barely scratch the surface of the need.

 The bigger question

 As the country grapples with these systemic failures, a fundamental question emerges: Should access to emergency medical care depend on one’s ability to pay?

 For many Kenyans, the answer is already evident in lived experience.

 In the critical moments after an accident, survival often hinges not just on the severity of injuries, but on whether an ambulance is available, how quickly it arrives and whether the victim can afford the service.

 Back in Zimmerman, life continues. Boda boda riders still line up at the stage. Customers still come and go. The city moves on, as it always does.

 But for James, that night remains etched in his memory. The frantic calls. The helpless crowd. The race against time that ended in silence.

 “We tried everything,” he says nostalgically. “But without the right systems, it wasn’t enough.”

  And across Kenya, in countless unseen emergencies, that same story continues to unfold — one delayed response, one missing ambulance, and lives regrettably lost due to this systematic failure.