Emergencies often present urgent threat to human wellbeing, property and/or environment. According to United Nations Office for the Coordination of Humanitarian Affairs, the scope and frequency of medical emergencies have increased nearly three times in recent times compared to about 40 years ago [18]. Most of these emergencies necessitate medical interventions to avert their immediate threat to life. The current empirical data-driven assessment of emergency care capacities across 460 health facilities in the two most populous regions (i.e., Ashanti and Greater Accra) in Ghana reveals several critical gaps that require urgent attention. The lack of adequate qualified personnel, equipment, medications, protocols, and training indicates that most facilities are ill-prepared to effectively manage medical emergencies. A key finding is the shortage of critical care staff, with 78.3% of facilities lacking specialised personnel to handle emergency and critical care. This shortage of trained emergency care professionals significantly limits these facilities' abilities to manage acute, life-threatening cases. Even where equipment and medications are available, few staff have the expertise to use them appropriately. Targeted training and recruitment of critical care providers should be prioritised.

Another major gap was in supplies and infrastructure for emergency care. While most facilities had basic oxygen, the vast majority lacked essential equipment like defibrillators and monitoring devices, along with associated protocols. Defibrillation within minutes is often essential for cardiac arrest patients, and not having these devices severely limits resuscitation capabilities. There were also shortages of lifesaving medications for conditions such as  stroke, diabetes complications, and heart failure. With 80–90% of health facilities lacking these medications and protocols, it is unlikely emergencies like diabetic crises, heart attacks, strokes, and trauma can be managed appropriately. Meanwhile, cardiovascular diseases or heart failure emergencies have emerged as a major health threat, and quite prevalent among the working class causing significant economic losses. For example, in the 2019, approximately 74% of global mortalities were attributed to non-communicable diseases. Cardiovascular related deaths accounted for about 32%, with Ischaemic heart disease and stroke being the two most fatal conditions, accounting for 16% and 11.2% respectively of the global death [2]. In sub-Saharan Africa, cardiovascular diseases-related mortalities averagely contribute to about 9.2% of all deaths [18, 19]. In Ghana, Ischaemic heart disease is the 4th leading cause of death, with incidence rate of approximately 47 deaths per 1000 population [2]. These conditions form part of the medical conditions which require immediate health attention else they will result in premature deaths. Equipping facilities with standardised emergency crash carts containing protocols, medications, and devices could help bridge these gaps efficiently. This could lead to preventable patient mortality and morbidity.

The study also revealed significant gaps in cardiopulmonary resuscitation (CPR) skills among healthcare workers. CPR can help save a life during cardiac arrest, when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs. However, even after training, remembering the CPR steps and administering them correctly can be a challenge. CPR training is another domain requiring urgent attention and regular training [20]. With only 36 out of 460 in-charges adequately trained in CPR, most facilities lack staff who are competent in this basic lifesaving technique. Routine training and skills assessments should be implemented based on international CPR guidelines. These could be augmented with brief intermittent CPR training for all clinical staff to help increase competency levels. Having properly trained staff is essential for administering appropriate emergency protocols, operating specialised equipment, and providing lifesaving interventions during time-sensitive emergencies.

The absence of standardised protocols compromises the capacity to rapidly mobilise staff, allocate resources, and provide coordinated care. Specifically, the lack of protocols for two common medical emergencies, namely, road traffic accident and acute care protocols, highlights systemic inadequacies in these facilities' abilities to effectively manage such scenarios. We observed a location effect on the severity of inadequacy. There were higher probabilities for health facilities in the Ashanti region to lack road accident protocols (55%) and acute care protocols (65%) compared to facilities in the Greater Accra region with probabilities of 45% and 31% respectively. As the most urbanised region, containing the national capital Accra, Greater Accra having more emergency care resources is predictable. Still, nearly a third of facilities lacking acute care protocols is concerning given the population density and health risks in Accra. Overall, the regional disparity points to unequal distribution of emergency preparedness across Ghana's health system. There is a clear need for comprehensive assessments of emergency protocols and capacities in facilities across all regions [21]. A well-balanced regional health system must be urgently prioritised to strengthen emergency response and ultimately protect patient outcomes.

The type of facility significantly influenced the availability of protocols and resources for emergency care, which highlight important disparity in emergency and acute care preparedness across different lower-tier healthcare facilities in the country. Primary hospitals, polyclinics, and clinics were more likely to have acute care protocols compared to health centres and maternity homes. This aligns with previous research showing that hospitals and larger facilities generally have more standardised policies and procedures for emergency situations [22]. However, even at the hospital-level, availability of protocols specifically for road traffic accidents was relatively low, with just a 53% probability of having them on hand. This lack of trauma-specific protocols is concerning given the high burden of injuries from road crashes in many developing countries [7, 10, 23]. In Ghana, mortalities and permanent bodily injuries associated with road traffic accidents are alarming and a major public health issue. For example, between January and October of 2020, 12,096 road traffic accidents involving over 20,400 vehicles were recorded [24]. It is reported that 72 persons out of every 100 000 population, suffered from grievous bodily injury, and close to eight of the same population died from road traffic accidents over the past decade [8, 25]. Recent WHO guidelines have called for improved trauma and injury protocols across all levels of healthcare facilities globally [26]. In medical crises, preparedness saves lives. The lack of protocols would lead to disorganisation and delay in care, risking preventable morbidity and mortality.

The availability of emergency equipment and infrastructure was predictably worse in clinics and maternity homes compared to primary hospital and polyclinics. For example, oxygen with flowmeters were missing in an estimated 46% of maternity homes. Oxygen is considered an essential medicine by the WHO and a lifesaving intervention for many childbirth and neonatal emergencies [26, 27]. Its absence in lower-level facilities likely indicates a lack of basic emergency obstetric capacity. Similar gaps have been reported in maternal health facilities globally, contributing to preventable mortality in obstetric and neonatal emergencies [28]. Even at the hospital-level, life-saving resources such as defibrillators, stroke medications, and heart failure medications were often absent. This aligns with prior studies showing major gaps in basic emergency equipment and medications in many developing country hospitals [22]. The lack of trained critical care personnel further compounds these resource limitations.

The study found important differences in emergency preparedness between government-owned and private-owned health facilities. A major deficiency across both facility types was a lack of designated emergency area space, highlighting the infrastructure limitations faced even by government hospitals in many developing nations. However, the government-owned facilities were relatively more likely to have protocols and critical resources for emergency and trauma care compared to private-owned facilities. Specifically, government facilities had a higher probability of having road traffic accident and acute care protocols. They also had significantly greater availability of trained emergency personnel. Additionally, life-saving equipment like defibrillators and oxygen tanks were more commonly present in government facilities. These findings align with prior research demonstrating gaps in emergency care capacity at private facilities in low- and middle-income countries [29, 30]. The absence of these basic protocols and resources in many private facilities could be attributed to a lack of oversight, and financial and infrastructural limitations. However, improving private sector emergency preparedness is essential given increasing privatisation of health systems globally [30]. Stronger regulation and oversight of minimum standards for protocols, staffing, medications, and equipment may help bridge emergency care disparities across different facility ownerships. Ultimately, integrating private facilities into coordinated trauma systems and emergency care networks could strengthen capacity at all levels of the healthcare system [30].

The data indicate that the qualifications and training of the personnel-in-charge have a significant influence on the emergency care capacity at health facilities. Facilities managed by medical doctors appeared to be generally better equipped and prepared compared to those managed by midwives, nurses, or physician assistants. Having a medical doctor as in-charge increased the likelihood of having dedicated emergency areas and critical care staff. This suggests doctors are better able to advocate for and provide oversight of emergency resources. The lack of emergency areas in 57% of midwife-managed facilities is particularly concerning given their role in obstetric emergencies. For instance, a multi-centre prospective cross-sectional study found that preeclampsia, which is a hypertensive disorder of pregnancy (HDP) and a major health burden in the obstetric population, is highly prevalent (8.8%) in Ghana [31]. Ensuring midwives receive leadership and emergency care training could help address this gap.