Based on the presentation given by Dr Dagmar Mühlbauer, Medical Operations Manager – Starlite Aviation Group
South Africa’s Helicopter Emergency Medical Services sector occupies a complex position within the country’s emergency-care landscape. While the value of rotary-wing medical response is well established internationally, the local system reflects a series of structural, operational and clinical gaps that limit its ability to deliver the benefits seen in higher-resourced, better-integrated HEMS networks.
Insights shared at the recent HEMS Symposium highlighted both the achievements and the shortcomings of the current model.
HEMS globally is expected to provide three core advantages: speed, access and enhanced clinical capability. In mature systems, these elements significantly reduce pre-hospital time and improve survival, particularly in critical medical emergencies. In contrast, the South African system struggles to consistently realise these advantages, largely due to the way HEMS is dispatched, staffed and deployed.
A central issue is the reliance on a non-simultaneous dispatch model. Under this approach, a ground ambulance must first arrive at the scene, identify the need for advanced care and then request helicopter activation. Additional layers of administrative authorisation often further delay the mission. This multi-step process erodes the time benefit that should distinguish HEMS from ground operations. Several retrospective studies conducted locally reinforce this concern, consistently demonstrating longer on-scene times for HEMS compared with ground services, along with mean mission durations exceeding two hours.
Crew configuration represents another area where South Africa diverges from international best practice. In most operations, aircraft are staffed by combinations of Emergency Care Practitioners and paramedics. While these clinicians are highly skilled, the configuration does not consistently elevate the level of care beyond what is already available on the ground. In effect, the aircraft often replicates the capabilities of a response vehicle rather than functioning as a mobile extension of the emergency department. Junior clinicians are at times dispatched to scenes where senior practitioners are already present, reducing the clinical value gained from the intervention.
The distribution of flights also raises questions about whether the current system is appropriately aligned with clinical priorities. Local research indicates that the vast majority of HEMS missions involve trauma, particularly motor vehicle collisions and pedestrian injuries. Time-sensitive medical conditions such as cardiac emergencies and stroke represent only a small fraction of cases, despite being scenarios where air transport may offer the greatest benefit. Comparative modelling exercises suggest that ground transport is frequently faster than air for short-distance urban missions, with a meaningful time advantage emerging only beyond approximately 119 kilometres.
HEMS coverage across the country is uneven, with considerable geographic gaps and several daylight-only operations. Large segments of rural and peri-urban populations have limited or no access to helicopter-based emergency care. Although many operators state that they support Department of Health missions, data indicates that very few public-sector patients are transported. This raises broader ethical concerns around equity of access in a country where disparities in emergency care outcomes are deeply entrenched.
The cost of HEMS remains a significant consideration. Operating a helicopter, particularly in a resource-constrained national health system, demands clear clinical justification. International evidence shows remarkable reductions in mortality when HEMS is deployed within well-designed, well-staffed, rapidly dispatched systems. South Africa’s model, however, has not yet demonstrated similar outcomes. Most available local studies are retrospective and limited to single-centre operations, reinforcing the need for national, prospective research to determine the true impact of HEMS under local conditions.
Historical comparisons also suggest that earlier South African HEMS configurations may have been more closely aligned with international norms, including doctor-led crews and more responsive dispatch mechanisms. Despite modern equipment and aircraft upgrades, the system has in some respects regressed, with operational and clinical structures no longer optimised to deliver the full potential of air-based emergency care.
Improving South Africa’s HEMS environment will require a combination of structural reform and comprehensive evidence generation. Priority considerations include revisiting base locations to address geographic inequities, restructuring crew models to ensure a higher level of clinical capability, refining call-out criteria to focus on time-sensitive conditions and reassessing dispatch processes to reduce delays. Ensuring consistent access for all citizens, regardless of socioeconomic status, remains a key challenge.
The debate now centres on whether South Africa is prepared to make the difficult decisions needed to reconfigure HEMS into a system that delivers demonstrable, equitable clinical value. This includes acknowledging the possibility that, under its current model, HEMS may not offer the benefits widely assumed. The future of South Africa’s helicopter emergency response will depend on the sector’s willingness to confront these realities, backed by rigorous research and a commitment to aligning resources with patient outcomes.
