The Value of Time and Location Commitment for Decentralized Emergency Medical Services

Problem definition: Emergency medical services (EMS) in many low- and middle-income countries utilize decentralized platforms coordinating independent ambulance providers. However, significant operational challenges arise from uncertainty in provider time availability and unpredictable idle locations. These uncertainties hinder reliable service coverage and negatively impact patient outcomes. Using data from our East-African partner Rescue.co regarding the operations of their emergency platform, Flare, in Nairobi, Kenya, we investigate the relative effectiveness of enhancing provider temporal commitment (time availability) versus spatial commitment (strategic location) to improve system coverage. Methodology/results: We employ optimization models tailored to ambulance commitment uncertainty, a detailed case study, data-driven simulations, and a game-theoretic model. Our findings quantify a stark “cost of decentralization”: The coverage provided by Flare’s 340 loosely committed ambulances could potentially be matched by fewer than 15 optimally deployed fully committed units. We find that enhancing spatial commitment typically yields substantially larger coverage gains than increasing time availability alone and that both dimensions are strongly complementary. Simulations validate these effects under stochastic demand, simultaneous calls, and strategic relocation. A stylized free-entry model, in which time- and spatially committed providers enter until profits vanish, shows that spatial commitment dominates except at very low temporal availability and that adding spatially committed units typically yields higher marginal value by filling geographic gaps. Together, all three approaches highlight the significant value of spatial coordination. Managerial implications: For managers of decentralized EMS platforms, the main priority should be to enhance spatial coordination. This can be achieved by deploying a small number of platform-controlled, location-flexible units or by incentivizing providers to relocate strategically, both of which are especially effective at closing the system’s most critical coverage gaps. Because these benefits persist even when accounting for stochastic demand, simultaneous calls, and potential strategic behavior by independent providers, managers need not account for every contingency when evaluating interventions; focusing on closing persistent geographic gaps yields robust performance gains in resource-constrained settings. Funding: This research was financed in part by the Netherlands Organization for Scientific Research (NWO) in [project number VI.Veni.191E.005 and VI.Vidi.241E.016] for P.L. van den Berg, and by the Natural Sciences and Engineering Research Council of Canada (NSERC) [Grant RGPIN-2025-05848] for G. Romero. Supplemental Material: The online appendix is available at doi.org .