Background Emergency referral care is considered an essential component of the district health system. Nevertheless, the establishment of effective and durable transport arrangements of such referral care by use of an ambulance is considered controversial in low‐income countries. Objective We aim to assess the extent to which an ambulance service as part of the district health system is feasible in rural Cambodia. Methods In a rural health district, we assessed the population's perception of the ambulance service, its recurrent costs requirements, government financial contribution to its operations, profile and medical conditions of ambulance (non)users, reasons for (non)use of the ambulance and contextual factors required for the ambulance services to operate. This observation was obtained through nine key informant interviews, five focus group discussions, structured interviews with 225 caretakers of admitted patients, a 1‐month census of admitted emergency cases and assessment of annual recurrent costs for the ambulance services. Results The ambulance services were well received by the population and authorities and appeared to reinforce an appreciation of the hospital. Ambulance services were mainly used by the poor and by women, especially for emergency obstetric care. Less than half the number of transported patients, 44%, was considered a medical emergency. The direct cost to the hospital per collected emergency case was $34.4. Conclusion When certain conditions are met, effective ambulance services can be an integral part of the district health system and positively contribute to the population's appreciation of the hospital services and respective district health system. Copyright © 2015 John Wiley & Sons, Ltd.