Study of Emergency Services implemented at Sankhali Primary Health Centre

Goa Institute of Management

Table of Contents
Executive Summary................................................................................................................................. 2 Models of Emergency Medical Services in India..................................................................................... 2 Details about the system ........................................................................................................................ 5 Decision making process when they have opted for this system ........................................................... 6 Strategic advantages ............................................................................................................................... 6 Revenue Model ....................................................................................................................................... 7 Future Scope ........................................................................................................................................... 8 Data Flow Diagram ................................................................................................................................ 10 References ............................................................................................................................................ 11

Executive Summary
The goal of emergency medical services is to either provide treatment to those in need of urgent medical care, with the goal of satisfactorily treating the malady, or arranging for timely removal of the patient to the next point of definitive care. This is most likely a Casualty at a hospital or another place where physicians are available. The term Emergency Medical Service (EMS) evolved to reflect a change from a simple transportation system (ambulance service) to a system in which actual medical care occurred in addition to transportation. In some developing regions, the term is not used, or may be used inaccurately, since the service in question does not provide treatment to the patients, but only the provision of transport to the point of care. In India, EMS is a relatively new concept, where the most dominant model is the EMRI services. As of December 2009, more than 2,600 ambulances are operating under EMRI across around 10 states in India. Some other states like Bihar, Kerala, Himachal Pradesh and Delhi, have adopted EMRI-like model, but have some other agencies operating the EMS in those states. States like Madhya Pradesh and West Bengal had opted for basic transportation services (without stabilization care) in the PPP mode through multiple agencies (mostly NGOs) contracted at district/block level. Various studies, including a review of EMRI by the health ministry found the following gaps in the existing EMS in India: Hospital infrastructure, especially in public hospitals, for treating and managing medical emergencies need further strengthening. Lack of training and training infrastructure for training health staff (public or private) and other stakeholders in medical emergency management/first aid.

Fleet of existing government owned ambulances not liked with the new ERTS schemes (in terms of operational linkages and standardization across fleet). Legal framework defining and regulating roles and liabilities of various stakeholders (like ambulance operators, emergency technicians, treating hospitals and staff, etc.) needs further clarity/transparency, standardization and enforcement across the states.

Models of Emergency Medical Services in India

In India, EMS is a relatively new concept, where the most dominant model is the EMRI services. As of December 2009, more than 2,600 ambulances are operating under EMRI across around 10 states in India. Some other states like Bihar, Kerala, Himachal Pradesh and Delhi, have adopted EMRI-like model, but have some other agencies operating the EMS in those states. States like Madhya Pradesh and West Bengal had opted for basic transportation services (without stabilization care) in the PPP mode through multiple agencies (mostly NGOs) contracted at district/block level.

Some of existing models of EMS being implemented in various states is explained below. 1. EMRI 108 Model (Comprehensive EMS model) The most widespread Emergency Response Model in India is the 108 Emergency service managed by EMRI (Emergency Management and Research Institute) across ten states. EMRI began operations in Andhra Pradesh on April 2, 2005 with a fleet of 30 ambulances across 50 towns of the state. It is responsible for handling medical, police and fire emergencies through the 108 Emergency Service. Presently EMRI has its operations in 10 states with 2,601 ambulances in Andhra Pradesh (752 ambulances), Gujarat (403 ambulances), Karnataka (408 ambulances), Tamil Nadu (385 ambulances), Goa (18 ambulances), Madhya Pradesh (55 ambulances), Rajasthan (164 ambulances), Assam (280 ambulances), Meghalaya (28 ambulances), and Uttarkhand (108 ambulances). The 108 Ambulance Service is a Public Private Partnership model between state governments and Emergency Management and Research Institute (EMRI) and the service provides complete pre-hospital emergency care from event occurrence to evacuation to an appropriate hospital. The concept of 108 Ambulance aims at reaching the patients/sites within 20 minutes in urban areas and 40 minutes in rural areas and that the aim is to shit the patient to the nearest hospital within 20 minutes after reaching him/her. The emergency transportation is conducted in a state-of-the-art ambulance, which is provided free. The transportation is coordinated by a state-of-art emergency call response centre, which is operational 24-hours a day, 7-days a week. In addition, the call to the number 108 is a toll free service accessible from landline or mobile. The ambulances have been designed with a uniquely Indian perspective and it includes space for the patient, paramedic in the back and also bench seat for family members. EMRI ambulance fleet includes Basic Life Support ambulances (BLS), Advanced Life Support ambulances (ALS). The ALS ambulances are available with cardiac monitor and defibrillator in addition to the basic provisions of a BLS ambulance. The Emergency Response System (ERS) implemented by EMRI also includes trained human resources form the call centre staff to support staff in ambulances. Each ambulance has three pilots (drivers) and three EMTs who work in pairs of two for every 12 hour shift with a break every fourth day. For every 15 ambulances there is one operation executive and one fleet executive. Above them there is one district manager and one administrative officer, for every district. One of the key functions that EMRI performs is to recruit private hospitals who would participate in the ERS and this would imply cashless service for the first 24-hours till the patient is stabilized. For this purpose EMRI has signed MOUs with large number of hospitals to formalise an understanding that the hospital would not refuse admission if a patient is brought to it. The financing of EMRI in the initial years including capital or operational from the central government expenditure routed through the NRHM flexible pool. The government provided 100 per cent capital expenditure for procurement of ambulances and infrastructure and also provided 95% of operating expenses. The rest five per cent contribution comes from the private partner EMRI as their share in the PPP initiative. But form the year of 2009-10 onwards, in the first year the state would have to bear 40 per cent of operational cost, 60 per cent in the second year, 80 per cent in the third year, and 100 per cent thereafter. The operating costs are currently approximately Rs. 15 to Rs. 17 lakhs per ambulance per year (including an annualised replacement cost of approx. Rs. three to five lakhs per year).

2. Janani Express Scheme (non-EMS, merely transportation model) The Janani Express scheme launched by the Department of Health and Family Welfare, Government of Madhya Pradesh (MP), on August 15, 2006 as a strong and innovative measure aimed at addressing the delay factor affecting MMR and the IMR, as envisioned by the National Rural Health Mission. The understanding behind it was that MP is not only the largest state in terms of area but also dominated by tribal areas with poor connectivity and inaccessibility to the cities/towns. The Janani Express scheme is a Public Private partnership model, where the contract is signed between the Government (at the district/block level) and the private vehicle provider who is generally a local transporter. The Janani Express is basically a vehicle (four wheeler jeep/Tata Sumo/Mahindra) hired locally for a period of one year, to ensure provisioning of 24-hours transport availability at the field level (Block level) in order to bring the pregnant women to the health institutions. Transport is made available in the area served by a government hospital, CHC, and PHC. The RogiKalyanSamitis (RKS) of the concerned health facility plays a vital role in all issues related to the contracted vehicle and all reimbursements and the monitoring and control of the scheme is with the respective RKS. There is also the provision of performance based incentives to the transport agency. 3. Bihar Model: 102 and 1911 (mix of EM and basic transportation model) In Bihar, the ambulances and respective hospitals are connected through a toll free number 102. In addition to this, doctors are also empanelled, who would provide services on conference call and also would visit the patients who needed immediate doctors assistance (using another toll free number 1911). The calls can be transferred from 102 to 1911. Details of the empanelled ambulances and hospitals are provided to the control room operated by IT managers who would contact the ambulance at the time of emergency. The State Health Society of Bihar (SHSB) under NRHM is the nodal agency for 102 control room. The SHS, along with District Health Society (DHS) has district wise empanelled list of ambulances (who are functional at that point of time) with their driver contact details and also enrolled ambulances from interested not-for-profit NGOs. The onus of maintenance and management of ambulances is with the respective owners. The ambulance operators charged user fees for the services provided, which ranged from Rs 75 to Rs 200 (Rupees per 10 kilometers, in respective areas/districts), with exemption to BPL Population (applicable for both private as well as government ambulances). The amount collected through government ambulances is pooled into the RKS fund of the respective hospital where these ambulances are located. In case of private ambulance, the amount collected is retained and utilized by the private operator. The role of private sector is twofold control room management and ambulance provision. The nodal agency monitors the management of the control room and also performs the regulatory role. 4. West Bengal Ambulance PPP Model (non-EMS, merely transportation model) Another model of emergency transport is contracting out of the management and operation of Ambulance services to various NGOs/CBOs/Trusts under PPP arrangement in West Bengal. In this PPP model the state government procured and equipped ambulances and handed them over to selected NGOs, keeping the ownership with itself. This was facilitated by entering into agreements with various NGOs/CBOs/Trusts by the respective District Health & Family Welfare Samiti (DHFWS) for a five-year period. These NGOs then operate the ambulance in the designated area on a user-fee basis. The DHFWS fixes the user charges and

these can be retained by the NGOs for meeting the recurring expenditure. The monitoring of the program is done by Block Health and Family Welfare Samitis (BHFWS). 5. Referral Transport System in Haryana (trauma/highway ambulance) To reduce the maternal & neonatal deaths the Government of Haryana has launched a unique scheme to provide referral transport service branded as Haryana SwasthyaVahanSewa No.102 on 14th November 2009. All the 21 districts of Haryana are covered under the scheme. The scheme offers (a) Transportation from the site of accident or home or any other place to nearest appropriate Medical Facility in case of medical need, and (b) Transportation from a Medical Facility to a higher medical facility. Free transportation Services are provided to pregnant women, victims of road side accident, patientsbelonging to BPL or notified slums, post natal cases in case of emergency (till 6 weeks after delivery), neonates in case of emergency (till 14 days after birth), freedom fighters and ex-defence personnel. For all other categories of patients, user-fees are chargedwhich amounts to Rs 7/per kilometer. The scheme is run by the government in collaboration with District Red Cross Societies and tollfree telephone number 102 installed at each district control room for easy access to the public. There exists a 24x7 Control Room in each district hospital, for receiving the calls and monitoring of ambulances through GIS/GPS. There is common pooling of ambulances belonging to the Health Department as well as those owned or operated by the District Red Cross Societies. The operating cost for ambulances run by District Red Cross Society is reimbursed to them by the government.

Details about the system

Salient Features of Dial 108Business Model: 1. One call centre located at state capital- with a single number 108. Call centre takes decision on sending vehicle. 2. Call service common to Police, Fire and Health Emergencies- 911 model-depending on the nature of emergency call is routed to the respective department. 3. One ambulance per one lakh population- with three drivers and three paramedics per vehicle and two supervisors for every 15 vehicles and two district managers. 4. A special cadre of paramedics with six weeks training on the van. The training has an institutional, hospital and ambulance component, certified by external faculty 5. Paramedics on van backed by telephonic advice from the doctor at the centre 6. Service is cashless- free to all. 7. Inter-facility transfer not advised 8. Patient given limited choice of facility to go to. But the facility has to be within the zone

Decision making process when they have opted for this system
Vision of GVK EMRI: To be the world's premier infrastructure and utilities organization that constantly strives to provide the highest standard of products and services and a sustainable quality of life for all stakeholders. Mission of GVK EMRI:

We will develop state of the art infrastructure through innovation, quality and high productivity which enriches the lives of people We will invest in our people so as to create future business leaders who espouse our core values and beliefs We will be a socially responsible and environmentally conscious corporate citizen while creating a foundation of sustainable growth for business, stakeholders and the community

Strategic advantages
Strengths of the 108 emergency system can be enlisted as follows: Dominant model of publicly financed emergency response systems in the nationwith- now close to 18 states committed to it. It is the only publicly financed model of care which provides for emergency care en route. Almost 78 per cent of the patients had received some sort of stabilization care in the ambulance. It has clear life-saving impact on road traffic accidents and injuries. It is emerged as the major form of assured referral transport services for care at child birth- both for normal delivery and for obstetric emergencies. The model is an adequately staffed, adequately financed, adequately advertised programme-with adequate investment in management personnel, structures and systems- which is in contrast to almost every other government health programme. It is ironic to reflect on, but no doubt the leadership style of ShriRamalingaRaju, had much to do with both conceiving it thus and also getting it financed by the government. There are excellent standards of corporate management- There are no conflict of interests on which facility the patient is taken to, there are no informal charges being

made from users, and there is good monitoring which identifies gaps and acts to rectify it. It is also the most successful public private partnership going. Essentially it is a management contract- as there is no investment that the private partner brings in, nor do they have any share in the risk. Thus it becomes a corporate social responsibility action. It is not designed as a commercially successful version which can recover costs, let alone give dividends. But for a management firm with specialization in this area, it is an attractive contract to win. The call number has become well known and is a common channel to police, fire and ambulance services - even if health department is paying for all. Cost per trip has been coming down and is currently projected by EMRI at Rs 427 /per trip of Rs one lakh per vehicle per month, which makes it affordable. Since the system aims for one ambulance per lakh population the costs could also be expressed as Rs 1/ per capita per month that the government spends towards assuring a timely and appropriate emergency response ambulance service which also does substantial elective patient transport. This is really affordable. This improved efficiency over time (from close to Rs 750 per trip in 2009), is by sustained quality of management, and the introduction of a limited level of competition. The threat of a monopoly in single private hands is much less, though not altogether gone- since we have only two proven players. However we should aim for a policy framework such that there are at least five or six reliable suppliers of these services across the nation.

Revenue Model
GVK EMRI is a Pioneer of Emergency Management in India, wherein 108 evolved with initial model of a Corporate Social Responsibility. The model was later adopted by state governments and migrated to a framework of Public-Private- Partnership (PPP) mode with individual State Governments sculpturing a way forward to become a National Entity. GVK EMRI manages and leverages local government resources for better outcomes to serve the poor, utilizing technology and advanced equipped ambulances to provide assistance in emergency. Providing cost effective solution with a total financial burden of Rupee 1 per citizen per month, the 108 project funding is minuscule in comparison to the overall health budget and State Government expenditure on health. Ziqitza is a company that started with an initial idea of running an emergency ambulance service from charity donations. But they realized soon enough that a service like this could not be run sustainably on charitythe concern being, what if the funds dry up? Around the same time, Sam Pitroda, well-known Indian innovator and policymaker, was also mentoring the team. Mangal recollects Pitroda telling them that when one is running a service as essential as an ambulance service, it has to be on a sustainable basis. The pricing model was one of their most important innovations. They also realized that the poor would mostly take the ambulance to government hospitals, while those who could afford it would go to private hospitals. Also, traditionally, the poor and the rich rarely ever got access to the same

servicesthe rich would call for ambulances from private hospitals while the poor would get the service from an NGO. With this in mind, Ziqitza began to provide the same service to both sections of the society, but the way they did it was by subsidizing the cost by 50 percent for those who took the ambulance to a government hospital. The price put on the service wasRs. 1,500 for the first 10 kilometers for a private hospital, and Rs. 750 for a government hospitalfor the basic life support ambulances. The company also has advanced life support ambulances, which have ventilators, resuscitation kits etc. equipped to provide more complex medical support. For these, Ziqitza charges Rs. 2,000 for the first 10 kilometers for a private hospital, and Rs. 1,000 for a government hospital. The companys services are now available in six states through two models, the first of which is a public-private partnership (PPP) with the government. The other model sees the company operate on its own. The PPP model works through the helpline number 108, while Ziqitzas own helpline number is 1298. The founders claim that the 108 services are provided for free by them; and paid for by the government. On the other hand, their customers pay for the 1298 services. Since the initial motive was to reach out to as many poor people as possible, tying up with the government was their best bet. The company has 800 ambulances in various parts of the country via the PPP model and 60 in the 1298 direct service model. Most of the ambulances in the 108 model are basic life support ambulances. Resultantly, the company earns a larger section of its income through the PPP model. Another revenue source is through advertising and corporate sponsorships on the body of the ambulances from socially responsible companies. Hospitals also outsource their ambulance services to Ziqitza, which opens up another revenue channel. Chains like Max Hospitals and Fortis Hospitals have outsourced their ambulance services to the company. They bid for the tender in whichever state that invites private companies to provide the 108 service. For most of the social ventures, working with the government has been the greatest challenge and is also potentially a big opportunity.

Future Scope
Aadharas a Service Delivery Mechanism - 108 ambulance service in India has been modelled after the 911 service in The United States. Just as SSN numbers are used there for delivery of welfare programmes, Aadhar UIDs, once implemented, can be used to deliver108 services to individuals. As a free service offered by the government, the future of 108 is questionable and might meet the same fate as that of our medical colleges which are congested. To ensure the sustenance of the project, Aadhar numbers can be used to deduct a pre-determined amount from each individual earning a certain amount of annual salary. This can be used to sustain the 108 services and improve the reach and efficiency of the system. Aadhaar can be leveraged effectively across industry domains for improving service delivery to theresidents irrespective of service being delivered by government, public sector or private sector.Aadhaar is an IT enabled identity solution which needs to be leveraged appropriately by serviceagencies.Majority of welfare programs use physical identity

documents and rely on manual processes forbeneficiary identification. These practices results in following issues: o Lack of identity documents prevents poor and marginalised residents from accessing the benefitsprogram. o Existence of duplicate and fake beneficiaries. o Residents may avail of benefits from multiple programs simultaneously when they may not beentitled to. For example a resident can only avail one of the pensions like old age pension, widowpension, and handicapped pension. Use of Aadhaar to link beneficiaries with their Aadhaar numbers in Beneficiary identification andapproval process can address these issues. Ambulance services exclusively for pregnant women- The aim of launching this service will be to ensure that pregnant women, who face lot of hardship and difficulties in going to hospitals for delivery a child, are transported immediately to the nearest government hospital. The ambulance would be equipped in a manner that in case the woman delivers a baby in ambulance, the same could be taken care of.In case such patients are not admitted, it would be the responsibility of the concerned doctor on duty and action should be taken against him and this would help in taking care of the complaints from the patients that they don't get admission at maternity centre or super specialty hospitals as hospital authorities cite non-availability of beds as the reason. The single biggest weakness is to see ambulance services in isolation from facility based emergency care. Emergency response system must be seen as a chain- immediate pre-hospital care, retrieval and transport, en route stabilisation care and emergency care at the facility. These should be part of an integrated district plan to develop a network of assured service delivery points for each type of emergency care: Obstetrics, trauma care, burns, poisoning, cardiovascular, other medical emergencies, surgical emergencies and ophthalmic emergencies. In large states there should be more than one call centre, perhaps two to five, instead of only one per state. The call centre should link both government ambulances and EMRI ambulances and if needed local patient transport vehicles. The call centre would know the situation of each ambulance by both GPS and a simple time out and time on call from the vehicle. It would also know the exact location of assured services for every type of emergency. It would be thus able to choose which vehicle to send to pick up what type of patient and take them where- in a much more organized way. Each district and each ambulance and the call centre should be aware of which facility provides care in what emergency situations and be able to shift the patient there- providing stabilisation on the way- which could be on ambulance or at an en route facility. Deputing and incentivising a trained ANM or staff nurse in the van, at least for pregnancy despatches and at least where travel times are high or labour is advanced, could take care of high numbers of on-the-way deliveries and deliveries taking place at the pickup point. This is most needed for tribal areas and dispersed populations where turnaround time is very high. Even incentivising the ASHA to accompany the van rather than leaving the driver and male paramedic alone at the point of emergency would be a step forward. Given the high absolute numbers of deliveries happening on the way or at the point of pick up, birth asphyxia management and immediate post

natal care must be part of paramedic training must be made available in all the ambulances. There is considerable room for point of care innovations and with telemedicine, for better on the way stabilisation, and for better human resource development. More investment in creative management and research support is also needed. Note that the current process of limited competition has helped the process of innovation to bring down costs and improve on features and this must be retained. We suggest a national workshop where the major national ERS service providers are invited, some good international agencies, and key decision makers from the states on this theme. The workshop should help the MOHFW finalise its strategy for taking this initiative forward under the 12th Plan. The system should then be decentralized to state and intra-state regional level models, and rolled out at a pace that recognizes the differing capacity to implement in different states and regions- but at the same time, all the models should conform to a consensus on design principles and standards of emergency care and patient transport that are arrived at jointly between centre and the states.

Data Flow Diagram

References
1. Case Study on Emergency Response Service of Bihar: Ambulance Services by National Health Systems Resource Centre (NHSRC), Ministry of Health & Family Welfare, Government of India; 2009 2. Case Study on Janani Express Model in Madhya Pradesh by National Health Systems Resource Centre (NHSRC), Ministry of Health & Family Welfare, Government of India; 2009 3. Haryana SwasthyaVahanSewa No. 102: A scheme to provide referral transport byFinancial Management Group (FMG), NRHM, Ministry of Health & Family Welfare, Government of India; 2010 4. Study of Emergency Response Service EMRI Model by National Health Systems Resource Centre (NHSRC), Ministry of Health & Family Welfare, Government of India; 2009 5. Emergency Management in States at http://www.emri.in/content/view/32/54/ 6. Emergency Medical Services at http://en.wikipedia.org/wiki/Emergency_medical_services