“ANGEL OF MERCY” - 108-EMERGENCY RESPONSE SERVICES

A STUDY OF EMRI MODEL EMERGENCY RESPONSE SERVICE

The team of expert advisors from National Health Systems Resource Centre (NHSRC), commissioned by Government of India after a detailed study of EMRI-108 model, observed that, “EMRI is undoubtedly a historic landmark in the provision of health care in the nation. To its credit goes the achievement of bringing Emergency Medical Response on to the agenda of the nation. Though not part of the original NRHM design, its tremendous popular appeal along with the flexibility of the NRHM design made it possible for it to emerge as one of the leading innovations of the NRHM period.” NHSRC which is strongly in favor of replicating the model in the entire country seeks to build on the EMRI model of Emergency Response Services (ERS), not replace it, and much less abandon it. According to the experts, “ERS has to be perceived as an entitlement and service guarantee. There can be no going back on this. The National Health Bill if passed would also make this mandatory. The focus is really not on whether we need an ERS, but what form of operationalization of ERS would be most efficient and most effective.”

Emergency Management and Research Institute (EMRI), established in April 2005 as a non-profit organization for providing comprehensive ERS (Emergency Response Services-Medical, Police and Fire) in Andhra Pradesh to begin with, expanded to eight more states during the last three and half years, providing the service free of cost, to over 350 million population through 1800 ambulances in Public Private Participation (PPP) - the first of its kind PPP model. Round the clock ERS are provided by EMRI through 108 toll-free number. EMRI’s slogan has been to ensure “Right to safety” of each and every citizen.

EMRI ‘integrates’ many resources and provides sustainable round the clock safety to citizens in a timely and effective manner through SENSE (Communication and Dispatch – collects the facts about the emergency and assign the strategically located vehicle), REACH (Transport of vehicle to reach the site) and CARE (Providing the Pre-hospital care while transporting the patient/victim to the nearest Hospital of patient’s choice for stabilization). It is professionally managed, has proven technology and software and offers an integrated total turnkey solution. The Ambulance (Advance Life Support) is equipped with a defibrillator, an echocardiogram, ventilators, oxygen supply, intravenous flu¬ids, blood substitutes, snake ven¬oms, five stretchers and extrica¬tion tools to pull out victims from accident sites as well as to attend to any life threatening situation to any one.

With the emerging significance of the EMRI model as a preferred option for providing ERS across most of the states in India, Government of India, in November 2008, commissioned a review of EMRI scheme in selected states of Andhra Pradesh, Gujarat and Rajasthan, through the NHSRC. This appraisal would help in suggesting replication and improvement of the EMRI managed ERS. The team submitted its report recently to the Government of India.

Tracing the origin of Emergency Response Services in the world, the Study team observed that, in the Indian context, the much discussed and successful PPP- Public Private Participation-model for ERS is the 108 Emergency Service being managed and operationalised by EMRI-Emergency Management and Research Institute, a non-profit organization established in April 2005 in many states in India. Presently eleven states have already signed MOU with EMRI for running the ERS and 9 out of these (Andhra Pradesh, Gujarat, Uttarakhand, Rajasthan, Goa, Tamil Nadu, Karnataka, Meghalaya and Assam) are in operationalization. There are other states who are considering the same.

The study team has been asked to address issues like requirement of number of ambulances to provide quality emergency response, the estimated case load of each ambulance, major cost implications and to assess the unit cost of this service – “per ambulance trip” and “per ambulance per year” as well as to estimate these unit costs for different volumes of utilization and distances and years of functioning.

The team opined that, if EMRI were adopted by all the states in India with an ambulance density of one ambulance per Lakh population as recommended by EMRI, it would need around 10,000 ambulances to cover the entire country at an estimated cost of Rs. 1700 Crores annually. This is on the assumption that, at the current rates, both the operational as well as the annualized capital costs would be approximately Rs. 17 Lakhs per ambulance per year. Since this amount represents around 10% of current NRHM allocations, the government would need to satisfy itself that the deliverables are being achieved in the most cost-effective way possible and the service provider is also accountable for its performance. In addition, the NHSRC team feels that the investment and expenditure in transporting the patients to the hospitals (free, without charging any fees for transportation) should be proportionate to the cost of providing the clinical management in the health facility (cost of treatment and the proportion of this, which is free).

According to the NHSRC study team the estimated cost of Rs. 1700 Crores annually for replicating the model all over the country, which accounts for only 3% of the projected cost of Rs. 55,000 Crores per year by 2012, by National Rural Health Mission (NRHM) cannot be considered too high a cost for guaranteeing comprehensive Emergency Responsive Services (ERS) to all the people of this country. “The average cost of Rs 450 per ambulance trip, provided free to every emergency medical, police or fire needing help anywhere in the country, and that too within 20 to 40 minutes, is almost a dream, and it is a dream that is tantalizingly within our reach, not within a lifetime but within a plan period!!” observed the team.

However, taking in to consideration the Satyam Crisis affecting the EMRI’s executive board structure, seriously affecting their corporate governance, credit worthiness and liquidity in particular, evaluation team felt that “today there is a situation that without central intervention into the governance of the EMRI, the whole system could collapse. Yet such intervention if poorly planned could create more problems than it would solve.” NHSRC to overcome these issues, recommended to the Government of India, for creating a company called the EMRI- ERS Company and the Board. Patterns of representation to the central and state governments are suggested in detail to enable more say to the PPP partners.

The study team made many interesting observations on the functioning of the model: “The tremendous gratitude and praise of the family members of the emergency victim for the timely arrival of this Angel of Mercy when heard in first person is most convincing and moving and makes the service very popular. The project enjoys wide spread political support. The pattern of utilization- though typically low in the initial period but increased later- is mostly that of medical emergencies. Among them pregnancy related, trauma related and acute abdomen related emergencies account more. The promptness with which the ambulance arrives and the pre-hospital care provided en-route speaks of its quality service. The investment in training a cadre of paramedical staff, move to institutionalize such training to create a new human resource dedicated to emergency care and equipping the ambulance with necessary requirements is laudable. The key function that is being performed by EMRI by way of recruiting private hospitals to participate in the ERS implying cashless service for the first 24 hours till the patient is stabilized is laudable. There is however no record or track of quality of care on arrival and on refusals to care. If the services are not available and if the patient has to be shifted to elsewhere, which is not EMRI responsibility, there is no answer”.

“The emergency transportation provided in a state-of-the-art ambulance is, free, 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. EMRI has tie ups with 3331 private hospitals in Andhra Pradesh, apart from the government hospitals that can handle emergencies. These hospitals provide free stabilization services for the first 24 hours to the patient. The ambulances have been designed with a uniquely Indian perspective.”

Observing that the utilization curve is ever-rising due to several reasons like increase in the range of emergencies, increased awareness the team cautions that emergency response sought could go up dramatically. Then raises issues like: “what would be the implication if every pregnancy requiring institutional delivery seeks the ERS, even where there is no emergency and private means of transport are available? What if, a much larger proportion of asthma and epilepsy sought an emergency response?” Utilization patterns would also go up due to the problems of over-consumption or inappropriate consumption (moral hazard). We need to answer these questions now; as we are expanding the ERS in the country observe the study team.

On the issue of number of ambulances required the team speaks of two factors that influence promptness of response – the first is geography and the second is rate of utilization. Thus on a road which allows an average of 60km per hour (national highway in the Indian context) that would mean an ambulance has to be stationed within 40 km of every habitation. If the roads are such that it allows only an average of 30km per hour (all village roads, hilly terrain and non-metallic roads) than we need an ambulance within every 20 km of every habitation.

On the issue of inter-hospital transfers also the study team made critical observations and gave suggestions. “Government owned and operated ambulances were playing this role and therefore a parallel fleet of ambulances becomes necessary even where there is EMRI. The concern of the government has been that EMRI or whatever ERS is put in place must take care of inter-hospital transfers too- thus saving the government from duplicating its expenses. EMRI on the other hand is concerned that if it agrees to this, a considerable part of its resources would be shifted to this task - which they estimate at 18% increase over current requirements. This would displace the priority of ERS. Shifting a case from a block to a district hospital would mean a longer travel time and therefore for a longer time the ambulance would be busy and unavailable. An even greater concern is that many hospitals would, for a variety of reasons, decide to pass many patients brought to it.”

With regards to the care at the hospital described as “one of the weakest links of the chain”, the team feels that “there is a need to have matching investment in strengthening the quality of emergency medical services (as different from emergency response services) at the hospital. Public investment in this crucial aspect is however not as visible as is the investment made in 108 services, and there is a need to ensure a verifiable strengthening of the emergency care aspect too.”

Rich complements were paid to EMRI for its high order management processes and competences. “Impressive staff strength and this ideal pyramid of supervisory staff to manage the staff would be the envy of every program manager in the health system. It is to the credit of the EMRI that it could put in place such a structure. It is unlikely that any other program, especially if done within the government would have been allowed this. And yet this adequacy in the supervisory structure is essential to this schemes success. When costs are lowered through a tendering process, or there is a rationalization of costs that is attempted, it is precisely this part that may get axed, and that would not be good for the outcomes.”

The study team felt that organization of these services and its massive expansion across the states, achieved in a very short time is a major achievement. The team was truly impressive of the whole system of monitoring including a voice recording of every single one of the tens of thousands of calls received daily and the documentation trail of every single step which allows a 100% recall and analysis of every process for quality, efficiency and effectiveness - both at the level of program management and for redress of every single grievance. “There is justifiable pride in the professionalism and excellence in the design and operational management of the program. It would be difficult to reinvent all this, though not impossible to do so” concluded the team.