PPP Model for Emergency Response Services
A Successful Indian Case Study
Vanam Jwala Narasimha Rao
Former Advisor, EMRI - 108
(Drafted by Jwala N Rao in consultation with Mr. Venkat Changavalli, CEO EMRI, in July 2009, few days before leaving EMRI as its Advisor, Public Private Partnership)
ACKNOWLEDGEMENTS
The “EMRI-CASE STUDY, UNIQUE-SUCCESSFUL INDIAN PPP MODEL-INITIATED IN ANDHRA PRADESH” has been prepared by GVK EMRI at the request of Dr. S.K. Rao, Director General, Administrative Staff College of India, Hyderabad (AP-India). The team that prepared this case Study expresses sincere thanks to him and to Dr Paramita Dasgupta, Dean of Training & Conferences (ASCI) for giving EMRI an opportunity to present its initiative of provision of Emergency Response Services in Public Private Participation, the first of its kind in India.
The Administrative Staff College of India under the India, Brazil and South Africa (IBSA) Cooperation in the field of Public Administration as part of the Seminar titled “Capacity Building for Effective Service Delivery” from August 24-29, 2009 is discussing this Case Study under the special module on “Improving Delivery of Health Services to Vulnerable segments”. The seminar is sponsored by the Department of Administrative Reforms and Public Grievances, Government of India.
The team that prepared this case Study expresses sincere thanks to its colleagues in EMRI in the areas of Research, Emergency Medicine Learning & Care, Alliances & Partnerships, Technology, PPP and Fleet for their ready cooperation in facilitating the gathering of information and for readily discussing their perceptions and concerns with the team.
The case Study Preparation Team gratefully acknowledges the contribution of one and all in this effort.
The case study among others includes detailed description of EMRI, the achievements aimed at “Improving Delivery of Emergency Health Services to Vulnerable Segments”. I am sure the content will help in discussing methods to meet the targets of the Millennium Development Goals.
CASE STUDY-EXECUTIVE SUMMARY
Title of the Case Study:
“EMRI PPP-CASE STUDY, UNIQUE-SUCCESSFUL INDIAN PPP MODEL-INITIATED IN ANDHRA PRADESH” for Provision of Emergency Response Services by “EMERGENCY MANAGEMENT AND RESEARCH INSTITUTE (EMRI) and GOVERNMENT OF ANDHRA PRADESH In Public Private Partnership (PPP) For Improving Delivery of Emergency Health Services to Vulnerable Segments.
Why was the Case Study prepared?
The Case Study was prepared by EMRI at the request of Dr. S.K. Rao, Director General, Administrative Staff College of India, Hyderabad (AP-India). The Administrative Staff College of India under the India, Brazil and South Africa (IBSA) Cooperation in the field of Public Administration as part of the Seminar titled “Capacity Building for Effective Service Delivery” from August 24-29, 2009 is discussing this Case Study under the special module on “Improving Delivery of Health Services to Vulnerable segments”. The seminar is sponsored by the Department of Administrative Reforms and Public Grievances, Government of India.
The Project - How, Who, When?
As there was an urgent need for Transforming Emergency Management in India EMRI was established as a nonprofit organization to provide ERS free of cost.
Funding:
The Institute was founded and funded initially by former Chairman of Satyam Computers and his brothers.
Consequent to the developments EMRI’s Governing Board invited Dr GVK Reddy of GVK group to be the Chairman of EMRI. The Board also approved the name of EMRI to be changed as “GVK Emergency Management and Research Institute”.
EMRI founder promoters – the Ramalinga Raju Family members funded the project totally during first two years of operations (2005-2006 & 2006-2007), up-to 50% during third year (2007-2008) and 5% during fourth year (2008-2009) in AP. In other eight states from the beginning respective state governments funded the project (100% CAPEX and 95% OPEX). This is in addition to the management, research and training costs which are being borne by EMRI.
Stakeholders:
Police, Fire, Medical Departments of government; private health Institutions; Indian Red cross Society’s state branches; Media; Emergency Victim; Victim’s Near & Dear; National & International Partners who are engaged in similar activity etc.,
SRC process to provide ERS:
EMRI ‘integrates’ many resources and provides sustainable round the clock safety to citizens in PPP frame work SENSE, REACH and CARE.
Principle of Partnerships:
Among many innovations that were brought in by EMRI, the key differentiator was the partnerships. Since inception EMRI firmly believed to partner with Government for competitive advantage towards fulfillment of the objectives. This kind of an initiative in Andhra Pradesh as well as replication in future in other states would not have happened without the Government support. Initially when EMRI on its own approached Andhra Pradesh Government for PPP framework it was more for recognition, credibility and sustainability rather than for seeking funding support.
Evolution of PPP framework:
In India, as in other countries evolved the concept of “Public Private Partnership” and steadily gaining strength against the unpleasant experience of the functioning of Public Sector Undertakings and Joint Ventures. It is assumed that Government’s collaboration with non-profit private sector in the form of PPP would improve equity, efficiency, accountability, quality and accessibility of the system. Advocates argue that the PPP can potentially gain from one another in the form of resources, technology, knowledge and skills, management practices, cost efficiency and so on.
Memorandum of Understanding (MoU):
Arrangements between the government and the NGO are governed by long-term and short term understanding in the form of “Memorandum of Understanding” or “PPP Agreement”. It specifies the obligations of both the parties to deliver within the broad framework of performance indicators and standards.
Significance of PPP in Emergency Management:
Public safety and security is a task that requires on-going cooperation and seamless integration amongst resources and stakeholders. Due to the varied nature of emergencies, vast coverage of EMS providers and the number of stakeholders’ involved, frequent bottlenecks could be witnessed in standardizing the operations and extending timely services. Besides, such services are highly capital-intensive and require continuous infusion of funds for operation and maintenance. This combined with nil returns make it less attractive for private investors for long-term and continual commitments. Partnerships and collaborations are imperative for ensuring safer, more resilient communities and measured responses to emergencies and relief actions. The Government has a formidable role to play in ensuring efficient EMS in terms of creating an enabling environment characterized by a harmonious policy, regulatory framework and funding and infrastructure support.
Rural Emergency Health Transport Services (REHTS-PPP model ERS):
In pursuance of the National Common Minimum Programme, Government of India launched the National Rural Health Mission (NRHM) in April 2005, for providing integrated, comprehensive primary health care services with special emphasis on poor and vulnerable sections of the society and REHTS was part of it. REHTS is aimed at transporting pregnant women, infants, children below 12 years of age and any other cases in need of emergency health care services to the nearest hospital.
In Andhra Pradesh the scheme was piloted in four districts- Kadapa, Kurnool, Mahaboobnagar, Nizamabad and the tribal areas of nine other districts in the year 2005. Initially 122 ambulances were deployed under the scheme and were operationalized through individual Non-Governmental Organizations as PPP concept in the districts, selected by a District Level Selection Committee headed by the District Collector.
In addition to REHTS, Government of Andhra Pradesh also recognized Emergency Management and Research Institute (EMRI)-a nonprofit organization established in April 2005, as the State Level Nodal Agency to provide comprehensive emergency response (Medical, Police and Fire) across the state, in PPP and signed Memorandum of Understanding (MoU) on 2nd April 2005.
Expansion to Ten more states:
On seeing the successful implementation of ERS in PPP in AP several state governments deputed their representatives to study the model while some preferred to straight away nominate EMRI as nodal agency to provide similar services in their states others preferred to follow tender process where as a mix of the two methods were followed by rest. Whatever was the process followed to choose EMRI as nodal agency, it was entirely the decision of the respective state governments. Thus the Emergency Response Services initially provided in AP later expanded to ten more states subsequently, providing the service free of cost, to over 350 million populations through nearly 4000 ambulances in Public Private Participation (PPP).
Over View of impact of 108 PPP model:
Reduces Maternal Mortality: A study of the 1,21,454 pregnancy cases handled by the EMRI for a year from July 2007, showed that there were 73 maternal deaths while the MMR in the State during 2007 was 197 per Lakh live births. In other words, effective pre-hospital care by 108 emergency services in more than a Lakh pregnancy cases has brought down to less than 50 per cent the maternal mortality rate, underscoring the importance of timely transport to a health facility in ensuring a safe motherhood.
Reduces Neonatal Mortality: Study had shown that there is a huge amount of demand for emergency services pertaining to neonatal complications particularly from the rural areas of Andhra Pradesh with specific reference to vulnerable segments. This is evident from the fact that 93% of the total reported cases were from rural areas and only 7% cases were reported from urban areas.
Study of Emergency Response Service –EMRI Model by NHSRC-Government of India:
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
In the Indian context, the much discussed and successful PPP model for ERS is the 108 Emergency Service being managed and operationalized by EMRI
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.
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.
NEED, CONCEPT AND EVOLUTION OF TRANSFORMING EMERGENCY MANAGEMENT:
EMERGENCY RESPONSE SERVICES (ERS) SCENARIO IN INDIA PRIOR TO 2005:
Emergency is an occurrence of any sudden event that threatens life, health, property, order or daily life, and demands immediate attention, often requiring coordinated response from multiple agencies such as Police, Fire and Medical. Emergencies could vary vastly in scope, magnitude and management at an individual level. Effective emergency response significantly reduces deaths, disabilities, suffering from length of hospital stay, losses from fire incidents; improves the chance of apprehending the criminals etc.
Prior to 2005:
Inadequate Emergency Management Infrastructure in India to meet demand…
Medical Side:
· 2.4 million Deaths (2004) on health diseases, 312 self-inflicted injuries per day and 324 deaths per day on accidents.
Police Side:
· 1 theft every 2 minutes, 1 murder every 16 minutes and 1 rape every 29 minutes.
Inadequate infrastructure:
· 1.5 hospital beds per 1,000 person; 0.6 physicians and 0.8 nurses per 1,000 population (WHO), 700,000 ICU beds across all hospitals and nursing homes, Only 5% of GDP against 16% in US on health spending and 1.2 police personnel per 1,000 population.
· Only 20-25% emergencies get treated in India
· 17% emergencies reported in rural districts in AP and 40% emergencies reported in leading metros.
· Absence of:
o Legal Framework for Encouraging Emergency Care Providers and Crime/Accident Reporting
o Nodal Agency, Accreditation of Ambulances/Trauma Centers/ Paramedical Staff and Pre-Hospital Care
· Presence of:
o Multiple Agencies with different telephone numbers and delay in accessing Appropriate Treatment Facility
SUPREME COURT OF INDIA OBSERVATIONS IN 1989:
The Supreme Court of India as long back as 1989 in one of the historical judgments observed that:
“Every injured citizen brought for medical treatment should instantaneously be given medical aid to preserve life and thereafter the procedural criminal law should be allowed to operate in order to avoid negligent death. There is no legal impediment for a medical professional when he is called upon or requested to attend to an injured person needing his medical assistance immediately. The effort to save the person should be the top priority not only of the medical professional but even of the police or any other citizen who happens to be connected with the matter or who happens to notice such an incident or a situation.”
“Preservation of human life is of paramount importance. That is so on account of the fact that once life is lost, the status quo ante cannot be restored as resurrection is beyond the capacity of man. The patient whether he be an innocent person or be a criminal liable to punishment under the laws of the society, it is the obligation of those who are in charge of the health of the community to preserve life so that the innocent may be protected and the guilty may be punished. Social laws do not contemplate death by negligence to tantamount to legal punishment.”
The Supreme Court further held that, “the Constitution envisages the establishment of a welfare State at the federal level as well as at the State level. In a welfare State the primary duty of the government is to serve the welfare of the people. Providing adequate medical facilities for the people is an essential part of the obligations undertaken by the government in a welfare State. …………... Art. 21 impose an obligation on the State to safeguard the right to life of every person.”
IMPERATIVES AND IMPLICATIONS OF SUPREME COURT OBSERVATIONS:
• Every injured citizen brought for medical treatment should instantaneously be given medical aid to preserve life (Imperative)
Safe and easy transportation of the victim to the nearest hospital – Pre hospital care based ambulance facility and Emergency Response Services (Implication)
· The effort to save the person should be the top priority (Imperative)
Provision of Emergency Response Services with speed, accuracy and efficiency either by Government on its own or in association with a experienced organizations (Implication)
• In a welfare State the primary duty of the government is to serve the welfare of the people. Providing adequate medical facilities for the people is an essential part of the obligations undertaken by the government in a welfare State. …………... Art. 21 impose an obligation on the State to safeguard the right to life of every person (Imperative)
Provision of emergency response services free of cost as part of the obligations of the welfare state need not be guided and led by normal Government processes that either delay or defer for ever (Implication)
In the above judgment, the Apex Court of India clearly directed immediate steps to be taken for the preservation of life, which was a fundamental right, including in respect of the life of a patient during the course of an accident.
Thus there was an urgent need for Transforming Emergency Management in India.
Chapter-II
ORIGIN AND EVOLUTION OF EMRI:
Emergency Management and Research Institute (EMRI) was established in April, 2005 in Hyderabad (Andhra Pradesh-AP) as a nonprofit organization for providing Emergency Management & Response Services in a way similar to or better than the 9-1-1 system in United States of America. The vision of EMRI is to provide leadership through Public-Private Partnership (PPP) framework to save one million lives a year nationally by the year 2010, meeting global standards in Emergency Management, Research and Training. The Institute was founded and funded initially by former Chairman of Satyam Computers B. Ramalinga Raju and his brothers.
Consequent to the developments surrounding the founder promoters of EMRI, Government of AP has requested GVK to take over the management of EMRI and provide leadership, guidance and resources to the project and be the PPP partner. Accordingly EMRI’s Governing Board has invited Dr GVK Reddy to be the Chairman of EMRI.
Apart from the team in the governing body and the large number of patrons which the organization has had on account of its impeccable record and the social objectives envisioned and duly delivered, EMRI also is a professionally managed organization with a dedicated team of hardcore professionals who have contributed substantially in this field for many years respectively and accordingly are associated with the organization taking forward the envisioned social cause successfully.
AIMS AND OBJECTIVES OF EMRI:
EMRI was established for bringing the benefit of the emergency response within the affordability of a common man and accordingly its objectives as briefly mentioned below were drafted and incorporated.
• Give citizens in an emergency the benefit of getting timely attention and support
• Serve as a vital emergency management information and assistance resource and thus save lives and reduce the economic impact to the citizens
• Provide national leadership and expertise in comprehensive emergency management and strive to position itself as an institution dedicated to promote Emergency Management and Research.
• Build the soft-infrastructure for emergency response.
• Advance continuous improvement in emergency management through strategic partnerships, innovative programs, and collaborative policy positions.
• Design services to meet the needs of the citizens
• Suggest Preventive methods to reduce the need for emergency response
• Undertake practical research assignments in alliance with the best institutions in India and outside.
• Document case studies of typical emergencies attended.
• Conduct conferences, retreats and workshops to increase awareness among the top policy makers in India
The broad structure and framework for implementation of the emergency response services envisage architecture of nine elements namely: Non-Profit Organization, PPP (Public Private Partnership) framework, Leadership & Partnerships, Single Toll Free 108 Number accessible from Mobile and land line, 24X7 Unique ERC staffed by Trained Personnel, Technology, Ambulance, Research and Training. EMRI’s slogan has been to ensure “Right to safety” of each and every citizen.
EMRI-JOURNEY TOWARDS PROVISION OF EMERGENCY RESPONSE SERVICES:
EMRI’s values, management concepts and partnerships (with Government, Hospitals, and international organizations such as Stanford, Carnegie Mellon, Singapore Health, Shock Trauma Center, NENA etc.) have been helpful to focus and deliver an autonomous and professional emergency response system that has received praise from international experts. EMRI has been providing comprehensive emergency response services covering Medical, Police and Fire services since August, 2005 effectively and efficiently in the state of Andhra Pradesh, with Satyam Computer Services Ltd., (Satyam) as Technology Partner. Tech Mahindra, the new owners of Satyam Computers, committed to continue the technology support free of cost to EMRI.
EMRI ‘integrates’ many resources and provides sustainable round the clock safety to citizens in PPP frame work 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 Hospital for stabilization).
EMRI, apart from providing integrated emergency response services through toll free emergency number (108), has been undertaking research projects (prevention, diagnosis, treatment and prognosis) related to emergencies and offering various Emergency Medicine training programs to first responders, emergency medical technicians and doctors for emergency skill building.
EMRI started to address the absence of a coordinated national emergency response system in India, prevalent in the developed countries of the world. Moreover, the cultural understanding of emergency care which is absent among the Indian people was targeted to be changed by the EMRI. The underlying principle behind the EMRI was to establish Emergency Response System services in few cities, and once the citizens came to appreciate the quality of service provided by it, to take the service to a national level. Because of the nature and scale of operation, a private party could not have sustained the model unless the entity partnered with State Governments.
EMRI initiated the said services with the social objectives of: (a) To provide free emergency response services for medical, police and fire emergencies across India by 2011 in Public Private Partnership framework, (b) To conduct research in the field of emergency services such as tracking emergency calls to better position ambulances, and to identify dangerous inter-section on the roads and to pass on such information to local governments to encourage better traffic management, study best practices of emergency medicine in other countries etc. and (c) to organize emergency management/ medicine conferences, run world-class training programs for paramedical staff etc.
EMRI is the first of its kind in India wherein it has managed to partner with several hospitals in the country in order to synergize emergency response systems. GVK EMRI uses state-of-the-art software and technology developed by Satyam Computer Services, and other facilities in order to maximize efficiency of the emergency response system.
EMRI-MODE OF OPERATION:
EMRI’s mode of operation as followed first in the State of Andhra Pradesh and replicated in other states is as follows:
· In case of an emergency, any citizen can dial the toll free number ‘108’ from any landline or cellular phone.
· The call goes through to a centralized Emergency Response Centre (ERC) normally in the state head quarters, where the ERC officers (communication/ dispatch officer) gets the location of the caller and the type of emergency involved.
· Using the Global Positioning System (GPS) and Geographical Information System (GIS) the officer can track the nearest ambulance and direct it to its destination. A map showing the road routes of the region appears on the computer screen.
· The officer in the ERC then scopes the problem and according to the nature of the problem, decides on the required help such as fire engine / police vans / ambulance.
· Doctors (known as Emergency Response Center Physicians ERCP) who have been employed in the centre give pre-arrival medical instructions before the ambulance arrives.
· In case of road traffic accidents, the nearest possible ambulance is sent to the site of the accident while coordination occurs with the police and fire departments. These Emergency Response Vehicles are equipped with devices designed with public and patient safety in mind.
· EMRI uses Advance Life Saving (ALS) Ambulances and Basic Life Saving (BLS) Ambulances depending upon the contingency of the situation. The ambulances are fully furnished with equipments like detachable stretchers, wheelchairs, life saving drugs, ventilators, (in ALS ambulances) IV fluids and seat belts.
· Emergency Medical Technicians (EMT s) and other duly trained personnel provide care enrout to the hospital. In case of medical emergency the patient is transported to an appropriate facility. Trained technicians stay in constant coordination with the ERCP at the centre to monitor the patient’s health and try to stabilize him before admitting to the hospital.
EMRI-INITIATION AND MARCHING FORWARD:
EMRI on its own and with the funding support of initial promoters-the Raju Brothers, launched 70 ambulances in 50 towns of Andhra Pradesh to cater to 25 million population-mostly urban - to meet the operational and other expenditure entirely for almost two years.
The successful track record of EMRI in the field of Emergency Response
Services that too without charging any fee from the patients/affected persons bears testimony in promoting social causes and successfully implementing the said project which had been conceived in the first place by it at such a vast magnitude. On account of the relentless efforts made by EMRI, it has successfully implemented ERS not only in AP but in various other states where it has expanded the services network crucially saving lakhs of lives.
The conceptualization of the project initially and the successful implementation of the same gradually including the expansion of the service networks in various other states clearly established the impeccable commitment shown by EMRI in undertaking its operations and thereby resulting in large scale benefits trickling to the grass root levels in the interest of the citizens and saving large number of lives which is a significant achievement.
EMRI – PRINCIPLE OF PARTNERSHIPS:
EMRI in the beginning borrowed the experience and best practices of similar services of other countries leading to choose an integrated, centralized model along with the development of eco system (e.g. research and training, as the name indicates). Among many such innovations that were brought in, the key differentiator were the partnerships.
Since inception, EMRI realized the importance and the role of government which ultimately proved to be the success of the project. When explained the future benefits of the project, the then newly elected Chief Minister of AP Dr. Y. S. Rajasekhara Reddy convinced and gave a green signal to proceed. A Memorandum of Understanding (MoU) was signed on 2nd April 2005 by EMRI with Government of Andhra Pradesh in the presence of Chief Minister of Andhra Pradesh. This partnership paved for subsequent MoU s in the state as well as with many other states in the years followed.
The next step was to meet all the stake holders in the state (police, fire and medical officials from the state head quarters and district level officials) and medical professionals (both individuals, organizations such as Indian Medical Association, AP State Nursing Home Association, Indian Red Cross, etc.) to seek their inputs and support for the project. As many hospitals as possible were contacted and with the exception of a few, most of the hospitals have also signed agreements to stabilize patients brought by GVK EMRI free of cost and provide emergency treatment for 24 hours also free of cost. This partnership with hospitals has proven to be invaluable.
Government of India allotted the toll-free “108” number accessible from both land lines and mobiles without prefixing area code.
Satyam Computer Services Ltd. (Now Mahindra Satyam) is a Technology partner to EMRI and contributed to development of integrated technology solutions free of cost.
There are more than 6,500 centers in USA that attend to 9-1-1 calls. National Emergency Number Association (NENA), USA was founded 30 years ago to address the common challenges faced by the 9-1-1 professionals. EMRI entered in to strategic alliance with NENA, USA to quickly learn from them instead of reinventing the wheel the hard way.
To get a firsthand experience, EMRI team attended NENA conference in June 2005 at Long Beach, California, USA. EMRI CEO, during his presentation to Bill McMurray, out-going president of NENA, made a comment “I may sound arrogant; but we want to beat you in emergency management”. Bill thought for a moment and said “I take it as a compliment that you are taking NENA as a bench-mark”. EMRI team had fruitful discussion with the then incoming president David Jones who also joined the meeting.
On knowing EMRI plan to launch emergency response services on August 15, 2005, barely seven weeks away from then, though several major subsystems were not yet in place, including the allotment of single number the NENA team expressed surprise but encouraged and promised all possible help they can. That’s the kind of camaraderie the Public Safety community shared around the globe initially and continues to do even now.
Similarly constant touch and visits from either side resulted in a partnership between EMRI and Stanford University and EMRI offered a two year PG Program in Emergency Care (PGPEC) in collaboration with Stanford.
EMRI strongly believed in inclusive partnerships. With the initial successes, EMRI was quickly able to sign up partnerships with Shock Trauma Center of USA, Richmond Ambulance Authority of USA, Carnegie-Mellon University of USA, Singapore Health Services, City of Austin, USA, Geo-Med of Germany, Public Health Foundation of India. These relationships helped EMRI to understand the issues deeper and look for common solutions.
EMRI and its leadership, ever since its establishment, firmly believed to partner with Government for competitive advantage towards fulfillment of the objectives. This kind of an initiative in Andhra Pradesh as well as replication in future in other states would not have happened without the Government support. Initially when EMRI on its own approached Andhra Pradesh Government for PPP framework it was more for recognition, credibility and sustainability rather than for seeking funding support.
EMRI as a humble organization approached Government of AP and over a period established its credibility, in respect of its openness, transparency in providing quality emergency response services. Its work has been constantly reviewed by Government leaving the control of day-to-day functioning to EMRI so that there was never ever scope for dilution of the scheme. Both EMRI and Government acknowledged each other’s work supplementing and complementing roles and responsibilities.
Chapter-III:
EVOLUTION OF PPP FRAMEWORK:
FROM PSU s TO JOINT VENTURES TO PPP:
During the period immediately after independence, in order to overcome the red-tape and indifference in the functioning of Government Departments and to serve the citizen better, several Public Sector Undertakings (PSU) were established all over the country. As they were incurring losses public sector reforms were introduced leading to closure of PSU s in large numbers.
Later over a decade and half ago, when the Indian economy was opening up, several joint ventures were formed in just one year between Indian and foreign companies. Majority of them ended up in breaking within five years later as they failed to produce the expected results. The objective of partnerships, through joint ventures, of making one plus one produce three, could at best be realized in producing just less than two-the reason being ‘cultural’ problems. The development of a comprehensive shared vision, going beyond the financial value of the Joint Venture to surface and match the cultural values of partners was absent then. Thus the experience in India revealed that joint ventures are notoriously difficult to manage with some notable exceptions.
Against this experience, in India, as in other countries evolved the concept of “Public Private Partnership” and steadily gaining strength. It is assumed that Government’s collaboration with non-profit private sector in the form of PPP would improve equity, efficiency, accountability, quality and accessibility of the system. Advocates argue that the PPP can potentially gain from one another in the form of resources, technology, knowledge and skills, management practices, cost efficiency and so on.
PPP EVOLVING CONCEPT:
Public-Private-Partnership (PPP) is an evolving concept as well as practice in many developing countries, in which an otherwise government (Public) service is funded by state either totally or partly, and operated through a partnership between government and one or more non-governmental organizations or private sector companies (Private).
The (Private) non-governmental organizations as well as some Corporate as part of social responsibility have been providing citizen services in a majority of democratic and developing countries including India. The commitment and efficiency with which these services are being provided by some of them forced the government to prefer for an increased involvement of them in the provision of services traditionally provided by, and seen as a function of, the state. This entails a paradigm shift in the role of the government from provision of services to partnering with a private non-governmental organization in making available these services, through a meaningful arrangement. Such arrangements are referred as Public Private Partnerships (PPP). However, the responsibility for providing the service still rests with the government.
The NGO or a similar organization initially invests (as in the case of GVK EMRI) in developing infrastructure, leadership and technology and provides related services in partnership with the government by way of making proper use of the state machinery which often do not add any additional financial burden to the state.
The government subsequently adds strength to the PPP by providing both Capital and Operational Expenditure within its budgetary limits for a particular service while retaining responsibility for the delivery of core services.
Arrangements between the government and the NGO are governed by long-term and short term understanding in the form of “Memorandum of Understanding” or “PPP Agreement”. It specifies the obligations of both the parties to deliver within the broad framework of performance indicators and standards.
The essential role of the Government (Public) in all PPP s is to define the scope of activity of service, specify priorities, targets & outputs and allow operational freedom to deliver the services to its private partner.
PPP takes many forms such as design, construct and maintain or build, own, operate & transfer. The choice of form depends on factors such as the government's objectives, the nature of the project, the availability of finance, and the expertise that the private sector can bring. It also equally depends on the values, objectives and goals of the partnering private sector. PPP is increasingly being used in social service activities such as providing Emergency Response Services to everyone in general and to vulnerable sections in particular.
It is a prerequisite to make the partnership a publicly driven process in order to improve its legitimacy in the eyes of the common citizen. It is also important that there is clear articulation of responsibility, an open process and meticulous detailing to avoid suspicions and apprehensions in the minds of all. Therefore the power relations in the partnership also needed to be understood.
SIGNIFICANCE OF PPP IN EMERGENCY MANAGEMENT SERVICES (EMS):
Public safety and security is a task that requires on-going cooperation and seamless integration amongst resources and stakeholders. Due to the varied nature of emergencies, vast coverage of EMS providers and the number of stakeholders’ involved, frequent bottlenecks could be witnessed in standardizing the operations and extending timely services. Besides, such services are highly capital-intensive and require continuous infusion of funds for operation and maintenance. This combined with nil returns make it less attractive for private investors for long-term and continual commitments. Partnerships and collaborations are imperative for ensuring safer, more resilient communities and measured responses to emergencies and relief actions. The Government has a formidable role to play in ensuring efficient EMS in terms of creating an enabling environment characterized by a harmonious policy, regulatory framework and funding and infrastructure support.
In Emergency Management Services (EMS), the relationship of stakeholders who are primarily Government (both at Central & State level) and private partners, is driven by operational & financial capabilities and also by the overall socio-political climate in the country. Various factors which reinforce the need for a balanced partnership between these stakeholders are as follows:
· Huge & continuous funds commitment towards operational set-up of EMS and maintenance of the same needs financial support by the Government.
· Infrastructure support in terms of ERC, ambulances, fire engines etc.
· Standardization of services through policies & procedures is crucial for imparting services such as EMS across the country, where Government intervention has to be maintained.
· Operational capabilities combined with technological excellence.
· Effective public awareness across the nation calls for support from the Central as well as the State/ local Government.
PPP however would not mean privatization of the sector. Partnership is not meant to be a substitution for lesser provisioning of government resources nor an abdication of Government responsibility but as a tool for augmenting the emergency response services. Against this background evolved the provision of emergency response services by Emergency Management and Research Institute (EMRI) and Government of AP in PPP for improving delivery of emergency health services to vulnerable segments.
RURAL EMERGENCY HEALTH TRANSPORTAT SCHEME (REHTS) ORIGIN OF PPP MODEL FOR PROVISION OF ERS IN INDIA:
Out of the several reasons for non-utilization of healthcare services in general and for institutional deliveries by the pregnant women in particular in rural and tribal areas, lack of transportation was found to be one of the most important reasons. Therefore, the Government of Andhra Pradesh under the Reproductive and Child Health-II Project initiated the implementation of the scheme “Rural Emergency Health Transport Services (REHTS)” in rural and tribal areas of the state.
In pursuance of the National Common Minimum Programme, Government of India launched the National Rural Health Mission (NRHM) in April 2005, for providing integrated, comprehensive primary health care services with special emphasis on poor and vulnerable sections of the society and REHTS was part of it. REHTS is aimed at transporting pregnant women, infants, children below 12 years of age and any other cases in need of emergency health care services to the nearest hospital.
In Andhra Pradesh the scheme was piloted in four districts- Kadapa, Kurnool, Mahaboobnagar, Nizamabad and the tribal areas of nine other districts in the year 2005. Initially 122 ambulances were deployed under the scheme and were operationalized through individual Non-Governmental Organizations as PPP concept in the districts, selected by a District Level Selection Committee headed by the District Collector.
Thus the Government of Andhra Pradesh successfully initiated and implemented the process of improving the accessing of healthcare services, in emergency situations by the pregnant women, neonates, parents of neonates, infants and children below 12 years of age (in situations of serious ill-health condition), and any other health emergencies in the general population; and thereby help the state to achieve the critical Millennium Development Goals in the health sector, i.e., reduction of Infant Mortality Rate, Maternal Mortality Ratio, and in general improve the health-confidence in the people through improving their ability to access healthcare service in case of emergencies.
In addition to REHTS, Government of Andhra Pradesh also recognized Emergency Management and Research Institute (EMRI), as the State Level Nodal Agency to provide comprehensive emergency response (Medical, Police and Fire) across the state, in PPP and signed Memorandum of Understanding (MoU) on 2nd April 2005.
The MoU defined the roles and responsibilities of each of them without any financial commitment from Government. References to relevant paragraphs on PPP are detailed below:
· In the Preamble: “….it is essential to work in partnership with private agencies such as EMRI, service providers such as hospitals, blood banks, ambulances, and telecom providers, and donors (individuals, body corporate or Non Governmental Organizations)”. “…it is essential to focus on core competencies of the government and partners so that the synergies can benefit both the citizen in need and the government”.
· As part of State Government’s obligations it is agreed that: “Government recognize EMRI as the nodal agency to provide emergency response across the state, in public private partnership and in coordination with the public agencies, which will help drive greater transparency, agility, and better citizen service”.
· As part of EMRI Obligations it is agreed that: “EMRI to establish and operate an emergency response system in the Metropolitan Hyderabad in public private partnership”.
Consequently, EMRI launched 70 ambulances from August 2005 to June 2006 covering 50 towns of 25 million populations in AP and set-up state of art emergency response centre as well as provided training facilities with its own funding. In true spirit of PPP Chief Minister of AP launched the services formally on 15th August, 2005. Satyam Computers as Technology Partner provided EMRI the required technology support free of cost. The same is passed on free of cost to other states also.
At a time when EMRI was planning to expand its services to rural areas, State Government having piloted the REHTS in four districts and ITDA areas with 122 ambulances thought of expanding the Scheme to the other 18 (Rural) districts of the state and decided to utilize the services of the EMRI as the State Level Nodal Agency and accordingly entrusted the responsibility of operationalizing the Rural Emergency Health Transportation Scheme for operationalizing the balance of the 310 ambulances and signed the 2nd MoU on 22nd September 2006. The rural expansion with EMRI as Nodal Agency was formally launched by Chief Minister of AP Dr. YS Rajasekhara Reddy on January 26th, 2007.
Government of AP subsequently decided that the Ambulances in the four pilot districts and nine ITDA areas that were being run by various NGO s, also to be handed over to EMRI in the interest of unified implementation of the scheme in the rural and tribal areas with a single toll-free number-108, and extend the “free of charges” ambulances to those areas also.
The third MoU signed in October 2007 further strengthened the PPP. While retaining most of the provisions of the earlier MoU s. The Government through this decided to further expand the Public Private Partnership for strengthening the emergency services being provided by the EMRI by augmenting 122 more ambulances and also decided that 108 service would be brought under a common logo of the state government sponsored Health Care Program named after former Prime Minister of India Late Sri. Rajiv Gandhi known as ‘Rajiv Arogyashri’ and the logo will be prominently displayed on all the 108 ambulances and other publicity material of the scheme.
Later, Government of Andhra Pradesh decided to further expand the Public Private Partnership for strengthening the emergency services and to expand the capacity of 108 Emergency Response Services to meet the increasing number of emergencies. A revised MoU was signed between Government and EMRI on 5th May, 2008 and accordingly Government committed to provide 300 more ambulances in two installments and during the financial year 2008-09, out of the total direct operational cost (embracing the cost of call center, communication cost, additional cost on emergency management technicians, pilots, fuel and medical consumables due to enhancement of operations) to be incurred Government agreed to bear 95%. Thus, EMRI founder Ramalinga Raju funded the project totally during first two years of operations (2005-2006 & 2006-2007), up-to 50% during third year (2007-2008) and 5% during fourth year (2008-2009). This is in addition to the management, research and training costs.
From the financial year 2009-10 AP Government has agreed to bear the entire cost of operations (Other state Governments are also indicated to do the same). The sanctity of observance of the sharing of operational expenditure between the Government and the EMRI shall however be maintained, as it is one of the fundamental features of the PPP model and concept. Towards meeting this requirement, the senior management cost being incurred by EMRI shall be counted as private contribution.
EXPANSION TO OTHER STATES: REPLICATION OF AP PPP MODEL:
Emergency Response Services initially provided in AP later were expanded to ten more states, providing the service free of cost, to over 350 million populations through a network of 4000 ambulances in Public Private Participation (PPP).
On seeing the successful implementation of ERS in PPP in AP several state governments deputed their representatives to study the model while some preferred to straight away nominate EMRI as nodal agency to provide similar services in their states others preferred to follow tender process where as a mix of the two methods were followed by rest. Whatever was the process followed to choose EMRI as nodal agency, it was entirely the decision of the respective state governments.
State governments of Gujarat, Uttarakhand, Goa, Assam, Karnataka and Meghalaya appointed EMRI as nodal agency without any formal tender process, but, based on a series of negotiations and discussions leading to signing of MoU between EMRI and the state governments. It was for the respective governments to follow the method that suited them. However, Tamil Nadu and Rajasthan (Rajasthan cancelled the contract subsequently) preferred to go for tender though there were negotiations prior to the tender notification. Government of Punjab also preferred Tender route.
In another instance, then Chief Minister of Maharashtra visited EMRI in January, 2006 to study the model. A year later the then Health Minister visited and few months later, on the government of Maharashtra invitation CEO, EMRI made a presentation to senior health officials in Mumbai. This was followed by series of discussions and negotiations between representatives of both parties culminating in a formal approval of the Cabinet on 15th October, 2008 to appoint EMRI as Nodal Agency to provide ERS in Maharashtra in phases. However, for various reasons EMRI could not enter in to MoU with Maharashtra Government till now.
One year after Maharashtra Government representatives’ first visit to EMRI, Minister for Health along with senior officials of health department from Madhya Pradesh (MP) visited EMRI in January 2007. As in the case of Maharashtra here again in addition to series of negotiations including presentation to Chief Minister by CEO, EMRI the state government also issued notification inviting non-profit organizations for expression of interest for developing and operationalizing comprehensive ERS in MP. EMRI responded to it and subsequently forwarded proposals as required by MP Government. The government decided in EMRI favor and signed MoU in November, 2007 nearly 10 months after their representatives’ first visit.
Every where the process involved visits of either side’s representatives, discussions between EMRI and top administrators of the cadre of Chief Secretary and or Chief Minister, formal or informal project proposals including financial implications, tender suiting to the state’s requirement in terms of bidder’s capacity and capability to provide service and finally appointing EMRI as nodal agency after necessary approvals and clearances. Transparency, accountability and citizen friendly principle was the process that was adapted.
On the occasion of either signing the MoU or launch in every state the Chief Minister, the Health Minister, the Chief Secretary and other senior Government officials from Police, Fire and Medical departments were present with few exceptions. Even in subsequent launches to true to the spirit of PPP presence of Government partners was ensured.
DETAILS OF EXPANSION – MoU Signing:
· Andhra Pradesh First MoU April 2, 2005
Latest 5th May 2008
· Gujarat 29th August 2007
· Madhya Pradesh 25th Nov'2007
· Uttarakhand 8th March 2008
· Tamil Nadu 6th May 2008
· Rajasthan 23rd May 2008
· Goa 14th June 2008
· Assam 8th July 2008
· Karnataka 14th August 2008
· Meghalaya 5th Nov' 2008
· Punjab 1st Jan' 2009
· Himachal Pradesh
· Chhattisgarh
PROCESS OF PPP REPLICATION IN OTHER STATES:
There is no hard and fast rule that, the governments, to follow in choosing a non-profit organization to partner with it for providing services in PPP framework either in the health sector or in the social sector. Nor there are any standard guidelines in this regard. An expert study on this observed that, except in very few cases where government resorted to open tendering most of the partnerships revealed that the government and the private partner chose to consult each other, formally or informally, before venturing into partnership agreements. In such partnerships, charismatic leadership and vision of the personalities, from both sectors, played a critical role. There were also compelling circumstances and relationships based on trust that were critical in triggering partnership initiatives. Either the government may approach the private organization or the private organization may work hard to convince the political and administrative leadership in the government for finalizing PPP.
Several analysis and studies suggest that a competitive process of selecting the private partner for PPP framework is less effective than an invited or negotiated partnership. While competing to win the deal, the private partner’s primary concern is to quote less to become the lowest bidder whereas the government side officials’ main concern would be to meet procedural requirements than meeting beneficiaries’ needs. Tendering process in government is adapted to choose the lowest bidder. Though it is economical initially, the trend later would be up-ward revision of costs and if government disagrees, then the level of quality and effectiveness comes down. Resorting to transparent and competitive process may be useful for commercial projects but not in social sector where reaching the poor is a priority rather than pricing of services. Hence either prior negotiations with the potential partner or a tender where eligibility conditions are tailor-made or the prior experience of the private partner to be used as a basis for choosing is ideal for the success of PPP.
It is often observed that partnerships are formed between organizations but succeed because of individuals who are strong leaders and who champion the partnership projects with vision, energy and enthusiasm. If it is the CEO-EMRI and his team from the private side, it has been either the Minister concerned or the Secretary concerned or a combination of both from each and every state who championed the cause. In most of the states like AP, Gujarat, Assam, Uttarakhand and Tamil Nadu the Chief Ministers pro-actively pushed the project. Partnership requires governmental leadership also. Partnerships work typically with one providing the financing and the other providing the services (like 108-ERS in PPP in NINE states).
Typical enabling conditions identified worldwide for the success of PPP are: a clear understanding between the partners about mutual benefits, a clear understanding of the responsibilities and obligations between the partners, strong community support, need for some catalyst to start the process of partnership, stability of the political and legal climate, regulatory framework that is followed and enforced, capacity and expertise of the government at different levels in designing and managing partnership and so on. Public Private Partnership is different from privatization and the message has to go without ambiguity.
Partnership is not meant to be a substitution for lesser provisioning of government resources nor an abdication of Government responsibility but as a tool for augmenting the services.
The very fact that even after three and half years in AP and ranging from few months to year and half in eight other states, GVK EMRI has been successfully providing uninterrupted round the clock Emergency Response Services with an average response (reach) time of 15 in urban and 21 minutes in rural areas, pre-hospital care in ambulances by trained staff and to save 80000+ lives, proves that the way it was chosen by different states as Nodal Agency is absolutely right.
Chapter –V
OVER VIEW OF IMPACT OF 108 ERS IN PPP MODEL
IMPACT OF 108 SERVICES ON GOVERNMENT HOSPITALS:
Before launching the rural expansion, EMRI undertook an informal study to examine various aspects related to government hospitals in rural areas for provision of emergency care when 108 ambulances brings the patient. This included interaction with District Collectors, DM&HO s, qualified Private Medical Practitioners as well as Social Activists. The informal consensus opinion expressed by many was that due to several reasons, in majority of PHC s, CHC s and even in couple of Areas Hospitals either the Doctor may not be available & accessible, or the skill levels of emergency care may not be up to the expected level, or adequate facilities may not be available, or poorly equipped to handle emergency cases and so on. Notwithstanding all this EMRI proceeded with its plans of expansion beginning with Medak district and completed launches all over the state. With this the emergency response services took off in rural areas.
In majority of cases the experience of 108 has been that the same doctor, in the same hospital-be it a PHC or CHC or Area Hospital- not only began to be available and accessible but also provided emergency care with the same available existing equipment and facilities. The doctors confessed that, they could not be available earlier because they had no patients on a regular basis and after the 108 services started along with emergency victims other patients also started coming and hence they also preferred to treat them. Doctors (Who are eligible to do private practice) also mentioned after some time, that even their private practice has gone up because of the experience they are gaining and also because of the awareness as a result of patients flow to hospital.
Slowly not only doctors but also paramedics and nurses realized the need for their skill enhancement particularly to treat emergency patient which resulted in APVVP-EMRI agreement to conduct series of training programs in addition to GVK EMRI initiated training programs. As on date 1107 doctors, 375 paramedics and 232 nurses received training. The Training among others:
· Oriented doctors to the importance of pre-hospital care, Basic Life Support Skills, Advanced Life Support Skills and Team Work in Managing Emergency Patients
· Impressed upon the doctors to realize the need to follow Standard Operating Procedures (SOPs) called Clinical Care Protocols to manage common emergencies
· Doctors recognizing the need to attend the emergency patients without delay and application of Triage Principle in Multi casualty Incident
· Practically experienced the need for updating the CPR Skills
· Precious Lives can be saved if resources can be utilized optimally
· Importance of Inter Facility Transfer and the Role of Physician
· Realization that Life Saving Skills if Universally made available to the Doctors and Nurses in the Government Hospitals and in all Low Resource Setting Health Care Institutions deaths can be prevented, duration of hospital stay can be reduced.
ERS IN PPP REDUCES MATERNAL MORTALITY
In addition to this, Pre-hospital care by 108 emergency services is also resulting in bringing down maternal mortality rates. A study of the 1,21,454 pregnancy cases handled by the EMRI for a year from July 2007, showed that there were 73 maternal deaths while the MMR in the State during 2007 was 197 per Lakh live births. In other words, effective pre-hospital care by 108 emergency services in more than a Lakh pregnancy cases has brought down to less than 50 per cent the maternal mortality rate, underscoring the importance of timely transport to a health facility in ensuring a safe motherhood. 65% of these cases were treated in government hospitals.
ERS IN PPP REDUCES NEO-NATAL MORTALITY IN AP
Inadequate transport facility, absence of timely treatment and management of newborn complications are the main reasons for increase of Neo-Natal Mortality. With the introduction of EMRI PPP ERS Model in AP, reduction in the neo-natal mortality is noticed according to a study conducted by the research team of EMRI adopting scientific methodology.
The study shows that there is a huge amount of demand for emergency services pertaining to neonatal complications particularly from the rural areas of Andhra Pradesh with specific reference to vulnerable segments. This is evident from the fact that 93% of the total reported cases were from rural areas and only 7% cases were reported from urban areas. NFHS 3 India survey found that the neonatal mortality is 50% more in rural than urban areas. It may be inferred that the neonatal complication are significantly high in rural than urban areas and provision of emergency medical services in rural areas would result better in reduction of neonatal mortality.
The maximum cases (60.9 per cent) were related to birth asphyxia followed by unconsciousness (7.5 per cent), convulsions (4.6 per cent) and other infections. It was estimated that EMRI handled 16500 to 33000 pregnancy cases in 2007 which required the resuscitation to the new born. Again considering one third of the cases of non-institutional delivery which are of high risk for birth asphyxia, EMRI intervention has ensured proper medical management including resuscitation either through quality pre hospital care and transporting to a suitable health facility.
Apart from the birth asphyxia, infections viz. sepsis, pneumonia, diarrhea etc. contribute significantly to the neonatal mortality. Neonatal sepsis constituted nearly one third of the health problem in neonatal ward and majority of them are early onset infections. This requires specific emergency management and medical management unlike birth asphyxia. An effective emergency management system would ensure the fulfillment such factors to a greater extent. It is important to note that 52% of the neonatal deaths are due to infections which could be managed better through a good emergency response service system like that of EMRI.
Neonatal mortality of AP is 40.3 (by NFHS-3) which show one neonatal death occurs per 25 live births where as EMRI data reveals that one neonatal death per 13 emergencies. This translates to 51% of the live births require Emergency care services including emergency transport to definite care unit.
Chapter-VI
STUDY OF EMERGENCY RESPONSE SERVICE - EMRI MODEL
By NHSRC- GOVERNMENT OF INDIA
EMRI-A HISTORIC LANDMARK IN PROVISION OF HEALTH CARE IN THE NATION
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 operationalisation of ERS would be most efficient and most effective.”
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 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.
ORIGIN OF ERS IN THE WORLD:
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 operationalized 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 operationalisation. 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 (340M US $) annually. This is on the assumption that, at the current rates, both the operational as well as the annualized capital costs would be approximately Rs. 17 Lakhs (34,000 US$) 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 (340M US $) annually for replicating the model all over the country, which accounts for only 3% of the projected cost of Rs. 55,000 Crores (11,000 M US$) 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 (9 US$) 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.
ANGEL OF MERCY-108 AMBULANCE
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.”
“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.”
EMS AT HOSPITAL
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.”
EMRI’s HIGH ORDER MANAGEMENT PROCESSES
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.
Chapter-VII
BROAD STRUCTURE AND FRAMEWORK FOR CAPACITY BUILDING
CAPACITY BUILDING is a planned, conscious and deliberate effort for initiating, implementing, Institutionalizing and accelerating provision Emergency Response Services (ERS) free of cost in Public Private Partnership (PPP) as is being done by EMRI in 11 states in India catering to about 400 million populations round the clock.
CAPACITY BUILDING is an attempt to bring together all the stakeholders vertically integrating from top to the bottom who matter in planning and implementing ERS in the country.
CAPACITY BUILDING program may initially include the concerned Minister, Senior Bureaucrats belonging to Health, Police, and Fire departments as well as all those support functionaries who matter in formulating and delivering all that is required for provision of ERS.
The essential requirement for this is a Strategic Planning for the Government concerned to be implemented by way of:
· Identification of 20-25 Core Group members (Change Agents) to carry forward the implementation of the strategic Plan
o Identification of right people
o Initiation of support building
o Moving innovations downward-Obtaining feedback
o Forming implementation teams
o Action Planning for diffusion of innovation
o Integration and diffusion of results
o Among the people to be identified and taking forward the following are desirable:
§ A Group of Leaders for whom the Capacity Building Activity is only in the form of seeking their “commitment” to provide emergency response services in PPP mode
§ Designated Coordinator to be entrusted with Capacity Building function and to be made responsible for implementing Capacity Building across the country and to all who need to be brought in to the activity of provision ERS
§ Panel of resource persons and train/ develop them as trainers and designers for conducting programmes
§ To organize large number of improved quality training programmes ensuring certain level of standards and uniformity in delivery system
· STEPS TO BE INITIATED AND AREAS TO BE COVERED
§ Design of Training (DOT) skills
§ Management of Training (MOT) skills and
§ Orientation to Management of Training (OMOT) – For seeking commitment from the policy makers
§ Sector specific trainer training programs (Sense, Reach and Care – the three essential processes for providing emergency response services
o DEVELOPMENT STAGE: - Aiming to convert design specifications as course-material.
o TESTING STAGE: - Aiming to validate course-structure, objectives, contents, instructional strategy and course-material by obtaining detailed feedback from a selective target group. This will result in standardized and finalized-version of the course.
o TRAINER DEVELOPMENT STAGE: - Aiming at building trainer-capacity, who will be responsible for delivery of the course to the target population.
o OPERASIONALISATION STAGE: - Aiming to organize training-courses so as to cover complete target group.
The whole process will adhere to the principle of Cascading and Multiplication methodology to meet the targets beginning with infrastructure development to actual provision of emergency response services in PPP. The actual process depends on the size of the country and requirement of ambulances as well as other ingredients.
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