108 & 104 totally dissimilar services
Vanam Jwala Narasimha Rao
Former Consultant 108 & 104
The Hans India
(04-07-2022)
Telangana State Technology Services on
behalf of National Health Mission of Family Welfare Department, Government of
Telangana issued a notification for Request for Proposal for Selection of
Agency for Setup, Operations and Management of 108 Emergency Medical Ambulance
Services (EMAS), 102 Ammavodi Services, Free Hearse Services and 104 Health
Helpline recently. The salient features of the scope of work, eligibility
criteria and prescribed formats for submission are provided in the RFP document
as uploaded on the Telangana State Government eProcurement System website. The
notification says that Interested parties are requested to submit their
Pre-qualification, Technical and Financial proposals. Besides this the
government also decided to close 104 Fixed Day Health Services and sell
ambulances. This heralds yet another step in implementing these services.
Having worked for four years in 108
services and four years in 104 service in united Andhra Pradesh, as a PPP (Public
Private Partnership) consultant and having closely associated with their
expansion to several states, I am well aware of the need, concept and evolution
of these most successfully operated PPP schemes. 108 was steered by its CEO
Venkat Changavalli and 104 was steered by its CEO Dr Balaji Utla. The
conceptual frame work for both 104 and 108 was designed and developed by Late
Dr AP Ranga Rao as Medical Advisor while the initial funding was provided by
Satyam Computers Ramalinga Raju. Government extended funding support as part of
Public Private Partnership Scheme.
In fact, the concept and operation of
these two services are distinctly different from one another, both are
dissimilar and hence they were operated separately. In combining them for
operation in future, the government may have its own valid reason and better
performance.
108 was conceptualised in the united Andhra Pradesh, with a desire
to design, build and operate, a robust medical emergency system. On 15th
August 2005, this Service launched the first fleet of 15 ambulances in
Hyderabad. By August 15, 2007, the State government had 700 ambulances running
on its 108 service. Later they were expanded to several states.
The 108 Emergency Response Services came into existence in the
context of an approximate 75,000 different kinds of emergencies ranging from road
traffic accidents to cardiac every day across the country, that often became
fatal for want of immediate relief, a single toll-free number; an accredited
ambulance; pre-hospital care and a single nodal agency to coordinate the various
operations.
At that time, there were multiple helpline numbers, no
standardised ambulances that offered pre-hospital care and merely functioned as
transporting patients without the requisite equipment or expertise to stabilise
the patient on way to hospital. Three critical facets of the 108-emergency
response service were Sense, Reach and Care (S-R-C).
When one dials 108, the call lands at the Emergency Response
Centre, where a communication officer (CO) receives it. The CO takes down the
relevant details, fills them on the screen and sends it to the dispatch officer
who has some medical training, who takes the call from call taker, validates
the information about when and where the incident happened, locates the nearest
available ambulance and relevant hospital, and accordingly transfers this
information to the requisite ambulance personnel. This is part of the Sense
process.
The Reach process starts when the
ambulance receives information and proceeds to the emergency site. While
heading to the site, the team gets in touch with the caller, who could be the
victim, a relative or a friend, and asks them to take some basic precautions
like ensuring the patient breathes properly. These suggestions fall under
pre-arrival instructions so that if the ambulance take 15 minutes to reach,
both the patient, their family and friends remain calm during the whole
process. Each ambulance covers a population of about 80,000-1,00,000 on an
average.
The care process starts at the site of
the incident. These trained ambulance personnel offer immediate relief like
stopping the bleeding in the event of injury, splint the patient in the event
of a fracture or put the patient on a defibrillator or ventilator in case of a
heart attack. They check for clear airways, ensure the patient is breathing and
that the blood circulation is maintained.
At the hospital, the ambulance hands
over the patient and collects an acknowledgement in the form of PCR (Patient
Care Record), that contains the patient’s basic details and vitals at the time
of transfer to ambulance, during the travel and at the time of handing over.
Vitals include body temperature, SpO2 levels, pulse rate, respiratory rate, and
other such signs. Due to these ambulance services, an average patient’s vitals
have improved at the time of handing over.
EMRI, the Emergency Management and
Research Institute which operated 108 services provided a rigorous two-month
training programme to BSc graduates, on human anatomy, physiology and
pathology, followed by knowledge on how to identify types of emergencies and
what must be done to save the patient under each situation. The students
practiced on mannequins, rode in the ambulances as trainees and then posted in
an ambulance. Every six months ‘refresher training’ was provided.
Technology was used in ambulances for
pre-hospital care. A GPS system was put in place to track the nearest ambulance
and relevant hospital and an automatic vehicle location tracker system. Within
6 years of launching, the 108 Services was handling 12,000 emergencies per day
in 12 states– 3,200 ambulances serving 430 million people - all free of cost. Now
108 Services are available in most of
the states and run by a vendor selected through tender route responding to
around 40,000 emergencies per day with 8,000 ambulances. Initially there was no
tender process and instead selection process.
While this was so, 104 is a unique beneficiary outreach program
commenced in united AP in 2008, aimed to providing free primary health care
services through Mobile Medical Units (MMUs), at the doorstep of the
beneficiaries, especially in areas that are hard-to-reach through a Fixed Day
Route Schedule. Accordingly, this mobile service covered rural populations
living in villages that are more than
3 kms away from the PHC on a monthly basis in accordance with a fixed time
schedule.
The principal objective of this innovation, that is hugely popular
particularly among the elderly, was to diagnose and treat persons suffering
from diabetes, hypertension etc., at a time when there was no state government
program for addressing these two morbidities that were emerging as serious
concerns within the community. The principal
function of the MMU was to diagnose, test and treat the patient by providing
the required medicines for the month or as required.
The concept of a centralized state level call centre or Health
information centre to make available authentic and standardized health information
requirements to individuals was conceived leading to the establishment of the
first ever Health Information Help Line in the then United Andhra Pradesh
initially with the funding support of Satyam Computers Ramalinga Raju and
immediately supported by Late Dr YS Rajasekhar Reddy Government.
The then Government
of AP funded the HMRI, Health Management and Research Institute which started
the 104 HIHL in Feb 2007. GOAP funded the operations completely. It was
servicing 35,000 calls per day 24x7 with toll free 104. It was closed in
2011. The 104 HIHL, receives calls and provides services like, medical advice, accurate
information on national disease control programs, health care providers etc.
By managing these services under one single agency if
a better performance could be achieved then it is certainly a welcome feature.
It is better if experienced persons are consulted.
(With inputs from Venkat Changavalli and Balaji Utla)
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