Telugu Ramalinga Raju pioneered 108 : Vanam Jwala Narasimha Rao

Telugu Ramalinga Raju pioneered 108

Vanam Jwala Narasimha Rao

(Former Consultant 108 Emergency Services)

The news and views that appeared in a section of traditional print media as well as social media that the Ahmadabad based Lifeline foundation founder, Dr Subroto Das, is the pioneer and benefactor of the 108 (Emergency Response) Services in the country and hence he was honored with Padmasree award is not true! The services being rendered by Dr Das’ Lifeline Foundation may be of great significance and may be doing wonderful service. However, it is seriously objectionable to say that, it was because of efforts of his Lifeline Foundation the Gujarat Government passed the Emergency Medical Services Act-2007 and in the process 108 services were introduced in Gujarat and were expanded to 26 states through his initiative and contacts. To put the records straight and to bring facts for the benefit of the present and future generations, the pioneer and brain behind 108 Emergency Response Services is a Telugu man!

The then Gujarat CM and present PM Narendra Modi heard about the successful running of the 108 services in AP since August 15, 2005 and deputed Joint Secretary (Medical and health) in Gujarat government Ms Mona Khandar to Hyderabad to study the services. She visited 108 Services head quarters EMRI (Emergency management and Research Institute) during May 2007. Later, a team of EMRI officials that included me visited Ahmadabad and met its Chief Secretary and the Health Minister. It was followed by a series of correspondence. All the correspondence done between the EMRI and Gujarat was with my signature. Later a MoU between Gujarat Government and EMRI was signed and on Aug 29, 2007, CM Narendra Modi himself launched the 108 services in the State. Against this backdrop the Gujarat government came out with Gujarat Emergency Medical services Act 2007. Dr Subroto Das had nothing to do with this! When 108 services launched in Ahmedabad, along with the then CM Narendra Modi, former President of India Dr APJ Abdul Kalam, EMRI Chairman B Ramalinga Raju, EMRI CEO Venkat Changavalli were present on the dais. Ramalinga Raju was also present at the special dinner hosted by Modiji.

Many may not be aware these days the kind of relationship Ramalinga Raju had with the 108 services, described as the “Angel of Mercy” by the National Rural Health Mission way back in 2008. Need concept and evolution as well as the expansion of 108 services are not only interesting but precious material for those pursuing research.

When Satyam Computers, founded by Ramalinga Raju attained reputation nationally and internationally and earned him crores of rupees as profits, the philanthropic urge in Ramalinga Raju came to the fore. In the backdrop of this, on June 27, 2001 when Ramalinga Raju lost his father Byrraju Satyanarayana Raju, he along with his brothers established Byrraju Foundation on August 15, 2001. It started providing rural transformation services in 5 districts of AP that included extensive healthcare services that included three ambulances also. Subsequently these services were extended to 200 villages, directly or indirectly covering a population of a million. 25 different services were being provided in each village in areas such as healthcare, education, literacy, livelihood development, environment, Sanitation, drinking water, agriculture, sports, village BPOs known as Gram IT and emergency services. On July 16, 2003 Emergency Care Service called “Sahaya” backed by a call number +91 98494 54321 was started on an experimental basis. This covered 19 villages in Undi Mandal of West Godavari district which proved to an unmitigated service. This led to the formation of 108 services later.

Prominent among the first to help Ramalinga Raju were Dr Balaji, Dr AP Ranga Rao, Varanasi Sudhakar, Srikanth, Krishna Koneru, Srinivasa Rambabu and Polimallu Siva. These members and several others worked together to plan and execute the 108 services successfully. CEO of the EMRI for over five years, Venkat Changavalli was responsible for expanding the services to other States. It was worked out, that, by spending a meager Rs 10 on each citizen per year, the 108 Ambulance services can be made available all over the country.

Emergency Management and Research Institute (EMRI) was registered as a non-profit Society. It was modeled along the lines of 911 services offered in the USA. While providing the initial investment and infrastructural facilities, Raju signed a MoU with the then State Government on April 2, 2005. By July 14, 2005 infrastructure related to the Information technology was put in place. Due to the personal rapport Ramalinga Raju had with the then Union Telecom Secretary also happened to be a Telugu Person an IAS cadre from AP, J Sridhar Sarma, 108 number was allotted by Government of India a toll free number that can be used all over the country for ever and orders were issued accordingly. This was how the entire credit of getting 108 services goes to Ramalinga Raju. Sridhar Sarma gets the credit of making 108 toll free all over the country. Arrangements were made to launch the 108 services formally in Hyderabad.

Services were rolled out in Hyderabad and several cities and towns in the then AP. Chief Guest of the launching function in Hyderabad Grand Kakatiya Hotel was the then Union Communications Minister Dayanidhi Maran, while the Guests of Honor were the then CM Dr YS Rajasekhara Reddy, the then Finance and Health Minister (Later CM of AP and Governor of Tamil Nadu) K Rosaiah, and the then Chief Secretary Mohan Kanda. For the first time in the country the three-digit 108 number was operational.

Initially the services that were started with 75 Ambulances later expanded to 14 States with 10,500 Ambulances. In quick time EMRI was providing services in 10 different states in the country covering a population of 450 million people including Gujarat as supported by the then CM Narendra Modi. State Governments were providing most of the funding while EMRI part funded and managed the services in PPP mode. This was the time when Ramalinga Raju had to resign from the Chairman’s post following some unfortunate events in Satyam. Later GVK Group took the responsibility of running the EMRI. GVK Group made efforts to reach the services to another 35 Crore people benefitting on the whole 80 Crore people as on date. EMRI now covers a population of more than 2.5 times in the USA. It has cumulatively attended 48 million emergencies and saved 1.85 million lives so far.

After the then United AP, Gujarat was the first state to implement these services. It was followed by Madhya Pradesh, Uttarakhand, Tamil Nadu, Rajasthan, Goa, Assam, Karnataka, Meghalaya, Punjab, UP, West Bengal, Himachal Pradesh, Jammu and Kashmir. In 14 states 108 Ambulance services are provided to benefit 80 Crore people. Thanks to the efforts put in by the GVK Group, these services are available in Sri Lanka.

Facts should be stated as facts. They should not be distorted. A good work done by one should not be credited to someone else. The pioneer to launch the 108 service, which is saving lives of crores of people, in undoubtedly B Ramalinga Raju, former Satyam Computers Founder and Founder Chairman of the EMRI! This credit should have to go to him and him alone!

(Based on an interview with former founder Chairman Satyam Computers and founder Chairman EMRI 108 Ambulance Services)

Supreme Court Dismisses Public Interest Litigation against EMRI-108: V. Jwala Narasimha Rao

Supreme Court Dismisses

Public Interest Litigation against EMRI-108

V. Jwala Narasimha Rao

Former Advisor EMRI-108

Public Private Partnership

The Supreme Court on Thursday (18th November) dismissed a PIL which involved allegations against Emergency Management and Research Institute (EMRI), funded by the former Satyam chief, B. Ramalinga Raju. The apex court while dismissing the PIL observed that state governments are in a better position to make and implement policies regarding award of ambulance and emergency services contract.

The petitioners, Ambulance Access Foundation India, had alleged that a number of states had awarded contracts to EMRI funded by Raju, for running Ambulance and Emergency Response Services without observing proper procedure. The petitioner had sought adoption of transparent and fair process in awarding the contracts for running Ambulance and Emergency Response Service.

Rejecting the PIL, the apex court observed, "We are of the considered view that it would be appropriate that the various issues raised in this matter would be examined by the respective State Governments, who will be in a better position to examine and implement them depending upon the specific needs of those states like disease burden, health infrastructure, road connectivity etc."

The petitioners had alleged that there was discrimination in the awarding of the contract as no open tender was invited violating the spirit of Article 14 of the Constitution of India. Shri F.S. Nariman, learned senior counsel appearing for EMRI submitted that some of the States have already entered into MOU with EMRI and they have a well laid monitoring and review mechanism consisting of Advisory Council headed by the Chief Secretary and other senior secretary level officers of the State.

Learned senior counsel also submitted that issues and grievances raised by the petitioners have to be addressed before the respective State Governments. Learned counsel also submitted that there is no illegality in the process of entering into MOUs by the States.

The Supreme Court observed, "If there is any irregularity in the tendering process, already adopted by the various states, the same can be brought to the notice of the respective State Governments." The apex court also said that it is open to the petitioners and other aggrieved persons to approach the respective High Courts, if found necessary, as these courts would be in a better position to effectively supervise, taking into consideration, the local conditions and requirements.

Ten States have already entered into MOUs with EMRI for developing and operationalizing Emergency Response Services in their States.

Emergency Management and Research Institute (EMRI), a non-profit organization, is India’s largest, professional, integrated emergency management, research and training institute. Through a single toll – free emergency number 108, any individual, in any emergency situation be it Medical, Police and Fire emergency can call and get help in an average of 20 minutes. The 108 Emergency Response Services is dedicated to help save lives in an emergency. It has now has a fleet of 2,600 ambulances covering 400 million population in 9 states. It has so far saved 285,115+ lives with the help of 16,058+ employees and responded to 9.6 million+ emergencies.

COPY OF THE JUDGMENT

2010 STPL (Web) 947 SC Ambulance Access Foundation India vs. Union of India

2010 STPL (Web) 947 SC SUPREME COURT OF INDIA

(S. H. KAPADI, K. S. PANICKER RADHAKRISHNAN & SWATANTER KUMAR, JJ.)

AMBULANCE ACCESS FOUNDATION INDIA & ANR (Petitioner)

VERSUS

THE UNION OF INDIA AND OTHERS (Respondent)

Writ Petition (Civil) No. 518 of 2008­Decided on 18­11­2010.

Ambulance/Emergency Response Service

JUDGMENT

K.S. Panicker Radhakrishnan, J.­ This public interest litigation petition has been filed under Article 32 of the Constitution of India seeking a writ of mandamus directing Respondent No.1, Respondent Nos.2 to 13 and Respondent Nos.27 to 44 to put in a place a transparent and fair process in awarding the contracts for running Ambulance/Emergency Response Service in their respective jurisdiction. Petitioners submit that some of the States have already entered into and/or are considering awarding the nominated contracts and /or `tailor made' EOI process to Respondent No.14 to run Ambulance/Emergency Response Services in their respective jurisdictions in the name of saving human lives using funds under the National Rural Health Mission (NRHM) of the Union of India, which according to the petitioner will violate Article 14 of the Constitution of India.

1 Petitioners have stated that Respondent Nos.2 to 9 and 12 ­States have already entered into MOU with Respondent No.14 for developing and operationalizing Ambulance/Emergency Response Service in their State. Further it is also stated that Respondent No.13, the State of Maharashtra has approved the MOU with Respondent No.14 without any formal competitive bidding process or any transparency whatsoever in the MOU signing process.

2 In response to the notice issued by this Court few States have already filed their counter affidavit/response giving reasons for entering into MOU with the 14th respondent.

3 Learned counsel appearing for the petitioner urged that Union of India should lay down some guidelines in the matter of awarding and administration of MOUs/Contracts for emergency medical services in various states in public interest. Learned counsel submitted that they have made some suggestions which do not meet with the approval of the 1st respondent, fully. The stand of the counsel for the 1st respondent is that there are matters which are primarily to be considered by the respective State Governments.

4 Shri F.S. Nariman, learned senior counsel appearing for Respondent No.14 submitted that some of the States have already entered into MOU with Respondent No.14 and they have a well laid monitoring and review mechanism consisting of Advisory Council headed by the Chief Secretary and other senior secretary level officers of the State. Learned senior counsel also submitted that issues/grievances raised by the petitioners have to be addressed before the respective State Governments who are already seized of the matter. Learned counsel also submitted that there is no illegality in the process of entering into MOU by some of the States. For example, it was pointed that State of Gujarat has enacted the Gujarat Infrastructure Development Act 1999 as amended by Gujarat Infrastructure Development Act 2006 which permits selection by direct negotiations. Reference was also made to the Karnataka Transparency in Public Procurement Act 1999 under which there are provisions for selecting a particular person or group for implementing various government schemes without inviting tenders.

1 We are of the considered view that it would be appropriate that the various issues raised in this matter would be examined by the respective State Governments, who will be in a better position to examine and implement them depending upon the specific needs of those states like disease burden, health infrastructure, road connectivity etc. Further, petitioners have also contended that the awarding of contract to Respondent No.14 was discriminatory and contrary to the spirit of Article 14 of the Constitution of India since no open tender was invited before awarding the contract to Respondent No.14.

2 We are of the view that if there is any irregularity in the tendering process, already adopted by the various states, the same can be brought to the notice of the respective State Governments. Further, it is also open to the petitioners and other aggrieved persons to approach the respective High Courts, if found necessary, so that those courts would be in a better position to effectively supervise, taking into consideration, the local conditions and requirements. With the above observations the writ petition is disposed of.

................................................CJI

(S. H. KAPADIA)

...................................................J.

(K. S. PANICKER RADHAKRISHNAN)

...................................................J.

(SWATANTER KUMAR)

New Delhi;

November 18, 2010.

(Respondents Number 1-14 are: Union of India, State Governments of AP, Gujarat, MP, Tamil Nadu, Rajasthan, Uttarakhand, Goa, Assam, Haryana, Punjab, Karnataka, Maharashtra and EMRI-108 Services respectively)

Supreme Court Judgments @ www.stpl­india.in

Hypocrisy touches its nadir! : Vanam Jwala Narasimha Rao

Hypocrisy touches its nadir!

Vanam Jwala Narasimha Rao

Perhaps, the great poet Bernard Shah was right when he said “World is a stage and we are all actors.’ But, many of us, who are hypocrites only, chose to criticize politicians, day-in and day-out, for their unethical and immoral acts. Did we ever dare introspect what way we are different from an immoral or unethical politician?

The other day I happen to attend a function of an NGO firm with which I was associated for quite some time. The NGO firm was started by none other than once icon of state IT industry-turned alleged economic offender Ramalinga Raju of Satyam Group. For genuine cause, he floated Emergency Management and Research Institute (EMRI) to help save lives of those who get trapped in various life threatening situations. Although, this great concept was developed by a committed medical and social practitioner, Dr A P Ranga Rao, Satyam Raju had heart and courage to take it further.

He got the toll-free telephone number 108 through former Chief Minister Dr Y S Rajasekhara Reddy and pressed few Ambulances into service for this unique charity work. Later, the state government headed by late Dr Reddy took the initiative under Public Private Project (PPP) and took it to greater heights. Being major fund giver of the scheme, the Rajasekhara Reddy government, not only increased the fleet of Ambulances vehicles from Raju’s 70 to PPP operated to 802, but also, ensured engraving of their beloved leader Rajiv Gandhi’s photo on all of them. This not only helped derive maximum political mileage in electoral battles, but also otherwise. Now, nine more states too emulated the concept and executing it to perfection. Two more have signed MoUs with EMRI.

That being the backdrop, during its fifth anniversary celebrations of the unique services, a function held with Chief Minister K Rosaiah as Chief Guest and others attended, what surprised me was that of the four speakers at the function, except for the Chief Minister, even for name sake took the name of his predecessor as well as Ramalinga Raju, the main architect of this unique project. All of them conveniently avoided to eulogize the person (or persons) who created and started these great services in the state.

Today, Ramalinga Raju, who is just out on conditional bail after being in the prison as an under trial for the alleged floundering of funds, is yet to be convicted by the special court. In such a scenario, does recalling his good work done become a crime?

Aren’t those whom he trusted and given an opportunity to take this unique concept to greater heights now scared to take his name even in their wildest dreams? If this is not hypocrisy, then what else is? I can understand if Rosaiah, as a seasoned politician had not taken the name of a tainted member, but what prevented others to pick up courage and acknowledge the man who helped them to form part of the unique scheme or service?

What amazes me more is that some of the speakers taking the name of former President Abdul Kalam as visionary of the scheme? But, who brought Kalam on the board of EMRI? Wasn’t Ramalinga Raju? Surprisingly he along with few more Governing Board members deserted EMRI after Raju’s propelled exit as its chairman. Why these guys shy away from this fact?

Does the Chief Minister insist the organizers of the said function sought a categorical assurance that they will not take the tainted Ramalinga Raju’s name as a precondition to preside over the function?

Apart from this, as a former consultant of EMRI and to the best of my knowledge, Ramalinga Raju never ever neither craved to call it Satyam’s 108 nor ever insisted to engrave his company’s name on these ambulances.

Contrary to this, today, the other major corporate giant, GVK, which came forward to fund the scheme as private partner, chose to have company’s name on these 108 service vehicles. Whether it was GVK’s insistence or the government’s gesture, none of us are aware of it!

The CEO of EMRI, who in the past quite often used to mention how he got entangled into this unique scheme showering praises on its founder Ramalinga Raju, too, conveniently ignored to take his name at the function. Even the video film which had shown August 15th, 2005 launch photo covered Raju and shown others! Hence, I wonder what way are we different from politicians? Does Shakesphere’s statement stand testimony, at least in this context!

Need for Permanent “Health and Emergency Care Developmental Fund”: Vanam Jwala Narasimha Rao

Rededicate to Health-Care

Honor the Commitments of

Former CM Rajashekhar Reddy

Appeal to Chief Minister Rosaiah

Vanam Jwala Narasimha Rao

I am shocked to see an un-believable news report in a regional television channel that the state government has decided to put on hold its share promised for the life-saving and preventive Emergency and Health schemes respectively, introduced and implemented during former Chief Minister Rajashekhara Reddy’s tenure. Having associated for more than three and half years with one of these revolutionary schemes that saved 50000+ lives in Andhra Pradesh, and continue to associate with the second now, I have every reason to express my concern when attempts are said to have been made to dislodge them.

Yes, I am talking in particular, about the most popular 108 emergency response services - the first of its kind Public Private Partnership, pre-hospital care based ambulance services in our state, which forced several state governments to replicate and introduce and run in their respective states as efficiently as in this state. Media has also been reporting for over a week that there is un-rest among a section of associates working in two very important Healthcare Institutions, EMRI (Emergency Management and Research Institute) and HMRI (Health Management and Research Institute). Preliminary enquiries by media confirm that either non-revival of the funding pattern or non-release of agreed operational expenditure in advance as per MoU norms or cuts in the unit costs on some pretext or other has become a regular phenomenon being resorted by the concern departmental heads supported by the concern Minister. The private partner is left with no option except delaying the monthly payments like salaries not to speak of annual incremental hikes. Hence the unrest in some quarters as reported in the media could be true.

The two Institutions EMRI and HMRI-one to provide 108 emergency response services and the other 104 Health Information Help Line & Fixed Date Health Service respectively are the two most successful Transformational Institutions conceived and developed in the state while Dr Rajshekhar Reddy was Chief Minster. Many thinkers and doers-some behind-have been associated in defining, conceiving, designing, developing, implementing and replicating these health-care schemes. The day is not far-off when these schemes would become instrumental in putting Hyderabad and Andhra Pradesh in the world Health-Care Map as the key Hub of reforms.

Dr. AP Ranga Rao as the Principal Advisor to EMRI, besides conceiving the idea, helped in establishing a state of the art Emergency Response System in Andhra Pradesh which paved the way for 10 more states to adopt it catering to 80 million populations. His role included providing concept, Architecture, design, algorithms, processes, monitoring tools and advocacy with Government. Thanks to EMRI and the forward thinking governments in 10 states in India, today, in almost half of India any person, round the clock, when in emergency, can be confident of transportation facility to be reached to the nearest medical stabilization center within the GOLDEN HOUR, through a net work of Pre-hospital care based Ambulances, by just dialing toll-free 108 number.

EMRI aims to provide emergency management in a way similar to, or exceed the 9-1-1 system in United States of America. The vision of EMRI is to provide leadership through Public (Not-for-profit) Private Partnership-PPP framework to respond to emergency calls round the clock and save lives meeting global standards in Emergency Management, Research and Training.

Dr Ranga Rao also as the Chief Advisor to HMRI helped in launching and scaling two very important healthcare interventions namely a 24X7 Health Help Line and the Fixed Date Health Service (FDHS). The Health Helpline provides Medical Triage and Advice, Counseling to people seeking help for psychological problems and provides information on health providers with the help of 150+ directories through 104 toll-free telephone. FDHS serves the 4.2 Crore population through a Mobile Health Unit which visits a habitation once a month focusing on pregnant women, children and the elderly.

Both EMRI and HMRI as non-profit organizations were established by the state IT icon Ramalinga Raju of erstwhile Satyam Computers Limited-now the Tech-Mahindra. Ironically, today Raju who “made the things happen” by establishing EMRI is a tainted IT icon. But, his passion to serve the people and save their lives through this unique 108 and prevent health related problems through 104 and FDHS is appreciable.

Dr Ranga Rao’s efforts and Raju’s vision of saving lives and preventing health related problems were supported and are being implemented right from day-one by another management brain behind-Dr Balaji Utla, who was initially with EMRI and moved to HMRI later and continues as its CEO till today passing through all the hard times. Venkat Changavalli as CEO of EMRI from the day the first PPP MoU was signed with AP Government five years ago in the presence of Dr Rajashekahara Reddy, through his management expertise initiated and successfully expanded EMRI to 10 states. He continues to lead EMRI despite Raju’s absence.

Much greater than these souls, was the former Chief Minister of Andhra Pradesh, Dr Y S Rajasekhara Reddy, who understood well the importance of the scheme as a doctor to save people of his state. The first-ever Public-Private Partnership health scheme started paying rich dividends as it helped save thousands of people. The concept inventor, the entrepreneur Raju, the management experts and the former Chief Minister ably supported by the then Chief Secretary J. Harinarayana as well as the then Principal Secretary Health PK Agarwal and Commissioners CBS Venkataramana & Anil Punitha carried forward the scheme further. If the EMRI concept was to help people trapped in emergency situations like ‘accidents’ or ‘sudden sickness’ reaching quickly to hospitals to provide emergency care free of cost, then the HMRI is meant to provide other than emergency health care.

In brief, These PPP Models-the Emergency Health Transportation, Health Information Help Line, Fixed Day Mobile Health Clinics and Telemedicine Center have resulted in either saving lives in emergency or helped people to plan to save their own lives preventively.

These two schemes were incorporated into the government’s Rajiv Arogya Sree, which also provides insurance cover, and are being implemented successfully in the state government. These schemes not only won many accolades from the Centre, but also from international community. As a hardcore doctor, the former Chief Minister thought providing basic Medicare is the responsibility of the government and agreed to fund cent operational expenditure (which progressively was raised from nominal to Cent Percent with his personal initiative and intervention).

Chief Minister Rosiah who as Helath Minister and Finance Minister not only supported the schemes but also provided the required funds for all the schemes under the Rajiv Arogyashri.

Other states were quick to replicate in their respective states. Believe it or, one should not shy away if a developed nation and world’s super power United States of America, too had taken a leaf out of our health scheme as the second non-white leader introducing similar Health Bill in that country.

But, today, if one has to go by the channel’s report and media stories, the 108 services are being starved of funds and the government apparently is in a mood to stop its share to support the scheme. GVK who agreed to shoulder the Private Part of the responsibility, as per the channel reports is also passive in providing funds as far as AP is concerned for reasons better known to him. Well what is the truth behind the news is anybody’s guess.

I am sure and confident that, Rajashekara Reddy’s successor, K Rosaiah, who promised not to dilute the schemes of his predecessor would initiate steps to see that the PPP services in the Health and Emergency sector are not suffered even for a minute. He as the one who evinced keen interest as the Health Minister to sign the MoU s would shoulder the responsibility to prove the Channel’s report and media stories are wrong. He should check the facts whether the Finance and Family Welfare departments have stopped funding these two unique institutions, which wedded for yeoman service.

The best way to channelize the funds would be to create a Permanent “Health and Emergency Care Developmental Fund” by pooling NRHM, State Government and Private Contributions from many but not from one single source. For such huge schemes one Raju or one GVK means "dependence in uncertainty". The operational Expenditure need to be finalized through consensus between EMRI-HMRI management and Government well in advance before the financial year commences and the agreed fund has to be deposited in a Bank account to be Jointly operated by CEO s of EMRI, HMRI and Commissioner Family Welfare. Accountability mechanisms could be worked out.

Such an arrangement do not require a Private Partner like GVK but would certainly require management experts as CEOs like Dr Balaji Utla and Venkat Changavalli. Let the PPP concept be dynamic and not static for ever with the boundaries well defined.

Any deviation from the implementation of the scheme that, brought name and fame, besides great satisfaction of serving the people in true sense and any delay in releasing operational expenditure, would send wrong signals to the people. What would be the outcome of it cannot be assessed. If these schemes fail now in future it would be difficult to bring them back again.

“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.