An emergency medical service in Andhra Pradesh, Gujarat, Uttarakhand, Goa and Meghalaya has revolutionised health care in those States. Its success could bring political dividends this election season, writes A Surya Prakash
This is election time once again and you are certain to hear political experts pontificate on anti-incumbency and poor governance. Millions of Indians who are fed on a staple diet of cynicism by sections of the media would find it difficult to comprehend that good governance is a reality, at least in some States and that visible, and at times spectacular breakthroughs have been achieved in tackling hitherto unresolved problems. In other words, whatever the negative media may be dinning into your ears about the failure of the political class and the incompetence of the bureaucracy, the truth is that things are happening at the grass roots and the change is visible to those who are willing to cast away their political blinkers.
The best example of this is the comprehensive emergency response ambulance service that is now available in all parts of Andhra Pradesh, Gujarat, Uttarakhand, Goa and Meghalaya and is being introduced in six other States. This service, which operates with remarkable speed and efficiency, has been perfected and executed by a non-profit organisation called Emergency Management and Research Institute (EMRI) in all these States, and would easily classify as the most efficient public service programme in the country. Also, thanks to media skepticism, it is India’s best kept secret. People outside these States are largely unaware of the fact that it is bringing new hope to rural India and bridging the chasm between the villages and the cities at least in the area of emergency medical care.
EMRI was the brain child of Ramalinga Raju of the Satyam Group, who felt that India too ought to have an efficient and comprehensive emergency service like 911 in the United States. The non-for-profit organisation was launched in April, 2005 and Andhra Pradesh became the first State to ask for the service. Impressed by the success of the programme in Andhra Pradesh, Narendra Modi, the Chief Minister of Gujarat, decided in August, 2007 to operationalise the service in his State by March, 2009. But, as we are all aware, where there is political will, there is speed. Therefore, with Modi pushing it, the 400 ambulances needed to cover the entire State were operationalised six months ahead of the deadline — in September, 2008 itself.
Apart from Andhra Pradesh and Gujarat, the other States which have fully operationalised the emergency ambulance service are Uttarakhand, Goa and Meghalaya. In all these States, villagers say the ambulance reaches their doorstep in 15-20 minutes after a call to 108, a toll-free number, and takes the critically ill to the nearest civil or private hospital. This is a facility which even residents of Delhi and Mumbai cannot claim to have. Some other States which have taken the first steps to introduce 108 are Rajasthan, Karnataka, Assam, Madhya Pradesh and Tamil Nadu.
States can get much of the capital expenditure needed for this emergency ambulance service through the National Rural Health Mission, provided they have a clear plan of action and pitch for it the way Andhra Pradesh and Gujarat have done. The cost per unit ranges from Rs 10 lakh to Rs 16 lakh depending on whether the ambulance is equipped with Basic Life Support (BLS) or Advanced Life Support (ALS) equipment. The running cost (Rs 1.25 lakh per ambulance per month) is provided by the State Government. The running cost of the present fleet in Gujarat is about Rs 60 crore a year.
Andhra Pradesh first secured 500 ambulances and later added 150 more to its fleet. EMRI has now been asked to augment the fleet further with 150 more units. In Andhra Pradesh, each ambulance handles eight cases a day while in Gujarat it is approximately five cases a day. Govind Lulla, COO, EMRI for Gujarat, Maharashtra and Goa, says, “The golden hour is critical in medical emergencies because 80 per cent of the deaths occur within that hour.” Hence the value of the ambulance, which reaches every nook and cranny of a big State like Gujarat or Andhra Pradesh within 15 to 20 minutes. BLS ambulances have oxygen cylinders, suction pumps, cervical collars for immobilisation of the patient, drips and measuring instruments to measure oxygen level in the blood, blood glucose etc. ALS ambulances have ventilators and defibrillators. They can take an ECG and transmit the same to the call centre where physicians work round the clock and advise the Emergency Medical Technician (EMT) in the ambulance on pre-hospitalisation medication to be given to the patient. The ECG and the call centre doctor’s opinion is dispatched to the hospital where the patient is being taken, so that doctors in the emergency room in the hospital have sufficient information on the patient’s condition. The ratio of BLS:ALS is 3:1. EMRI handles 2,000 emergencies a day in Gujarat.
The figures for Andhra Pradesh are indeed mind boggling. The 108 call centre in this State has handled over 22 million calls during 2008-09 of which 1.7 million calls related to emergencies. Pregnancy-related emergencies topped the list with 22 per cent, followed by stomach aliments and abdomen pain (17 per cent) and accident trauma cases (16 per cent). Cardiac cases accounted for four per cent of the emergencies. In this State alone, 108 has saved over 40,000 lives until now.
Such is the efficiency of the system that sometimes it makes you rub your eyes and ask whether all this is happening in India. The system operates as follows: When there is a medical emergency in a village, the villagers call 108, which is a toll free number. The call centre directs the nearest ambulance to reach the village. It has an Automatic Vehicle Location and Tracking System (AVLTS). The physician (there are 13 of them at the call centre in Ahmedabad) decides whether to dispatch a BLS or an ALS to the scene. On reaching the village, the 108 crew get down to their task. Whenever necessary, the EMT calls the call centre, gets on line with a doctor and seeks his advice. He also arranges a conference call of a friend or relative of the patient with the doctor, so that everybody is in the loop with regard to the nature of the emergency and the course of treatment suggested by the doctor. There are 3,400 hospitals in Gujarat. By end of 2009, the Government plans to double this number and ensure that there are 7,000 hospitals in place. The emergency medical service is absolutely free and the ambulances take patients only to hospitals which have signed an MoU with EMRI for receiving patients and handling emergencies. In Gujarat, in the first 16 months, EMRI has handled more than 4.25 lakh cases, of which 1.21 lakh cases related to pregnant women being rushed to hospitals.
Every ambulance has a pilot and an Emergency Medical Technician (EMT). The crew is trained for 45 days.
The pilot learns about extraction of vehicles in accidents and dealing with similar emergencies. The EMT, who is a graduate in life sciences or nursing or pharmacy, is trained to deal with medical emergencies. Since this is a service-oriented activity, EMRI places a lot of emphasis on ethics and attitude. As Lulla says, “If the attitude of an applicant is not okay, we don’t hire him.” Members of the crew are not to even accept tips from people. Such is the training that the crew of an ambulance handed over foreign currency worth Rs 30 lakh to the victims of an accident after admitting them to a hospital. The car was involved in a crash while the family was heading to the airport to board a flight to Australia. The 108 crew took charge of their bags, cash and travel papers and handed them back to the family after admitting them in a hospital.
Those who step outside this ethical framework are fired. EMRI ensures quality and courteous service because of the autonomy it enjoys in its operations.
EMRI pays special attention to the recruitment process. Lulla says the catchment area is “good souls with right values.” Soft skills and value skills are as important as technical skills. Amit Desai, head, EMRI Gujarat, says the challenge is to get the right people and to train them. As Lulla points out, “This is not a Government job and those who join us must realise this. We tell them that if money is your objective, don’t come here.” EMRI currently has over 12,000 employees all over India. Desai says the employees like it because “they have the best of both worlds — corporate culture plus public service.” The emergency service runs like clockwork because of the hands-on approach of the management. Lulla, Desai and other top executives often accompany ambulances when on call and watch the crew at work. The training programme is designed to make the employees mentally strong and sensitive. “It is a combination of leadership, technology, innovation and research, which are the four pillars of the organisation,” Lulla says. “We want persons with passion, energy, modesty and reliability.”
The dedicated crew have made 108 a roaring success. This writer caught up with the crew of one emergency unit — Preeti Patel and Vyas Pratik, the Medical Assistant and Pilot of the ambulance — on the outskirts of Ahmedabad. Both of them do 12-hour shifts but women are exempt from the graveyard shift. The ambulance is well-equipped with several emergency facilities. It has disposable syringes and anti-snake venom, and equipment to deal with emergencies like drowning and poisoning. The crew also has a digital camera to get photographic evidence in medico-legal cases. This evidence is passed on to the police. All calls to the crew and from them are recorded and made available in medico-legal cases to investigators and courts. Both Patel and Pratik are happy with their jobs. They say there is a lot of job satisfaction because they are able to help people in times of distress.
Anyone traveling through Gujarat or Andhra Pradesh today can sense the positive vibes that 108 has generated in even the remote villages of these States. Villagers in Narmada, Mehsana and Gandhinagar districts of Gujarat and Srikakulam, Vizianagaram and Vishakapatnam districts of Andhra Pradesh, where this writer travelled to assess governance at the village level, swear by this service. Amazingly, although a “government service”, there was not a single complaint of corruption, bribery, inefficiency or bad behaviour of the crew in any of the villages of these six districts in these two States. This is indeed something extraordinary for a “government service” in India, but it is true. There is such an outpouring of public gratitude for this free and efficiently delivered critical health care service that it is certain to bring in political and electoral dividends for all the chief ministers who have introduced it. In that sense, this could be called a “108 Election” in Gujarat, Andhra Pradesh, Uttarakhand and Goa.
That there could be political dividends from good governance is evident from the responses of village folk in these States. Says Diheshchandra Kalidas Shah of Garudeshwar Village in Narmada district: “The ambulance is just a call away. It reaches our village in five or ten minutes. There is no payment to be made and there is no corruption.”
Mohammed Bhai of Chanwada Village in Rajpipla echoes this sentiment. “Just the other day there were several medical emergencies in our village. We called 108 three times and on all occasions, the ambulance reached the village in 15-20 minutes.”
Praise for the service is uniform across the villages of north Andhra Pradesh too. Sayamma of Kurupam panchayat in Vizianagaram district says that recently, when they called 108 even at 2 am, the ambulance reached the village in 15 minutes and rushed the patient to the General Hospital. Poovalapatti of Biyyalavalsa village in Vizianagaram district said that the fact that 108 is a toll free number added to the value of the service. “Even a person who is broke can call the ambulance,” he says. Jyotamma, secretary, Mahila Mandal, Durubili village, says, “Earlier we used to carry patients to the Civil Hospital, which is 7 km away. Now we have the ambulance in our village in 20 minutes.”
This is also probably the first “government” service that is free of corruption and inefficiency. Shikalu Ushansa Diwan, of Bunjatha Village in Narmada district says this of the crew of 108: “They are very courteous and efficient. There is no corruption and bribery involved. All are treated equally and with respect.” Ashwin Patel of Amjagaon in Gandhinagar district agrees. “We have no complaints. We have not heard of any kind of corruption or bribery. There is no problem with this service,” he says.
SK Goush, a social worker in Parvathipuram in north Andhra Pradesh, says the quality of the service is attributable to discipline among the crew. “Strict action is taken against erring 108 employees. Also, much attention is paid to maintenance. The vehicles are serviced regularly and the tyres changed after the mandatory mileage.” This is rather unusual for a “sarkari service” because even residents of big cities in India often see ambulances with flat tyres and in various stages of disuse lying in the courtyards or sheds of Government hospitals.
The most obvious spin off of 108 is the contribution of this quality emergency medical care facility in bringing down the Infant Mortality Rate (IMR) and the Maternal Mortality Rate (MMR) in the States which have ensured State-wide coverage. This has further been dovetailed to the Janani Suraksha Yojana (JSY), which seeks to encourage pregnant women to deliver their babies in civil hospitals or primary health centres. For example, in Gujarat, 3,800 babies are “108 babies” in that they were born in these ambulances. The State Government has urged rural folk to discourage “home deliveries” and to reach pregnant women to primary health centres and civil hospitals in time for delivery. Anganwadi workers, rickshaw pullers and many others have been roped into this scheme. They get an incentive if they call 108. This is helping the State bring down both Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR). The 108 crew also explains the advantages of the Chiranjeevi Scheme which offers a cash incentive of Rs 500 plus a saree to every woman who delivers her baby in an established medical facility. The villagers are told that by calling 108, they ensure proper medical care for the expectant mother and the baby. People in the villages of Gujarat say that while the cash incentive and the saree offered by the State is a major draw, rural folk have also realised that by going to the Civil Hospital they get proper medical attention both for the mother and the baby. The facilitators at the local level also get a cash incentive.
Yet another advantage of 108 is the remarkable boost it has given to the health care sector in Andhra Pradesh and Gujarat. The number of hospitals in Gujarat will double within a year’s time and Primary Health Centres and Civil Hospitals are getting upgraded. In Andhra Pradesh, 108 provides a crucial link between medical emergencies and Arogyasri, the health insurance scheme.
The third important advantage of 108 is the valuable data that it provides to health authorities, the State police and traffic planners on road accidents and accident-prone spots. It also offers valuable research data in a variety of other areas which help public policy formulation. It is therefore no surprise that India’s 108 is being hailed the world over for its extraordinary efficiency, social purpose and commitment and is being showered with international awards and accolades. So, if you belong to a State that has still not woken up to 108, do not despair. Make the best of this election season and extract a promise from the parties that seek your vote that they will introduce an efficient emergency medical care service. Gujarat and Andhra Pradesh may have got ahead of you but remember, it is never late to demand 108! Meanwhile, whether you like them or not and whether or not the media tells you what they have done in their States, do not be surprised if 108 brings in electoral dividends to YS Rajashekara Reddy, Narendra Modi, BC Khanduri and other chief ministers who had the foresight and political will to introduce an emergency ambulance service that would make us all proud.
. Here, too, delayed marriages and the ensuing fertility problems are held responsible. “Many couples marry in their mid-thirties, and some never get married,’’ said Berjis Desai, social activist and columnist on Parsi affairs. 
