In 2007, writing in EMSIndia, India’s first peer-reviewed publication on EMS, Tamorish Kole, MBBS, MRCS, FRSM, a former president of the Society for Emergency Medicine, India (SEMI), stated, “With more than 100,000 road traffic related deaths, 98.5% ‘ambulance runs’ transporting dead bodies, 90% of ambulances without any equipment/oxygen, 95% of ambulances having untrained personnel, most ED doctors having no formal training in EMS, misuse of government ambulances and 30% mortality due to delay in emergency care, India portrays a mirror image of the U.S. of the 1960s. The good news is that EMS has taken firm root in India.”
EMS has changed since the time it was commonly stated that, “EMS systems in India are best described as fragmented.”1 Today, India boasts an EMS system that’s expanded exponentially and geographically. It’s gone beyond the early concepts, and the focus has shifted from being injury centric to covering all emergencies. It’s changed from being urban oriented to being pan-India. Like in the United States, the primary focus is no longer on road traffic accidents. EMS is fast evolving as an integral part of healthcare system.
India has two different yet overlapping publicly funded ambulance systems, with both popularly known by their helpline numbers, 108 and 102. Between them, they have more than 17,000 ambulances across the union of 31 states and union territories. The allocated federal funds for the ambulance services in 2013-2014 was $59 million.2
India has a multitude of providers, especially in urban areas (individuals, charities, private and public funded hospitals, self-help groups, nonprofits, political institutions and parties, institutions of religious practice), that run ambulance services both for retrievals and patient transport.
In 2007, the Indian government approved the establishment
of an integrated network of trauma centers along India’s
busy highways to care for patients involved in motor vehicle crashes.
AP Photo/Surjeet Singh
The first attempt toward establishing EMS in India wasn’t a countrywide movement, but a city-based effort in 1985 in Mumbai where 15 ambulances were connected to a central wireless dispatch center by the Association for Trauma Care of India. This coincided with the centenary celebrations of the Indian National Congress.
This typically exemplifies the development of EMS in India, which hasn’t had a watershed moment like the U.S.; there was no white paper nor was EMS born out of a structured national policy. It was driven by passionate individuals and organizations desirous of changing the “transport vehicle concept of ambulances” to “lifesaving emergency medical transportation,” and keen on having an evidence-based EMS driven by technology and trained personnel and not restricted by wallet biopsy.
India has adopted primarily the older “scoop and run” model and not the Franco-German model. The country learned a lot from the U.S.; however, it has developed and continues to evolve its own systems to match its socioeconomic needs.
The provision of emergency services is enshrined in India’s Constitution. Failure on the part of any hospital to provide timely medical treatment to a person results in violation of the person’s “right to life,” as guaranteed under Article 21 of India’s Constitution.1
Although India has the fastest growing population and an ambitious growth aspiration, it’s always had a disproportionately small health budget, with one doctor for every 1,700 people and 21% of the world’s burden of disease.3
Almost 23% of all trauma that occurs in India is transportation-related, with 1,374 accidents and 400 deaths taking place every day on Indian roads.4 The rest of the 77.2% of trauma is related to other events such as falls, drowning, agriculture related, burns, etc.5
Out of every one million people, 42,800 die every year from sudden cardiac arrest in India.6 India also has the highest snakebite mortality in the world, with the World Health Organization estimating it at 30,000 every year.7
Prior to 1985, like in the U.S., ambulance services in India were driven either by municipalities, hospitals or charities; even today, though EMS is well-rooted, there’s still a heavy dependence across the country on such services.
The first change started in the mid-1980s in Mumbai, the financial capital of India. At the same time, similar but government driven steps were taken in Delhi, the nation’s capital. Work had started on the first state funded EMS in the Indian sub-continent, which in 1991 was launched as the Centralised Accident & Trauma Services (CATS) with 13 ambulances. CATS continues to be the backbone of National Capital Territory EMS with 151 ambulances stationed across the region attending to more than 150,000 calls a year.8
In 1989, in the first of the many judicial interventions in EMS, the Supreme Court gave a big impetus to trauma care by its landmark judgement on a public interest litigation. In a prime example of solitary effort by an individual, Parmanand Katara, the judgement, colloquially named after him, directed doctors and hospitals to provide treatment to road traffic accident victims without paper formalities necessary for other emergencies.9 It ensured that treatment of the injured would not be held ransom to police work delays.
Alongside this early evolution of EMS, various healthcare institutions initiated revolutionary changes inspired by global practices in the early 1990s. India started moving from “casualty departments” to protocol-driven EDs. Between 1994 and 1996, three institutes in Southern India led these changes, which over the next three decades academically and functionally transformed Indian EMS.
In 1994, the Christian Medical College (CMC) in Vellore became the first ED in the country to have a formal accident and emergency department.10 The same year, 100 miles away in Chennai, the Sundaram Medical Foundation (SMF) established the first ED in the private sector. Modeled on the American community hospital emergency system, the endeavor was supported by the Long Island Jewish Medical Center.
Another Chennai-based medical institution, Sri Ramachandra Medical College and Research Institute (SRMC), initiated ED-monitored ambulance retrievals. SMF started nursing triage systems, the first for the country, followed soon by CMC, which also became the first center to organize protocol-based multi-specialty synchronous involvement replacing sequential consultation in poly-trauma management.11 The following year, CMC conducted the first formal training program in poly-trauma in India, the Early Management of Trauma Course.12
The last year of the century was a momentous year in the development of EMS and emergency management. In Pune, 100 miles from Mumbai, a study that cited only 7% of city residents arrived in hospitals by ambulances led to a concerted effort in the city to launch its own non-government EMS, the Pune Heart Brigade, dedicated to out-of-hospital cardiac care.13
In addition, a few visionary EM proponents got together to host India’s first national conference on emergency management. EMCON 1999 was hosted by Hyderabad-based Apollo Group. This gathering catapulted EMS to a national level.
Close on the heels of EMCON 1999, the early proponents got together to form SEMI.14 Today, SEMI has grown to be the flag bearer of emergency medicine across South Asia, representing India at the International Conference on Emergency Medicine.
Incremental development of independent ideas started coalescing to spur the growth of EMS in the twenty-first century. It was inevitable that the world would take note of the happenings of EMS in India. In January, an Indian born U.S. practitioner, S. Balasubramaniam, MD, joined hands with the Pune Heart Brigade to form the EMS Council in Pune with 16 hospitals and five nonprofits conducting the first ever scientific study of interventions in out-of-hospital cardiac arrest.15,16
A month later, seven U.S.-based EMS experts and emergency physicians got together in Monroeville, Penn., to form the American Academy of Emergency Medicine for India (AAEMI), which was aimed at promoting emergency medicine in India.
Apollo Hospital Group launched its four-digit short code (1066) EMS helpline in Hyderabad, soon replicated in all other Apollo Hospitals nationally and scaled up to create the National Network of Emergency Services to coordinate ambulance networks across all its hospitals.17 This in turn inspired other multicity private hospital chains to create their own ambulance retrieval systems.
The new century also brought forth the significance of paramedics in EMS. SRMC started a bachelor’s program in emergency and trauma care technology with an intake of 46 students, the first University-recognized degree for EMTs in India; a master’s program was started in 2015.18 Many more teaching institutes have since replicated the model with small modifications in the curriculum.
Highway trauma care took firm root in India in 2002, when the Lifeline Foundation, a nonprofit based out of the western Indian city of Vadodara, in partnership with the National Highways Authority of India, created the first EMS for highways across large geographical areas.19,20
Using a geographic information system and a cellphone-based communication system, the initial efforts spanned 200 miles, later growing to a network of around 600 ambulance providers across 5,000 miles of highways in various states.
Meanwhile in Pune, landmark developments continued to take place including the innovative first two-wheeler EMS in India. This would be replicated in various Indian cities to counter India’s traffic congestion issues that hamper ambulance movement.
EMS Pune received recognition by the National Highway Traffic Safety Administration and be allowed usage of the Star of Life logo on its ambulance, a significant appreciation of Indian EMS.17
As training and education courses were developed to help create the base of the EMS work force pyramid, modular courses were found to be a cost-effective way to train medical and nursing professionals not directly involved in EMS but who were part of hospitals without proper EDs.
American Heart Association (AHA) courses were the obvious choice and once Apollo Hospital had become an international training organization (ITO) of the AHA, the floodgates opened. Today, India has 61 ITOs.21 International trauma life support was the next to follow.
The public healthcare delivery system in India starts at the subcenter level, each of which caters to the need of approximately 5,000 people. There’s a vast infrastructure of health services in India which is comprised of 146,036 subcenters; 23,458 primary health centers, and 4,276 community health centers as of March 2008.
Irrespective of this, the country hasn’t been able to provide timely and quality EMS to masses, particularly in rural areas. As per a report by the National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare, Government of India, a villager has to travel an average distance of nearly 20 kilometers (12.4 miles) for hospital care.22
The year 2005 changed that permanently, and brought about unalterable changes in EMS that continue to impact the lives of millions of Indians-the provision of free universal access to prehospital care. This was initiated by corporate leader B. Ramalinga Raju, founder and chairman of Satyam Computer Services, when the company took up EMS as its corporate social responsibility.
The Emergency Medicine and Research Institute (EMRI) in Hyderabad launched the 108 service, a state-level emergency response service, in partnership with the state government of Andhra Pradesh. EMRI signed various partnerships and memorandums of understanding to bring quality EMS systems into India, including partnerships with the National Emergency Number Association, the American Association of Physicians of Indian Origin (AAPI), the Shock Trauma Center of Stanford University, City of Austin (Texas) and Singapore General Hospital.23
Another important milestone occurred in March 2007, when the Lifeline Foundation started the first peer-reviewed publication, EMSIndia, a quarterly print and electronic publication that reached throughout India and into Sri Lanka, Bangladesh and Nepal. With a widening audience in the region, in 2014 it evolved into the Asian EMS Journal and became the official journal of the Asian Association for EMS with Lifeline Foundation as the editorial secretariat.24
The Supreme Court of India gave a big impetus to trauma care in its
landmark 1989 judgement on public interest litigation. AP Photo/Dar Yasin
Key U.S. Collaborations
Although the AAEMI was the first effort by Indians settled in the U.S. to help Indians back home, the American hand-holding reached higher levels as the AAPI took up the cause of EMS in India in 2004. Various AAPI subgroups continuously penetrated the mindsets of government decision makers to rewrite policy changes.
In 2005, a new Indo-U.S. collaboration was established for furthering the cause of academic emergency and trauma care in India with the first INDUS-EM held in Delhi.
This effort has grown over the years, with the subsequent formation of the INDO-US Academic Council for Emergency and Trauma Care involving representatives from various medical colleges in India, a leadership incubator for emergency medicine in medical colleges has been established.25
Hospital-based EMS collaborations with U.S. institutes soon followed, and a landmark collaboration with Stanford University in 2006 started the EMT-1 training programs.
Stanford would later extend its handholding in India to partner with EMRI to develop the first internationally-affiliated training programs for paramedics and paramedic instructors, district hospital physician training programs, evidence-based care protocols for the 108 services, and focused refresher training programs for EMTs.
Another significant partnership between the Association of Trauma Care of India and the American College of Surgeons brought advanced trauma life support courses to India.26
In 2007, the Indian Council of Medical Research (ICMR) and Centers for Disease Control (CDC)started a collaborative effort toward motor vehicle injury prevention and control in south Asia. This was later scaled up to create a road map for trauma system development in India.
Law & Policy Changes
As countrywide activism and support for EMS emerged, there were important changes in law and policy that helped EMS to evolve.
National Numbering Plan: A key issue in India has been universal accessibility to EMS. That changed in 2003 when India formalized the National Numbering Plan, leading to three-digit and four-digit short code helplines. The Emergency Disaster Management Service helpline was identified as 108; this became the de facto EMS helpline starting in 2005.
Gujarat EMS Act: In 2007, Haren Joshi, MD, a vascular surgeon from Florida, along with various national and international experts championed and enacted the Gujarat EMS Act in the Western India state of Gujarat. This was a watershed landmark in the development of EMS across the entire subcontinent, because it defined infrastructural and functional frameworks of EMS providers.
Highway Trauma Care: Also in 2007, following intense persuasion by various groups of individuals and nonprofits, India’s government approved the establishment of an integrated network of trauma centers along India’s busy highways connecting the major cities; the ongoing project, the biggest such exercise in Asia, aims at creating layers of prehospital and hospital-based trauma care along highways.
Paramedics move a wounded policeman on a stretcher into a hospital in
Srinagar, India, following a bomb detonated outside a police station. AP Photo/Mukhtar Khan
National Disaster Management Authority (NDMA): On the heels of the disastrous Gujarat earthquake in 2001, the Indian government enacted the Disaster Management Act on December 23, 2005. Over time, the NDMA has come up with guidelines relating to the preparation of action plans for medical preparedness and mass casualty management, the prevention and management of heatwaves, and the management of hospital safety and chemical disaster.
National Ambulance Code: Judicial interventions have always been part and parcel of India’s policy change initiatives, and EMS and ambulances have not been exceptions. In 2005, the Delhi High Court intervened to force the capital region government of Delhi to lay down standards for ambulances.
Taking a cue from this, the Ministries of Road Transport and Highways and Health worked to create the National Ambulance Code, which will be applicable to ambulances across the country. The code defines structural and functional requirements for
Good Samaritan protections: For years, Indians hesitated to help an accident victim and Good Samaritan laws weren’t in place to protect lay rescuers. Eighty percent of road accident victims in India don’t receive any emergency medical care within the so-called “golden hour.”
Seventy-four percent of bystanders are unlikely to assist a victim of serious injury because of fear of legal hassles, including police questioning and court appearances. And many citizens who desired to help victims are unaware of where to take them for emergency trauma care.27
In 2015, due to a judicial intervention following a public interest litigation by the nonprofit SaveLIFE Foundation, the government passed guidelines to protect Good Samaritans against harassment by police, hospitals and all other authorities under the directives of the supreme court. These guidelines now empower the community to respond to medical emergencies.
National EMS Hotline
The National Rural Health Mission (NRHM), a central government-funded program, is at the core of India’s public EMS, and the 108 is predominantly an emergency response system primarily designed to attend to patients of critical care, trauma and accident victims.28
Started in Andhra Pradesh in 2005, this flagship initiative is executed through a public-private partnership model in various states of the Indian federation where it was being implemented. It was then replicated on a larger scale in Gujarat, followed by other states.
The federal outlay for this project has been consistent with capital expenditure of ambulances being supported under NRHM and operational cost is supported on a diminishing scale of 60% in the first year, 40% in the second year and 20% thereafter.
The Telecom Commission has promulgated unifying all emergency services and making 112 as the official all-in-one emergency phone number in the country and phasing out all the existing emergency numbers within a year of roll out.29
India’s EMS Globalization
India’s healthcare industry is growing at a rapid pace and is expected to become a $280 billion industry by 2020 with a high percent of global stakeholder involvement. Improvement in healthcare infrastructure and facilities and ease of access to them is the only way India can fight against diseases. EMS is an integral part of India’s health and its growth is irreversible.
Indian EMS has gone beyond the national boundaries and many international organizations and manufacturers have partnered with Indian EMS providers. American and European academic institutions have and continue to provide expertise to Indian providers, hospitals and teaching institutes, and with Indian EMS growing at an exponential rate, more such opportunities are opening. Global organizations like American Medical Response and Global Medical Response have already established footprints in India, as have Stanford and George Washington Universities, as investors, consultants, academic partners or technical expertise providers.
There are over 100,000 vacancies available in India for trained EMTs who can be deployed in ambulances.30 India needs training organizations and investments to bridge this gap. EMS education is an area that invites global attention. There’s been a surge in training programs for nursing and paramedic training.1
With more than 17,000 ambulances in the government sector alone, and an equal number in the private and charitable sector, equipment requirements to comply with the new standards mandated by the National Ambulance Code have caught the attention of U.S.- and European-based equipment manufacturers, who now recognize there’s a big market for their products-from spine boards to high-end automated external defibrillators to software for computer-aided dispatch.
EMS conferences held in India, such as EMSASIA in 2014, increasingly attract growing numbers of global exhibitors. In 2019, India will host the Asian Conference on Emergency Medicine, which will likely be well attended by exhibitors, who are finding India a good entry point for the entire subcontinent as India’s neighbors begin to rely on India’s EMS expertise.
The nonprofit Lifeline Foundation partnered with the National Highways Authority of India
in 2002 to create the first EMS for highways across large geographical areas. Photo Subroto Das
Challenges Going Forward
Though significant development has taken place, the continued evolution of EMS in India will require collaborative input from various stakeholders in EMS and emergency medicine, academia and industry, as well as activists and lawmakers.
There are huge gaps yet to be addressed, such as the lack of legislation and accreditations for the EMS workforce. This gap has resulted in a very low level of accountability amongst the smaller EMS providers.
A word of caution comes from N. Bhaskara Rao, chairman for the Centre for Media Studies, Delhi: “Making emergency medical service legally compulsory without ground level preparedness will not be enough.” He adds that people need to be aware of their responsibilities toward fellow citizens and insist on and be aware of the best emergency service available.31
Another huge hole in India’s EMS infrastructure is the lack of facilities for EMS education of paramedics. Larger EMS providers address this issue by building their own training facilities, and the lack of legislation has led to the mushrooming of various training institutes with homegrown curriculum.
Though there has been a considerable improvement, there’s still a long way to go before comprehensive EMS is implemented across the country.31
There’s also an urgent need for a centralized medical emergency authority which would be responsible for preparing protocols, imparting technical assistance, training, capacity building and accreditation of emergency services. Procedures, protocols and personal skills need to be standardized along with the formation of legislation in parliament to provide legal protection for the providers of emergency services.22
Health information gathering, a key component of any working health system, is weak in low and lower-middle income countries such as India, which are perennially plagued by problems of having data that aren’t only poor in quality but also inadequate for properly informing health policy.32
In the case of India, this systemic weakness has long been identified and acknowledged by the government. The National Health Policy of 2002 recognized the dire need for systematic and scientific population health statistics.33 Initial assessments have identified several key issues such as lack of information on non-communicable diseases and injuries, dearth of primary data on causes of death, lack of private health sector numbers and insufficient data at the district level.34
India’s achievements with health data remain limited, despite being a pioneer among developing countries in establishing data systems: The National Sample Surveys was initiated in 1950 and the Sample Registration System in the 1960s.35 In each of these examples, however, EMS data collection is dependent on differing, incompatible databases.
As the years have gone by, the speed of development of EMS in India has hastened. It’s important to understand India’s EMS history and how we’ve progressed since 1985, and after the quantum leap we made in 2005. It is time to take stock of where we are now and consider the direction we need to take and the challenges we need to overcome. India’s EMS system is on its way to being a leader of EMS development in Asia and globalization could be the key to overcoming the challenges.
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