Fragmented ambulance services evolve into a modern system
Situated in the Indian Ocean, separated from India by the Palk Strait, Sri Lanka is the 25th largest island in the world (See Figure 1). Its complex geographical features-peaks, plateaus, valleys, rivers and tropical forests-are subject to a variety of natural hazards, including floods, landslides, cyclones and tsunamis.1
With ancient cultural roots going back to the 6th century B.C., Sri Lanka’s modern colonial history began with Portuguese, Dutch and British settlements in the 16th century. By 1815, Britain was the sole colonial power. In 1948, Sri Lanka became an independent country within the British Commonwealth, and in 1972 it became a republic.
From a public health perspective, trauma in Sri Lanka has become a significant factor. On average, road injuries kill one person every 4.5 hours.2 With an aging population and an average life expectancy at 74.9 years, Sri Lanka is seeing an increase in the prevalence of noncommunicable diseases such as heart disease, diabetes, cancers and asthma. With coronary heart disease and stroke as the top two causes of death, the country faces escalating health costs and a need for timely emergency care.3
First Efforts & Setbacks
Modern initiatives to begin a comprehensive EMS system date back to 2003, when a consortium of government agencies, the National Hospital of Sri Lanka and SweRoad, a privately-owned company of the Swedish National Road Administration under the Ministry of Transport and Communication, collaborated to draft an EMS plan and begin its implementation.4 In 2003, Anil Jasinghe, MD, director of accident service and Shiranee Hapuarachchi, MD, consultant anesthetist for the neurosurgical unit of the National Hospital, provided guidance and key leadership for the pilot project.
Prior to these efforts, private ambulance companies often based at hospitals, and voluntary agencies such as the Red Cross Society and St. John Ambulance provided ambulance transfers, but not in any coordinated way.
To support the efforts, the Colombo Municipal Council purchased four ambulances and trained firefighters as paramedics to support the system. 89 firefighters were chosen to participate in basic training. Of those, 30 were selected to receive paramedic instruction. On Nov. 8, 2004, the first three-digit emergency service line, 1-1-0, was launched as a service of the Sri Lankan police departments.
The Colombo Municipal Council’s EMS pilot project came to a halt with the effects of a devastating tsunami that hit Sri Lanka on Dec. 26, 2004. Triggered by a 9.2 magnitude earthquake in western Indonesia, the tsunami first arrived on Sri Lanka’s eastern coast two hours after the quake, and subsequently refracted around the southern point of Dondra Head. The refracted tsunami waves then inundated the southwestern part of Sri Lanka, after some of its energy was further reflected from impact with the Maldives. The civilian casualties, which included a train derailment which alone killed 1,700 people, were estimated at 31,000-second only to Indonesia.5
In 2005, with the support of Johanniter International from Germany, efforts to establish an EMS system were relaunched. Technical support and four fully-equipped ambulances were provided, with local implementation of the donations by St. John Ambulance Sri Lanka. With this infusion of equipment and training, the first EMS system was launched in August 2005, using the 1-1-0 three-digit telephone access number.6
U.S.-based Medical Teams International (MTI) arrived in Sri Lanka in 2005 and signed an agreement with the Ministry of Health to assist with expansion of EMS, which became known as the 1-1-0 Prehospital Care System. The Ministry of Health formed the Trauma Secretariat to reduce morbidity and mortality of the injured through prevention of secondary injury.
With the MTI partnership, the Ministry of Health Sri Lanka and Trauma Secretariat published the first Sri Lankan edition of an EMT textbook in two native languages, Sinhala and Tamil. An EMT skills video was also created and released on DVD. Both the textbook and related video series have been recognized by the Sri Lanka’s Ministry of Health as the standard of training for EMTs.
MTI trained 2,700 EMTs in Sri Lanka from 2005 to 2010, using the approved materials and local trainers as partners. MTI, the Ministry of Health and local government health ministries collaborated to develop prehospital systems in nine districts outside the capital city of Colombo. Four of the district programs-Colombo, Badulla, Galle and Kandy-are fire-based systems. The Anuradhapura and Kurunegala prehospital care systems are based at regional hospitals, and the programs in Jaffna and Mannar were developed using the resources of the regional director of health services.
In 2011, MTI departed Sri Lanka and a group of former MTI staff started Med1 Ltd., a private company that focused on providing prehospital care services to Colombo and its suburbs. Med1Ltd. launched their services with a different public access number (1-9-9-0) and they were the first organization to launch motorcycle first responders to emergency calls.
In 2013, Med1 Ltd. was bought by Falck International to launch their services in Sri Lanka as one of the largest emergency medical service providers in the world. They had intended to provide an island-wide EMS as a private entity. After failing to expand their services outside of Colombo, Falck ceased to provide service in 2015.7
A Region at War
Development of EMS in Jaffna deserves special mention. Centered in the heart of a civil war that raged from 1983-2009, the Jaffna system began by providing transportation to the hospital for emergencies that occurred during wartime curfew periods. From 6:00 p.m. to 6:00 a.m., the ambulances were the only vehicles allowed on the road. Communications were difficult and conditions were dangerous.7
Separated from the rest of the country by the war, the only access to Jaffna was by air or sea. The Red Cross Society and St. John Ambulance Services in Jaffna invited MTI to train their staff, who was transporting patients during the curfew.
Later, MTI worked with the regional director of the Jaffna health services office leverage their resources and establish an EMS system. Jaffna received financial support for their efforts from the U.S. Agency for International Development.
With the arrival of peace, the Jaffna EMS system, which charged a nominal voluntary fee, was officially launched on Feb. 28, 2009. The system responded to more than 2,000 emergency calls in its first 11 months of operation. By 2016, the provincial council expanded the 1-1-0 system to serve the entire northern region.
Figure 1: Map of Sri Lanka and South India
Support from India
According to the World Health Organization (WHO), emergency care requires three main components: 1) community care; 2) care in health facilities; and 3) care en route from one location to another location.9A lack of centralized communication, inconsistent EMT training standards and a lack of public awareness about appropriate use of ambulances were some of the factors that presented obstacles to care during transport.10
Against a historical patchwork of volunteer services, commercial ambulance companies, hospital-based services, and an underutilized fire department service that responded primarily to trauma, Sri Lanka was clearly in need of a more effective EMS system.
In July 2016, ambulance services commenced in three provinces-a groundbreaking initiative that was the result of intervention by Indian Prime Minister Narendra Modi. With a personal interest in emergency response, Modi was well aware of the successful track record the GVK Emergency Management and Research Institute (EMRI) Company had in his country. EMRI, assisted by Stanford University Emergency Medicine International, had begun operating in India in 2005. Its ambulances now provide emergency care to three-quarters of India’s population. EMRI’s expertise was ideal for expansion to India’s southern neighbor.11
In Sri Lanka, the major change agent has been Deputy Minister of Foreign Affairs Dr. Harsha de Silva. While recognizing the high status of Sri Lankan healthcare in the region, he acknowledged that “the only lacuna that existed was in gaining timely access to emergency ambulances with trained paramedical staff.”12
The Indian grant of US $7.6 million provided for 88 ambulances, as well as training, at GVK EMRI in Hyderabad, India, for Sri Lankan emergency providers: 250 EMTs, 250 pilots and drivers, and 50 call center operators.12
EMS in Sri Lanka Today
Citizens may now call 1-9-9-0 to access free care. Public awareness of this new service has been promoted by print, radio, television media and via blanket texts from the major cellular telephone companies.
The new, modern ambulances, stationed at police stations, are now coordinated by a state-of-the-art command and control center located in the Rajegiriya area of Colombo. Vehicles can be tracked throughout the course of a transport. Medical control and advice is available at the center by trained physicians. Ambulance services, which began in the southern and western provinces, are provided free of charge.
The Sri Lankan Society of Critical Care and Emergency Medicine, which guided the development of emergency medicine, has taken on the responsibility of maintaining EMT training for the program.
Phase two of the undertaking, scheduled for early 2018, calls for more than 200 additional ambulances to be deployed in the rest of the country.
- Peiris, GH, Arasaratnam S. Sri Lanka. (Sept. 13, 2017.) Britannica. Retrieved Sept. 26, 2017, from www.britannica.com/place/Sri-Lanka.
- Perera C. Legal aspects of motor traffic trauma in Sri Lanka. Egyptian J Forensic Sciences. 2016;6(4):341-346.
- Sri Lanka: Life expectancy at birth. (n.d.) CountryEconomy.com. Retrieved June 25, 2017, from www.countryeconomy.com/demography/life-expectancy/sri-lanka.
- Sri Lanka Ministry of Healthcare and Nutrition. EMS. (n.d.) Trauma Secretariat. Retrieved June 24, 2017, from www.traumaseclanka.gov.lk/index.html.speedy-emergency-medical-service-launched-8793.html
- Moore M, Ritcie M. (Dec. 23, 2014.) How the Boxing Day tsunami unfolded, hour by hour. The Telegraph. Retrieved Sept. 26, 2017, from www.telegraph.co.uk/news/worldnews/ asia/indonesia/11309215/How-the-Boxing-Day-tsunami- unfolded-hour-by-hour.html.
- Sirimanna B. (Aug. 19, 2012.) Speedy emergency medical service launched. Sunday Times. Retrieved Sept. 26, 2017, from .
- EMS provider Falck exits citing commercial unviability. (June 10, 2015.) Daily Mirror. Retrieved June 23, 2017, from www.dailymirror.lk/90137/ems-provider- falck-exits-citing-commercial-unviability.
- Zimmerman JR, Bertermann KM, Bollinger PJ, et al. Prehospital system development in Jaffna, Sri Lanka. Prehosp Disaster Med. 2013;28(5):509-516.
- Razzak J, Kellerman A. Emergency medical care in developing countries: Is it worthwhile? Bulletin of the WHO. 2002;80(11):900-905.
- Wimalaratne K, Lee JI, Lee KH, et al. Emergency medical service systems in Sri Lanka: Problems of the past, challenges of the future. Int J of Emergency Med. 2017;10(10):1-6.
- Sri Lanka starts emergency paramedic service backed by India. (Aug. 12, 2015.) Economy Next. Retrieved June 22, 2017, from www.economynext.com/Sri_Lanka_starts_emergency_ paramedic_service_backed_by_India-3-2636-.html.
- Sri Lanka launch first free pre-hospital care ambulance service with Indian grant. (July 28, 2016.) Lanka Business Online. Retrieved Sept. 26, 2017, from www.lankabusinessonline.com/sri-lanka-launch-first-free-pre-hospital-care-ambulance- service-with-indian-grant/.