This month’s EMS Around the World column is an excerpt from William A. Haseltine’s 2018 book Every Second Counts: Saving Lives With India’s Emergency Response System (Yatra Books).
An emergency medical response system is a critical and often-overlooked requirement for universal healthcare coverage. Emergency medical care integrates different health system components that are necessary for delivering universal health coverage.
Emergency response systems save lives by delivering prehospital care for several life-threatening emergencies. An effective emergency medical response system can dramatically reduce neonatal and maternal mortality. The rapid transport of victims of two of the most frequent causes of death, heart attacks and stroke, to a hospital where they can receive care requires a well-functioning emergency response system. Similarly, household accidents such as falls (among the elderly) and burns (in children) are best addressed by rapid transport to a nearby medical facility.
Despite the vital role emergency systems play in connecting urban, suburban, and rural communities, the role of effective ambulance systems is often neglected in the roadmap for achieving sustainable development goals. The Emergency Management and Research Institute (EMRI) of India personifies the profound impact a high-quality, universally accessible, and affordable emergency system can have on the general population. I contend that no system of universal healthcare coverage is complete or even effective without careful integration of the ambulance service with other medical services and facilities.
Launching a System
India created a near-universal world-class emergency system within EMRI within a decade. The impact has been astounding. It validates the idea that, with the right design, intention, and partners, governments can create systems in a relatively short period to provide access to high-quality, affordable healthcare for their people.
EMRI connects 750 million citizens in India to high-quality, universal emergency care. As of early 2018, the institute has responded to 56 million medical, police, and fire emergencies, served close to 19 million pregnant women, and assisted close to 500,000 live births. Daily EMRI receives 150,000 phone calls, and responds to 24,000 emergencies.
EMRI provides an on-the-ground response to emergencies by an ambulance carrying lifesaving drugs and staffed by trained emergency technicians, within 15 minutes in urban areas and 25 minutes in rural and tribal areas. The service costs less than U.S. $15 per emergency, which is less than 1% of a U.S. 9-1-1 emergency response cost. The service is universal and free to the recipient.
EMRI deploys more than 10,000 ambulances and employs more than 45,000 highly skilled personnel, who respond in urban, semi-urban, rural, and tribal areas. The institute has trained half a million emergency responders within these communities.
Today EMRI, now known as GVK EMRI, is the world’s largest integrated emergency service created as a public-private partnership, with the participation of 15 state governments in India.
The institute uses world-class quality and data monitoring and information management systems. This kind of innovation was born in one of the most complicated and resource-constrained environments in the world.
The emergency services were started as a trial program by the founding organization, EMRI, with 75 ambulances serving five cities and 30 major towns in the former undivided state of Andhra Pradesh in August 2005. EMRI now serves 14 states and two union territories (territories governed directly by the union government of India).
The services managed by EMRI, alone or in partnership with other private-sector organizations, field 11,000 ambulances and employ over 20,000 medical and paramedical professionals. The Indian conglomerate GVK is currently in charge of the management of EMRI, which is run as a corporate social responsibility initiative of the GVK Foundation. The current management is discussing with a few South Asian governments taking the model to their countries. In 2016 the Dial 1-0-8 emergency response service was adopted by Sri Lanka with the help of EMRI.
The Dial 1-0-4 services were initiated by the Health Management Research Institute as a public-private partnership with the government of Andhra Pradesh in 2007 to run a health information help line. The main objective of setting up the mobile health service was to provide online medical assistance to people, particularly in rural and remote areas, with limited or no access to qualified medical practitioners. The help line gives health advice to callers to bridge the information gap and provides information on referral services through a teleconsultation.
The emergence of both these services is the story of political leadership working together with the nonprofit private sector with the common aim of improving the availability of and access to important public goods. In the case of emergency services, the professionalism of the private sector, coupled with strong political backing and the indispensable support of the government, is an essential part of the story of how a small trial program became a national asset.
Sustenance and Growth
Financial sustainability and cost efficiency are important qualities of the EMRI system. The system provides a complete range of integrated emergency care services at a cost of 24 cents (U.S.) per citizen per year. The operating and maintenance costs of one ambulance are around USD $2,000 per month.
Each ambulance travels about 6,000 kilometers per month. The average cost of running an ambulance is 30 cents per kilometer. This is on par with the cost of running a good taxi service in India, with the main difference that the ambulance carries emergency medical equipment and trained paramedics. The network can run and sustain the service at this low cost even in the most remote parts of the country.
The concept behind EMRI’s provision of services is an innovation developed wholly within India. The not-for-profit nature of the enterprise greatly facilitates public and government acceptance.
Government acceptance is also key to public perceptions of legitimacy. The emergency response system is supported by the government for its operational and financial efficiency. The idea behind it was well received by the political leadership for its potential to touch many lives.
As a result, government funding has been consistent, which has helped the system grow. EMRI facilities are today the largest emergency care provider network in the world. Twelve years later, EMRI envisions saving countless lives annually.
William A. Haseltine, PhD, is an American biologist, entrepreneur, and philanthropist known for groundbreaking work on HIV/AIDS and the human genome. He has taught at Harvard Medical School and founded several biotechnology companies. He is founder, chair, and president of ACCESS Health International, a not-for-profit organization dedicated to improving access to high-quality healthcare worldwide.