HEALTH ON WHEEL – AN AGROGYA KAVACHA SCHEME IN
KARNATAKA
Dr. Shoukat ali M Magalmani1
Introduction:
India being developing...
of a higher level or more specialized field of care but also to transfer patients from a specialized
facility to a local h...
to provide relief (ii) ensuring the transport vehicle reaches the site emergency and (iii) providing
pre-hospital care whi...
e. Commissioner of Health Services - Member
f. Four nominees of CEO, EMRI - Members
i. The Council shall meet quarterly an...
 Provide mutually agreed daily (operational), monthly (administrative and
financial) reports and quarterly (fund utilizat...
Box 1: GVK Emergency Management and Research Institute
GVK EMRI (Emergency Management and Research Institute) is a pioneer...
Table 2: Cost of Ambulance used under 108 Arogya Kavacha Scheme
(Rs. In Lacks)
S No. Particulars of Cost Elements
Type of ...
Problems Faced by Arogy Kavacha Scheme:
In an emergency, everyone wants to help the victim. If an emergency occurs, then p...
 Public support is invaluable in constructing a successful EMS system; involvement is
required to plan a system that work...
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Health on wheel

  1. 1. HEALTH ON WHEEL – AN AGROGYA KAVACHA SCHEME IN KARNATAKA Dr. Shoukat ali M Magalmani1 Introduction: India being developing country, as it moving towards economic development and increase urbanization of cities, there is also a parallel need and concern of the public and the international business community for enhanced public safety services. A major part of which is the role of the Emergency Medical Services (EMS) System, which is composed of a network of resources (health care facilities, police, fire department, public health, rescue groups, volunteers, etc.) linked together for the purpose of providing emergency medical care and transport to victims of sudden illness and injury. As development progress, the establishment of EMS is mostly concentrated on urban areas and most often rural areas are not covered or not within the minimum response time standard. Meaning of Emergency Medical Service and Its Need: Emergency medical services may also be locally known as a first aid squad, emergency squad, rescue squad, ambulance squad, ambulance service, ambulance corps, or life squad.etc. The use of the term emergency medical services may refer solely to the pre-hospital element of the care, or be part of an integrated system of care. The term emergency medical service also reflect a change from a simple system of ambulances providing only transportation, to a system in which actual medical care is given on scene and during transport emergency medical services is dedicated to providing out-of-hospital for medical care, transport to definitive care, and other medical transport to patients with illnesses and injuries which prevent the patient from transporting themselves. The aims of EMS is to either provide treatment to those in need of urgent medical care, with the goal of satisfactorily treating the presenting conditions, or arranging for timely removal of the patient to the next point of definitive care. In most places in the world, the EMS is summoned by members of the public (or other emergency services, businesses, or authorities) via an emergency telephone number which puts them in contact with a control facility, which will then dispatch a suitable resource to deal with the situation. In some parts of the world, the emergency medical service also encompasses the role of moving patients from one medical facility to an alternative one; usually to facilitate the provision 1 Associate Professor, Department of Economics, J. S. S College, Vidyagiri, Dharwad, 580004. E-mail smmegalmani@yahoo.co.in
  2. 2. of a higher level or more specialized field of care but also to transfer patients from a specialized facility to a local hospital or nursing home when they no longer require the services of that specialized hospital, such as following successful cardiac catheterization due to a heart attack. In some jurisdictions, EMS units may handle technical rescue operations such as extrication, water rescue, and search and rescue. Training and qualification levels for members and employees of emergency medical services vary widely throughout the world. In some systems, members may be present who are qualified only to drive the ambulance, with no medical training. In contrast, most systems have personnel who retain at least basic first aid certifications, such as Basic Life Support (BLS). Additionally many EMS systems are staffed with Advanced Life Support (ALS) personnel, including paramedics, nurses, or, less commonly, physicians. During sudden emergencies that take place to the threatening of life, health, property, demands immediate attention. These emergency like situations may arise due to an accident in the day to day traffic, disturbance of peace & tranquility in the public life, diseases afflicting individuals like the Cardiac problems, respiratory problems, acute abdominal problems, animal bite, poisoning or over dose of the drugs, allergic reactions, unconsciousness, epilepsy, fever, infection, burns, strokes, pregnancy, environmental/ Industrial issues, assault/violence, behavioral, disaster etc. Unless immediate and effective responses are provided in such situations, it would be very difficult to contain the loss that may be caused to the life and properties. Road accidents & life style diseases are increasing day by day and the affected people need immediate and timely response. Also timely movement of pregnant women to the hospitals during the period of labour saves both the mother and child. This often requires a coordinated response from multiple agencies like police, fire and medical service. In this background, the Government of Karnataka conceived the Arogya Kavacha (108) Scheme 2008. Arogya Kavacha Scheme (108 Ambulance Service): The responsibilities of Emergency Management and Research Institute (EMRI), Secunderabad and the Department of Health & Family Welfare, Government of Karnataka are spelt out in the Memorandum of Understanding, The Government of Karnataka entered into an agreement with GVK EMRI on 14th August 2008. The 108 Arogya Kavacha Services in Karnataka was launched on 1st November 2008 by Sri A P J Abdul Kalam, Former President of India under the Public Private Partnership (PPP) with EMRI, to provide Comprehensive Emergency Management Response Services to the people of Karnataka. Arogya Kavacha Scheme provides a comprehensive emergency service. It integrates many emergency resources and provides sustainable round the clock safety to the citizens in a timely and effective manner through three contiguous sectors viz., SENSE, REACH and CARE. i.e., (i) Collection of the facts about the emergency and assigning the strategically located vehicle
  3. 3. to provide relief (ii) ensuring the transport vehicle reaches the site emergency and (iii) providing pre-hospital care while transporting the patient/victim to the Hospital for stabilization. While implementing the Scheme some of the conditions laid down by the Government of Karnataka, those are as follows, a. Emergency Management Research Institute, Secunderabad is declared as the Nodal Agency to implement Arogya Kavacha Scheme in the State. b. The total cost for implementation of this Scheme was Rs.221.25 crores from the period 2008-2009 to 2010-2011. c. The Nodal Agency and the Health and Family Welfare Department, Government of Karnataka shall enter into a Memorandum of Understanding. As per MoU, the Nodal Agency as well as Health and Family Welfare Department, Government of Karnataka, shall ensure successful implementation of the Scheme. d. The Nodal Agency shall implement this Scheme by providing 517 ambulance services in phase wise from November 2008 to March 2010. Table 1: Phase wise investment for Ambulance a s T h e Note: * ALS means Advanced Life Support, BLS means Basic Life Support e. Agency should provide the required manpower and train the personnel required for efficient emergency management response system f. The expenditure towards the salary of the personnel working under the private partner in this project should be met out of the funds provided under the National Rural Health Mission. g. In order to sort out any major problem encountered in implementation of this Project and also to suggest further improvements an Advisory Council under the Chairmanship of the Chief Secretary to Government of Karnataka should be constituted with the following: - a. The Chief Secretary - Chairman. b. Principal Secretary, i. Health & Family Welfare - Convener c. Principal Secretary, Finance - Member d. Principal Secretary, Home - Member Phase Period Number of Ambulances Phase I November 2008 to March 2009 150 (38ALS & 112 BLS)* Phase II April 2009 to March 2010 367 (92 ALS & 275 BLS) Total 517 (130 ALS & 387 BLS)
  4. 4. e. Commissioner of Health Services - Member f. Four nominees of CEO, EMRI - Members i. The Council shall meet quarterly and the recommendations of which shall be mandatory. g. Similarly to redress any problems being faced at the field level, there shall be Committees in every district under the Chairmanship of Deputy Commissioner with Superintendent of Police, the District Health & Family Welfare Officer and District Surgeon of the concerned districts as members. Two Members of the Chief Executive Officer of Emergency Management Research Institute, Secunderabad, shall also be Members of this Committee. Responsibilities of EMRI: The main duties and responsibilities of GVK EMRI as per MoU are as follows,  Establish and operate Emergency Response Services in Karnataka State.  Provide technological, leadership, administrative and managerial support as the Private Partner in an open and transparent manner to produce mutually agreed outcomes.  Provide the application software for the project free of cost.  Serve as a vital emergency management information and assistance resource and raise societal awareness of, and capability in, Emergency Management and Response mechanisms and thus save lives and reduce the economic impact to the citizens, firms and the government through appropriate awareness, education and capacity building programmes.  Operate the ambulances and ensure that ambulance services are available on a 24 hours per day and 365 days a year basis to the people in Karnataka, through the segment-wise operational headquarters decided by the Government of Karnataka where the ambulances will be located.  Recruit, train and position the required man power, including Pilots (drivers), and Emergency Medical Technicians [EMT] who will be present in the ambulances while shifting an emergency case to a hospital. Ensure that in every ambulance operated under this scheme, at least one Pilot and one EMT shall be present at any given point of time to provide patient- stabilization, first-aid and other pre-hospital care.
  5. 5.  Provide mutually agreed daily (operational), monthly (administrative and financial) reports and quarterly (fund utilization) statements to the Government of Karnataka.  Attend periodical review meetings held by the Government of Karnataka (physically or virtually) for the assessment of the operationalization of the scheme.  Maintain separate financial accounts and records of its operations in Karnataka. These accounts shall be annually audited by a Chartered Accountant firm as approved by NRHM / Government of Karnataka and furnished to Government of Karnataka by the end of the first quarter of the succeeding year in addition to any statutory audit. The Government of Karnataka reserves the right for special audit as & when necessary.  Attend emergency calls that are received at the Emergency Response Center as per the agreed performance benchmarks.  Provide emergency response services to police, fire & medical emergencies including pregnancy related cases on an average of 30 minutes in rural areas and 20 minutes in urban areas (in Plain areas) assuming reaching the nearest point of motorable access. However, EMRI will also identify critical locations on various roads for connecting to hill terrains and remote areas with appropriate transportation vehicles.  Bring in technology and service excellence and work towards improving delivery of emergency response of global standards over a period of time.  Assist the Government when required in Accreditation of Hospitals in the state and such other matters from time to time.  Conduct training programs for paramedics, doctors and other academic activities (workshops/seminars) as required for governmental doctors and others.  Strive for continuous improvement in emergency management through strategic partnerships, innovative programs, and collaborative policies.  Undertake applied research assignments in implementing Emergency Response Services in the field.  EMRI shall appoint & position a Chief Operating Officer (COO) to head Karnataka operations along with the required supporting staff for Karnataka.
  6. 6. Box 1: GVK Emergency Management and Research Institute GVK EMRI (Emergency Management and Research Institute) is a pioneer in Emergency Management Services in India. As a not - for - profit professional organization operating in the Public Private Partnership (PPP) mode, GVK EMRI is the only professional Emergency Service Provider in India today. GVK EMRI handles medical, police and fire emergencies through the " 1-0-8 Emergency service". This is a free service delivered through state- of -art emergency call response centres and has over 2858 ambulances across Andhra Pradesh, Gujarat, Uttarakhand, Goa, Tamil Nadu, Karnataka, Assam, Meghalaya, Madhya Pradesh, Himachal Pradesh and Chhattisgarh. With the expansion of fleet and services set to spread across more states, GVK EMRI will have more than 10000 ambulances covering over a billion population by 2011s Achievements of Arogya Kavacha Scheme: As per the MOU, Arogya Kavacha Scheme has been operationalised with effect from 01.11.2008. It has been successfully operating in the public private partnership model. EMRI has been allotted a three –digit number - 108 by the Government of India and made it toll-free across the State for all emergencies and can be accessed from land line and mobile without prefixing area code. Every emergency call made to the number 108 will be attended to by the emergency team in the call centre and that centre would ensure that the ambulance with paramedical staff and necessary equipments reaches the spot and necessary pre-hospitalization care is rendered to stabilize the victim/patient before being shifted to the hospital. By now, State has deployed 517 Ambulances out of which 130 are Advance Life Support ambulances (ALS) and the remaining 387 Basic Life Support ambulances (BLS). These Ambulances operates covering all the 30 districts. Each ambulance caters to a population of about one lakh to 1.1 lakh. Deployment of 517 ambulances also translates to a per trip distance of about 25 KMs which results into transportation of the patient/victim within the ‘Golden hour’. Out of the total emergencies, 95-98% is related to Medical emergencies including medico legal cases and the rest are exclusively for Police& Fire Cases. Since inception, the EMRI call centre has received 2.77 Crore calls by 21st Feb.2012 of which about 29% are ineffective calls. Following table2 shows the cost of ambulance which is used under 108 Arogya Kavacha Scheme in Karnataka. The advance life support ambulance cost about Rs. 18.40 lacks where as basic life support ambulance cost about Rs. 12.40 lacks. In BLS model ventilator and defibrillator facilities will not found. This BLS model is used for ordinary type patients. If it is very serious patients like cardiac arrest, severe accident patients ALS ambulance is used.
  7. 7. Table 2: Cost of Ambulance used under 108 Arogya Kavacha Scheme (Rs. In Lacks) S No. Particulars of Cost Elements Type of Ambulance Advance Life Support (ALS) Basic Life Support (BLS) 1 Basic Price 5.70 5.70 2 Fabrication including AC & Stickering 3.22 3.22 3 Ventilator 2.00 - 4 Defibrillator 4.00 - 5 Medical Equipment 2.00 2.00 6 Insurance & registration 0.28 0.28 7 AVLT 0.20 0.20 8 Shelter Cost 1.00 1.00 TOTAL 18.40 12.40 Source: Government of Karnataka, Directorate of Health and Family Welfare Service. Following table 3 shows the percentage break-up of various categories of medical emergency calls attended under the Arogya Kavacha Scheme. Pregnancy related problems attended by 43 percentage then followed by14 percentage attended for various injuries due to accidents and 13 percentage patients belonging to acute abdominal problems. It clearly indicates that large numbers of delivery deaths have come down due to this 108 ambulance service scheme. From this Arogya Kavacha Scheme the State has been able to provide a highly effective comprehensive emergency response service to the people of the State. Table 3: Medical Emergency Calls Attended under the Arogya Kavacha Scheme S.No.. Medical Emergency Category Percentage 1 Injury 14 2 Pregnancy 43 3 Respiratory Problems 5 4 Cardiac 4 Th Diabetes 1 6 Acute Abdominal Problem 13 7 Animal bite 2 8 Poisoning / Drug overdose 3 9 Others (include Allergic Reactions, Assault/violence, behavioral, disasters, environmental, epilepsy, fever, infection, burns, Stroke/CVA, Industrial, Unconsciousness etc. 15 Total 100 Source: Government of Karnataka, Directorate of Health and Family Welfare Service
  8. 8. Problems Faced by Arogy Kavacha Scheme: In an emergency, everyone wants to help the victim. If an emergency occurs, then people immediately rush to the spot, to help and provide medical help as soon as possible so that the live is saved. Every second in emergency counts and demands the appropriate medical help. The situation is so sensitive, that even a single wrong move can result to death of a person or to a lifelong disability. In this sensitive and urgent situation, to reach the hospitals the roads are not up to the mark. The traffic jam is one of the major problems in urban areas. Lack of awareness about the scheme in rural masses, lack of education, proper telephone facilities in remote controlled areas, lack of technical skilled workers in the ambulance etc, are the major challenges faced by 108 ambulance service. Apart from this unnecessary calls made by the people for fun is also one of the serious problems faced by the workers in Arogya Kavacha Scheme. Suggestions for further Improvement: For further improvement and modification and modernization of the Arogya Kavacha Scheme some the recommendation can be made. Those are as follow  Every hospital should develop its capacity and capability to manage emergency patients at the time of arrival to the facility and without delay or interruption in the continuity of care delivery.  First-Aid skills can save many lives and therefore this should be considered as a priority in training staff of all agencies being involved in the management of situations where emergency patients can potentially be met.  In rural areas the staff of the primary health care stations should be trained in First-Aid. All medical and paramedical staff should be trained accordingly.  The appropriate management should be arranged for emergency patients during transport towards hospitals.  Ambulances can be divided into two classifications depending upon its function and purpose into Basic Life Support and Advance Life Support Ambulances.  The medical emergency call center should have a permanent capacity to link with all the facilities of the network and to make appropriate decision for transfer of patients if no medical dispatching center is in charge of that activity.  The medical emergency call center and the hospital network must have an efficient coordination mechanism with the other emergency centers (police, rescue, etc.).  Physician input, leadership, and oversight are essential in ensuring that the medical care provided is safe, effective in accordance with accepted standards.  The coordination of the activities of the various agencies dealing with medical emergency patients should be organized within an inter-sectoral network.  Education of the public on the appropriate use of hospital emergency services or of emergency medical call centers is an important aspect that is usually neglected.
  9. 9.  Public support is invaluable in constructing a successful EMS system; involvement is required to plan a system that works for everyone. Consumers need to be well informed of the benefits of having an EMS system and how to gain access to it.  Another issue on adaptability is the effective use of resources. Conclusions: As India is fighting to strengthen its health care delivery system, pre-hospital care (emergency ambulance services) still remains the most neglected part of India's healthcare service system. The importance of pre-hospital care is especially important in the rural areas where immediate health care is poor and services are distant. Most people in India succumb to death due to non-availability of quick and good quality emergency medical support. Access to health care and equitable distribution of health services are the fundamental requirements for achieving Millennium Development Goals and the goals set under the National Rural Health Mission (NRHM) launched by the Government of India in April 2005, and Karnataka Health System Development & Reform Project. Many areas in the district predominantly tribal and hilly areas, lack basic health care infrastructure limiting access to health services to vulnerable at present. Taking the primary health care to the doorsteps is the principle behind this initiative and is intended to reach underserved areas. So for lacks of lives were save in this scheme. References: --------(2011); Healthcare scheme for cattle planned, The Hindu, June 1. Government of Karnataka, Directorate of Health and Family Welfare Service. Joshipura MK, Shah HS, Patel PR, Divatia PA. (2004); Trauma care systems in India – An overview. Indian J Crit Care Med. Levick NR, Donnelly BR, Blatt A, Gillespie G, Schultze M, (2001), Ambulance crashworthiness and occupant dynamics in vehicle-to-vehicle crash tests: Preliminary report, Enhanced Safety of Vehicles, Technical paper series Paper # 452, May Miller L, Board (2006): Air Ambulance Accidents Needless. Air Ambulance Accidents Should not Have Happened, Associated Press ABC News, 25 January. Ramana Rao G V (2011); Effective Patient Handover from Ambulance to Emergency Department: A Critical Component for EMS, Indian Emergency Journal / Vol-VI / Issue-II / September. Venkatesh M.(2011): Funds for rural health infrastructure diverted, IBN Live, Karnataka, December 30. http://pubsindex.trb.org/paperorderform.pdf. http://www.emri.in/index.php?option=com_content&task=view&id=158&Itemid=174

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