108 & 104 totally dissimilar services

Telangana State Technology Services on behalf of National Health Mission of Family Welfare Department, Government of Telangana, issued a notification for Request for Proposal (RFP) for Selection of Agency for Setup, Operations and Management of 108 Emergency Medical Ambulance Services (EMAS), 102 Ammavodi Services, Free Hearse Services and 104 Health Helpline recently.

The salient features of the scope of work, eligibility criteria and prescribed formats for submission are provided in the RFP document as uploaded on the Telangana State government eProcurement system website. The notification says that interested parties are requested to submit their pre-qualification, technical and financial proposals. Besides this, the government also decided to close 104 Fixed Day Health Services and sell ambulances. This heralds yet another step in implementing these services.

Having worked for four years in 108 services and four years in 104 service in united Andhra Pradesh, as a PPP (Public Private Partnership) consultant and having closely associated with their expansion to several states, I am well aware of the need, concept and evolution of these most successfully operated PPP schemes. 108 was steered by its CEO Venkat Changavalli and 104 was steered by its CEO Dr Balaji Utla. The conceptual frame work for both 104 and 108 was designed and developed by Late Dr AP Ranga Rao as Medical Advisor while the initial funding was provided by Satyam Computers Ramalinga Raju. The government extended funding support as part of Public Private Partnership Scheme.

In fact, the concept and operation of these two services are distinctly different from each other; both are dissimilar and hence they were operated separately. In combining them for operation in future, the government may have its own valid reason and better performance.

108 was conceptualised in the united Andhra Pradesh, with a desire to design, build and operate, a robust medical emergency system. On 15th August 2005, this service launched the first fleet of 15 ambulances in Hyderabad. By August 15, 2007, the State government had 700 ambulances running on its 108 service. Later they were expanded to several states. The 108 Emergency Response Services came into existence in the context of an approximate 75,000 different kinds of emergencies ranging from road traffic accidents to cardiac every day across the country, that often became fatal for want of immediate relief, a single toll-free number; an accredited ambulance; pre-hospital care and a single nodal agency to coordinate the various operations.

At that time, there were multiple helpline numbers, no standardised ambulances that offered pre-hospital care and merely functioned as transporting patients without the requisite equipment or expertise to stabilise the patient on way to hospital. Three critical facets of the 108-emergency response service were Sense, Reach and Care (S-R-C).

When one dials 108, the call lands at the Emergency Response Centre, where a communication officer (CO) receives it. The CO takes down the relevant details, fills them on the screen and sends it to the dispatch officer who has some medical training, who takes the call from call taker, validates the information about when and where the incident happened, locates the nearest available ambulance and relevant hospital, and accordingly transfers this information to the requisite ambulance personnel. This is part of the Sense process.

The Reach process starts when the ambulance receives information and proceeds to the emergency site. While heading to the site, the team gets in touch with the caller, who could be the victim, a relative or a friend, and asks them to take some basic precautions like ensuring the patient breathes properly. These suggestions fall under pre-arrival instructions so that if the ambulance takes 15 minutes to reach, both the patient, their family and friends remain calm during the whole process. Each ambulance covers a population of about 80,000-1,00,000 on an average.

The Care process starts at the site of the incident. These trained ambulance personnel offer immediate relief like stopping the bleeding in the event of injury, splint the patient in the event of a fracture or put the patient on a defibrillator or ventilator in case of a heart attack. They check for clear airways, ensure the patient is breathing and that the blood circulation is maintained.

At the hospital, the ambulance hands over the patient and collects an acknowledgement in the form of PCR (Patient Care Record), that contains the patient's basic details and vitals at the time of transfer to ambulance, during the travel and at the time of handing over. Vitals include body temperature, SpO2 levels, pulse rate, respiratory rate, and other such signs. Due to these ambulance services, an average patient's vitals have improved at the time of handing over.

EMRI (Emergency Management and Research Institute), which operated 108 services, provided a rigorous two-month training programme to BSc graduates, on human anatomy, physiology and pathology, followed by knowledge on how to identify types of emergencies and what must be done to save the patient under each situation. The students practised on mannequins, rode in the ambulances as trainees and then posted in an ambulance. Every six months, 'refresher training' was provided.

Technology was used in ambulances for pre-hospital care. A GPS system was put in place to track the nearest ambulance and relevant hospital and an automatic vehicle location tracker system. Within 6 years of launching, the 108 Services was handling 12,000 emergencies per day in 12 states – 3,200 ambulances serving 430 million people – all free of cost. Now 108 Services are available in most of the states and run by a vendor selected through tender route responding to around 40,000 emergencies per day with 8,000 ambulances. Initially there was no tender process and instead selection process.

While this was so, 104 is a unique beneficiary outreach program commenced in united AP in 2008, aimed to providing free primary health care services through Mobile Medical Units (MMUs), at the doorstep of the beneficiaries, especially in areas that are hard-to-reach through a Fixed Day Route Schedule. Accordingly, this mobile service covered rural populations living in villages that are more than 3 km away from the PHC on a monthly basis in accordance with a fixed time schedule.

The principal objective of this innovation, that is hugely popular particularly among the elderly, was to diagnose and treat persons suffering from diabetes, hypertension etc., at a time when there was no state government programme for addressing these two morbidities that were emerging as serious concerns within the community. The principal function of the MMU was to diagnose, test and treat the patient by providing the required medicines for the month or as required.

The concept of a centralized state level call centre or health information centre to make available authentic and standardized health information requirements to individuals was conceived leading to the establishment of the first ever Health Information Help Line in the then United Andhra Pradesh initially with the funding support of Satyam Computers Ramalinga Raju and immediately supported by late Dr YS Rajasekhar Reddy Government. The then Government of AP funded the HMRI (Health Management and Research Institute) which started the 104 HIHL in Feb 2007. GOAP funded the operations completely. It was servicing 35,000 calls per day 24x7 with toll free 104. It was closed in 2011.The 104 HIHL, receives calls and provides services like, medical advice, accurate information on national disease control programs, health care providers etc.

By managing these services under one single agency if a better performance could be achieved then it is certainly a welcome feature. It is better if experienced persons are consulted.

(Writer is a former consultant for 108 and 104 services; With inputs from Venkat Changavalli and Balaji Utla)