Emergency response is a very important aspect of healthcare services. Ambulance services play a critical role in the delivery of emergency response services. What is the state of such services in India? Do we have adequate number of ambulances? What is the quality of such services? Here is a detailed story.
It is well known that easy & timely availability of ambulances can save a lot of lives, especially in case of emergencies. The state of emergency medical transport i.e. ambulances is a vast issue. In this article, let’s look at the number of operational ambulances across states and various studies that evaluate the functioning of ambulance services with various parameters.
To get an understanding of the total number of operational ambulances, we take stock of the state-run ambulances and commercial vehicles being used as ambulances. We gather data for state-run ambulances under National Rural Health Mission (NRHM) and state-run ambulances at Health Care Centers from Quarterly National Health Mission Report (June 2019 update). The data on commercial vehicles being used as ambulances has been gathered from Road Transport Year Book 2016-17.
In understanding whether the operational number of ambulances across states meet established standards, we take World Health Organisation’s (WHO) benchmark of at least one ambulance (emergency response) per 1 lakh population in the plains and estimate the required number of ambulances based on mid-year population projection published in National Crime Records Bureau reports. It has to be noted that this benchmark refers to the number of ambulances in the centralized emergency response system like 108 in some states and not the total number of ambulances available in the country, which includes private ones as well. The Emergency Management and Research Institute (EMRI) which manages the 108 service also talks about roughly one such ambulance for every one lakh people.
The National Health Mission website highlights that at the time of launch of NRHM in 2005, ambulance networks were non-existent. Now 33 States/UTs have the facility where people can Dial 108 or 102 for calling an ambulance. Dial 108 is predominantly an emergency response system, primarily designed to attend to patients of critical care, trauma and accident victims etc. Dial 102 services essentially consist of basic patient transport aimed to cater to the needs of pregnant women and children though other categories are also taking benefit and are not excluded.
Do we have enough ambulances to meet the requires standards?
Here is a comparison of the total number of ambulances operational across states and required number of ambulances as per WHO standards. It has to be noted the WHO standard pertains to a centralized public emergency response system and is not about private ambulances.
On the other hand, the data on private ambulances is available only up to 2016-17 and for several states, the data for commercial vehicles being used as ambulances was not reported in the Road Transport Yearbook. Even the available data pertains to those commercial vehicles registered as ambulances. There could be other vehicles used as ambulances but are not registered as ambulances. It is also surprising to note that in certain big states, there is not a single commercial vehicle that is used as an ambulance. It could be a case a data gap and hence the total number of ambulances across the country could be much higher.
Except for the state of Andhra Pradesh, all other states have reported a higher number of total ambulances as compared to the required number of ambulances as per WHO standards. This means, that the number of ambulances across states does not fall short of international standards set by WHO, at least in the reported figures.
However, the reported number of operational ambulances do not necessarily signify their functionality, access & qualify of infrastructure among other things. Multiple studies across different states that have evaluated various aspects of the functionality of ambulance services have highlighted gaps in these services.
Evaluation of ambulances services
According to a study conducted by AIIMS in 2012, summarised in the Wall Street Journal, reports that Delhi had 152 state-run ambulances. Of the city’s state-run emergency vehicles, only 21 have advanced life-support facilities such as defibrillators, ventilators and drugs for use in critical or trauma-related cases. Ten vehicles have basic life support systems without drugs or ventilators and the rest are basically white vans with stretchers. It was found that 28% of the 70,768 emergency calls received between March 2009 and May 2010 in Delhi were refused because of the shortage of ambulances.
A number of irregularities and issues have surfaced around the functioning of 108 services in recent years across states. One of the most rampant issues is that of sub-optimal response time and calls not being attended. Non-adherence to stipulated response time in delivery of the 108 service has been observed across several states. The mean time was between 41 to 47 minutes, as per the Comptroller Auditor General (CAG) report from Madhya Pradesh (2017). Further, the CAG report from Odisha observed that ‘during 2013-14 out of the total call received, ambulances were dispatched in 5.43% of calls’. Further, the audit report noted that ‘no details regarding calls not attended were recorded in the database’.
A more critical issue related to poor governance is that of insufficient supervision by state governments. CAG Reports from Kerala (2015), Orissa (2015) and Madhya Pradesh (2017) highlight oversight issues such as lack of due diligence in the tendering process, rising costs and idling of ambulances due to procedural delays in tender procurement, fabrication, delay in payment of operating expenditure to the private provider, inadequate performance monitoring, and forwarding commercial gains at the expense of public interest.
An article published in Economic & Political Weekly on 23 June 2018, summarising relevant newspaper reports and literature, argues that there are signs of complacency and compromise in the delivery of 108 services. It highlights another issue related to the non-fulfilment of conditions of the memorandum of understanding (MoU). Conditions like maintenance of equipment and vehicles, geographic information system (GIS) tracking, skill upgradation, networking with government hospitals, and generating awareness among the public about 108 services were not fulfilled as per the timeline prescribed.
While there are ample number of evaluation reports and studies, there is also a dearth of useful data in the public domain to determine the quality of ambulances services. As the report by Health Systems Resources Center in 2009 emphasises that there needs to be independent monitoring of appropriate response to the emergency call, the time in which patients were reached, the quality of stabilization care that was provided during transport. Quality data on these aspects is essential to evaluate the quality of these services.