A day before Christmas, last year, two-and-a-half-year-old Rohan was playing at an Anganwadi centre at Doddakallur village in Sakleshpur taluk of Hassan district when he was bitten by a viper. It was 9.30 am. Rohan’s parents rushed him to the nearest primary health centre, where they were referred to a government hospital at Sakleshpur. However, the ‘108’ ambulance service had been absent here for the past six months.
The nearest ambulance was at least 30 km away. The parents arranged for a private vehicle just to reach the ambulance. The family was in the ambulance, en route to Hassan Institute of Medical Sciences, when Rohan’s vitals dropped at 12.30 pm. When they finally reached the hospital, it was for an autopsy instead of emergency care.
Rohan’s story is not an isolated example. In Kerala — a state with one of India’s best public health systems — there are several reports of deaths due to the non-availability of ambulances and poorly equipped vehicles. And if such cases are reported from southern states with relatively better public healthcare systems, one can imagine what the situation can be in states ranking low on public health indicators such as Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, Jharkhand and West Bengal.
Uneven progress
Medical emergencies, including road traffic injuries, constitute one of the major causes of death in India. But states have made uneven progress in improving the emergency services in hospitals and providing a well-equipped fleet of ambulances to take trauma victims and emergency patients to a hospital within the golden hour. The question, therefore, is whether India has an effective and accessible emergency care system in place, starting with the first necessity, ambulances.
As per the World Health Organisation, it is recommended to have at least one basic life support ambulance for a population of one lakh and one advanced life support ambulance for a population of five lakh. But that is only the minimum requirement. In a country like India, with the world’s largest population, high rates of accidents and varying access to basic healthcare, a robust ambulance system is critical to emergency care.
In the last Budget session of the Parliament, Bharati Pravin Pawar, the Minister of State in the Union Health Ministry informed the Lok Sabha that as on September 2022, there were 2,423 advanced life support ambulances, 17,135 basic life support ambulances, 3,676 patient transport vehicles, 17 boat ambulances and 131 bike ambulances.
Taken together, there are nearly 23,400 ambulances (excluding Punjab) supported by the Centre under the National Health Mission. In addition, there are ambulances run by state agencies, local bodies, NGOs and private persons.
But merely having the numbers on paper is not enough, as reports of families carrying the patients on their own and delayed arrival of ambulances in critical cases are common across states.
Delayed arrival
In January 2021, when the car of Union Minister Shripad Naik met with an accident on its way to Gokarna, it took an ambulance almost 25 minutes from Ankola to reach the spot. By the time the emergency service vehicle reached the location, the minister’s wife and personal assistant were dead.
In remote areas of Uttara Kannada district, the average wait time for an ambulance can go up to 1.5 to 2 hours, say doctors and residents.
In Jammu and Kashmir, a study conducted by the Indian Council of Medical Research in 2017 showed that the union territory has the highest number of deaths and disabilities caused by road accidents. In 2022, more than 800 people died on the road across J&K. Most of the wounded breathed their last on their way to hospitals in ill-equipped ambulances. While the situation has improved a bit in recent years, ambulances with advanced life-support systems are currently available only in four districts of Kashmir — Srinagar, Baramulla, Anantnag and Kupwara.
Down south in Kerala, a major issue is the unavailability of the 108 ambulance service when required, as the vehicles are in use for shifting patients to other hospitals. The government has taken up the matter following a couple of occasions where ministers encountered the problem when they dialed 108, seeking the ambulance service to ferry road accident victims to nearby hospitals.
There are hundreds of private ambulances in Kerala, which mainly cater to needs like carrying dead bodies or taking bedridden patients to other hospitals or laboratories or to their homes. These private ambulances charge exorbitant rates.
A recent audit of the 108 services in Karnataka brought up the strange case of an ambulance crew stopping for dinner, during which the person requiring the ambulance made four follow-up calls to enquire about the arrival of the ambulance. When the ambulance did not arrive even after 80 minutes, the patient was transported to a hospital in a private vehicle. He died on the way to the hospital.
While things have improved in major cities, it is the rural areas and tier-two cities that are still grappling with availability issues, says Mujtaba Hasan Askari, founder trustee of Helping Hand Foundation, an NGO which works in the health sector in Telangana. Facilities are especially lacking in tribal-domniated areas like Bhadrachalam in Khammam district.
Lack of training
Having ambulances alone, however, is not sufficient. “Even though 91 per cent of hospitals had in-house ambulances, trained paramedics needed to assist ambulance services were present only in 34 per cent,” says a study commissioned by the NITI Ayog on India’s emergency care services.
The provision of specialised care during ambulance transport is largely poor with only 19 per cent hospitals having mobile stroke/STEMI programmes (for heart attacks) and merely 4 per cent having a mobile stroke unit. Also, most hospitals lack a pre-hospital arrival notification system which informs emergency departments that an ambulance is on its way to the medical facility.
Even though emergency care accounts for a substantial part of patient load in hospitals, it suffers from fragmentation of services. Considering the highly time-sensitive nature of emergency cases, quick coordination between first responders, ambulance drivers and paramedics and in-hospital medical professionals is the key to patients’ survival. But many times, experts say, the linkage is missing.
The system is also handicapped by lack of trained human resources, funding, comprehensive policy and regulations.
The NITI Ayog study was carried out by professors from All India Institute of Medical Sciences (AIIMS), Delhi with data from 100 tertiary and secondary hospitals. It reveals that emergency and injury cases annually account for 9-13 per cent of all patients presenting to a health facility. They also make up 19-24 per cent of admissions in government and 31-39 per cent of admissions in private hospitals. On any given day, 11-30 per cent of patients visiting the OPD seek emergency care.
Despite high patient load, the number of beds available in emergency departments is only about 3-5 per cent of total hospital beds. Only half of the hospitals assessed by the AIIMS experts even had adequate spacing for emergency departments.
Most hospitals also lack the presence of general doctors, specialists and nursing staff dedicated to emergency departments even though they had sufficient human resources overall. Besides, most emergency care departments were found to be managed by junior doctors.
The way forward
In a separate study published last month, three medical researchers from the USA, UK and India flagged the flaws in India’s emergency care systems and suggested the way forward.
“There is an immense scope for improvement in the pre-hospital ambulance service and emergency care, including the development of a centralised ambulance and referral system along with pre-hospital staff capacity building that can transport the patient to the nearest and the best-suited hospital mapped on the national network to avoid overcrowding of emergency departments,” Asit Misra and colleagues wrote in the Journal of Global Health.
Two years back, Tamil Nadu launched a scheme under which accident victims on the highways could be rushed to hospitals close to highways for immediate treatment. The state-sponsored scheme provides for free treatment up to Rs 1 lakh for the first 48 hours in 609 hospitals, of which 408 are from the private sector. The scheme also covers those from other states and abroad.
Such schemes, experts say, are required in every state to lower road-traffic injury, along with a systemic overhaul of the emergency departments. “Due to increasing demand, massive expansion of emergency services and glaring skill gaps, there is a staff shortage inside and outside the hospital to provide adequate care. This situation is worsened by violence against emergency department staff, paramedics, and stress due to systemic burnout,” Misra and his colleagues wrote.
Vinod Paul, a former professor at AIIMS and member, NITI Ayog summed up the journey so far, “Accident and emergency services have witnessed uneven progress in India. Given its extraordinary importance, it is time that India embarks on creating a world-class, efficient, professional and integrated system, enabled by technology, for the care of any victim of accidents, emergency or trauma in any part of the country.”
(With inputs from Pavan Kumar H in Hubballi, Shilpa P in Mysuru, Arjun Raghunath in Thiruvananthapuram, Zulfikar Majid in Srinagar, Mrityunjay Bose in Mumbai, E T B Sivapriyan in Chennai, Mohammed Safi Shamsi in Kolkata, Sumir Karmakar in Guwahati, Naina J A in Mangaluru and Vittal Shastri in Kalaburagi)