EMRI model - Indiagovernance.gov.in

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Study of Emergency Response Service (EMRI Scheme)With the emerging significance of the EMRI model as a preferred option for providing ERSacross most of the states in India, and its increasing support under the NRHM, the Ministry ofHealth & Family Welfare, Govt. of India, in November 2008, commissioned a review of EMRIscheme in selected states of Andhra Pradesh, Gujarat and Rajasthan, through the NHSRC.This appraisal would help the Ministry of Health & FW, Govt. of India, in suggesting replicationand improvement of the programme, and also help build systemic linkages so as to maximisehealth outcomes from this scheme.While assessing the EMRI model, this review has to address many of the issues that statesgrapple with. One such issue is related to the number of ambulances required to provide anemergency response of quality and another is the estimated case load each of theseambulances would have to deal with. These two issues have major cost implications. Also it isimportant to assess is the unit cost of this service – “per ambulance trip” and “per ambulanceper year”. One would also have to estimate these unit costs for different volumes of utilisationand distances and years of functioning. We may estimate that if EMRI were adopted by all thestates in India with an ambulance density of one ambulance per lakh population (which isrecommended by EMRI), we would need around 10,000 ambulances to cover the country. Thecost for this would be Rs. 1700 crores annually (current costs are approximately Rs. 17 lakhsper ambulance per year, taking both the operational as well as the annualised capital costs).Since this represents around 10% of current NRHM allocations, the government would need tosatisfy itself that the deliverables are being achieved in the most cost-effective way possible andthe service provider is also accountable for its performance. As government expenditure onNRHM is projected to reach Rs. 55,000 Crores per year by 2012, the ERS cost discussedearlier represents only 3% of it, and this by itself cannot be considered too high a cost forguaranteeing comprehensive ERS to all the people of this country. However this is based oncurrent utilisation patterns and density of ambulances deployed. If rising demand changes thecurrent ground rules, and if the provision within 20 minutes is insisted upon everywhere, thecosts could go up exponentially. There are also possibilities for making the system moreefficient 6 , and also estimating the break-even point beyond which rising utilisation will not furtherlower operational costs, even at optimal efficiency.On the service provision side of the ERS, the tie ups with hospitals are also very important inthis whole scheme as there has to be a linkage with a hospital that will be willing to providehospitalisation care to the poor. The investment and expenditure in transporting the patients to6 The per trip cost is likely to fall with increase in utilization(number of trips per day) and is estimated to stabilizearound Rs. 475/- per trip for an ambulance making around 8 trips per day, at current costs/prices. But as the prices offuel and medical consumables are expected to rise further, the unit cost can rise. Also stabilization of unit cost per tripdoesn’t stop the total operating cost per ambulance per year from rising, which will rise with the number of trips.National Health Systems Resource Centre (NHSRC)7
Study of Emergency Response Service (EMRI Scheme)the hospitals (free, without charging any fees for transportation) should be proportionate to thecost of providing the clinical management in the health facility (cost of treatment and theproportion of this, which is free). There are regulatory issues too regarding looking at ERS as aspecialised sub-branch within healthcare and the subsequent accreditation of emergencyparamedical staff.The larger issue is that if ERS becomes an entitlement under the proposed National Health Bill,as indeed it should become, then regulation would have a further positive content. That is therole of the state in guaranteeing universal access to such a service. In this context, both thefinancing of this scheme for different levels of utilisation and the mechanisms of governance andaccountability become much more urgentThe appraisal of the EMRI scheme was therefore proposed and initiated in this context. Within afew weeks of constituting and beginning our work and barely a few days of the first formalinterview with the EMRI, the crisis occurred in Satyam which involved its owner and chiefsponsor of EMRI. Though this had few direct implications on the study, the problems of liquiditythat EMRI encountered required states to make more advances, and for this purpose they werekeen to know the findings of this study. Also the states on the verge of entering into contractsalso started awaiting these findings. One immediate implication of this was that the study initiallyplanned as a six month work was now converted into a two phase study- one based on reviewof documents and interviews leading to a first phase overview report to be followed by a samplestudy and validation of data and a final report. Though this first phase covers almost all aspectsof the scheme, it is limited by the fact that it is entirely dependent on the secondary data takenfrom the EMRIs own reports. Though EMRI has been cooperative in sharing all the informationwe asked for, our information is limited to what is collected from them from their internalmonitoring and analysis systems and there is no independent validation of this data or primarydata collection.The Objectives of this study could be stated as follows:First Part:1. To examine and comment on patterns of utilisation of services in three sample states tounderstand present and potential demand for these services and the effectiveness ofEMRI to respond to this2. To review the operational aspects of EMRI scheme in the sample states of AndhraPradesh, Gujarat and Rajasthan. This would include operational efficiency of EMRI,financial management, and management of contractual obligations.National Health Systems Resource Centre (NHSRC)8
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EMRI model - Indiagovernance.gov.in

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