Nirbhaya, the young physiotherapy intern who was gang raped in a private bus in Delhi last year, became a household name in India for several reasons. Sadly, one of the reasons why she died was the delay of emergency care provided to her in the nation’s capital. Her companion had told in an interview, that passers-by did not come for their rescue for 30 minutes after they were thrown out of the bus and they lay by the road side naked and bleeding. And the police who reached the scene wasted more time by debating about jurisdiction. Today whether you are a resident of Mumbai or Assam, Kerala or Punjab, it is simply a matter of luck, whether you will get good medical care during an emergency. “There is a general lack of awareness among public and policy makers about what emergency medical care is all about. In most cases it is only understood to be an ambulance intervention, where a vehicle would be deployed,” says Piyush Tewari, founder of SaveLIFE Foundation. “Majority of ambulances are not able to provide any care to the victim. They only transport from point A to point B and are not able to stabilize the patient. The equipments or trained professional required to save someone’s life are missing,” explains Tewari. Emergency medical care is a systemic paradigm, where an entire system works towards saving a patient’s life. The chain of survival includes three major elements- What happens to the victim when he/she is lying on the road, when he/she is transported to the hospital and the care provided to victim in the hospital. Clearly, today nobody has moved the cheese when it comes to standard ED protocol or training practices for the existing workforce. “At present at most of the hospitals across the country, Emergency Medical Services are provided by MBBS graduates who work as Casualty Medical Officers (CMO) s or Medical Officers on the basis of whatever knowledge they received from their course and nurses who assist the doctors,” says Indrajith Khandekar, associate professor at Mahatma Gandhi Institute of Medical Sciences in Maharashtra. Last year, he submitted a 40 page study entitled “Emergency Medical Care in India-a cause of concern” to union and state health ministries and Medical Council of India (MCI). “Today at MBBS level there is no syllabus and university exam for emergency medical care,” adds Khandekar. Hiring of trained doctors also remains a challenge. “Majority of the hospitals in India have primitive 'casualty departments' which are manned by untrained doctors, many who are not even MBBS qualified. The biggest challenge is to get the hospitals to recruit qualified emergency medicine doctors, nurses and ambulance paramedics to take care of their emergency patients,” says Imron Subhan, a consultant emergency physician, at Apollo Health City, Hyderabad. The expert also says that acceptance of EM speciality within the hospital eco-system is still a challenge. “It takes time and effort for a new EM physician to prove that he/she is an expert in emergency care,” adds Subhan, who is also the administrator of the website www.emergencymedicine.in. According to Khandekar, an average Indian is vulnerable even after reaching the hospital during golden hour due to inadequate training in relation to emergency care. Khandekar also shares an anecdote to prove his point. “One of the patients brought to ED department of my hospital died due to incompetence of a young graduate. This is primarily because of inadequate practical emergency teaching curriculum for undergraduate students and interns prescribed by MCI. As interns they spend only two weeks at casualty during their internship period,” adds Khandekar, who had filed four PILs regarding this issue. Another source of concern for several EM physicians is that MCI has not included emergency/casualty department as academic specialty department in the list of 21 departments (as minimum requirement to run a medical college in the country). “The same is true with nursing education,” adds Khandekar. So what is the price paid by a nation of 1237 million people for the gaps in our emergency medical systems? One look at the survey conducted by SaveLIFE Foundation will tell you the whole story. The survey conducted by SaveLIFE Foundation last year states that 74 percent of bystanders are unlikely to assist a victim of serious injury irrespective of whether they are alone at the spot or in the presence of others regardless of whether there were others on scene or not. But why is it that citizens are reluctant to help victims? 88 percent of respondents who were unlikely to assist injured victims stated that they were reluctant to help for fear of legal hassles including repeated police questioning and court appearance. Interestingly, 77 percent of respondents, who were unlikely to assist injured victims, also stated that hospitals unnecessarily detain good Samaritans and refuse treatment, if money is not paid. The survey findings gain added importance in light of more than 1,35,000 deaths caused by road accidents in 2012 alone and the on-going debate that calls for a ‘Good Samaritan Law’ for India especially after the Delhi gang rape incident. No legal framework for Emergency Medical Services One strand of debate regarding emergency medicine is whether an appropriate legislation on emergency medical service can save lives. Piyush Tewari’s observation that a Good Samaritan Law can save lives of people is representative of this view. But before we inquire in to how a law can improve the quality of care, let us look in to some of the examples of countries where similar legislations have been enacted. “Many European countries with good EMS systems have a good Samaritan law that protects the citizens who help trauma victims and provides them immunity from civil or criminal liability. “In India because of the legal hassles most of the citizens are reluctant to come forward and help the victim,” says Tewari. “If we pass a law like Emergency Medical Treatment and Active Labour Act (EMTALA), which defines how emergency care is to be provided in the country to different kind of victims and create a systemic approach to trauma care, large number of people can be saved every year, “explains Tewari. Jesse Pines, professor of emergency medicine and health policy at George Washington University in Washington seconds his view. “The first thing that India can emulate is the legal framework in US that requires hospitals that accept government funding (i.e. Medicare and Medicaid insurance payments) must provide a medical screening exam and stabilize patients who present to the emergency department. EMTALA was passed in US in 1986,” says Pines. Beyond that, there is much that other can learn from the emergency care system in the US that does a great job taking care of the critically ill and injured. “However, the US is going through major reform in payments, which will make emergency departments focus more on care coordination,” adds Pines. The Law Commission of India has also taken up this issue and in its 201st report entitled ‘Emergency Medical Care to Victims of Accidents and during Medical Condition and Women under Labour’, mentioned that there is no appropriate legislation regarding the subject. It has given recommendations and a draft model bill for the purpose of emergency treatment of victims as early as 2006. Law Commission acknowledges that the state government must frame a scheme of reimbursement to hospitals, medical practitioners, ambulances and those who provide vehicles for transport. According to the draft model bill submitted by the commission the state must notify an authority which will deal with reimbursement. “The state must set apart substantial money for purpose of reimbursement. The scheme must provide for the procedure for reimbursement. This scheme must be published in State Gazette,” states the report. Numerous judgements of Supreme Court of India also reflect the fact that emergency care is part of right to life enshrined in Article 21 of the Constitution of India. The corner stone of several campaigns regarding the right to emergency medical care is the Supreme Court ruling on ‘Paramanand Katara v. Union’ of India. The verdict came on petition filed by Paramanand Katara regarding the death of a motorist severely injured in a road accident. He was refused admission when taken to the nearest hospital on the excuse that hospital was not competent to handle medico-legal cases. The apex court in its landmark judgement said that “Article 21 of the Constitution casts obligation on the State to preserve life. A doctor of the Government hospital positioned to meet this state obligation is, therefore, duty-bound to extend medical assistance for preserving life.” Then court also said that not only Government hospitals, but also “every doctor whether at a Government hospital or otherwise has the professional obligation to extend his services with due expertise for protecting life.” Initiatives to address emergency care With mounting pressure to increase emergency services, even the government has taken some concrete steps to improve the quality of care. Today, there has been an active transition from private ambulance services to public ambulances. Most private healthcare facilities realize that their earlier thought of increasing ambulance fleets to provide coverage to catchment areas is no longer a viable strategy. Most institutions have scaled back their EMS programmes as the quality and availability of public ambulances has risen. Many of these public/not-for-profit agencies have realized that it’s not just important to have the equipment, it’s more important to focus on what can be achieved with that equipment. So, while the initial challenge was building a quality ambulance, today this has transformed in to a renewed focus on paramedic and EMT education and training in India today, which is essential towards the delivery of quality pre-hospital care. The National Skills Development Council (NSDC) has been instrumental in developing criteria and scope of practice for EMS personnel in India. “Today Indian healthcare as an industry is bursting at its seams. There have been many dramatic changes in healthcare sector over the past decade and I believe many sectors in India are waking up consciously to the concepts of Emergency Medicine,” says Anunaya Jain, national service line manager of neurosciences and emergency medicine at Apollo Hospitals. Yet, it has taken the sector sometime to internalize the concept of emergency medicine. To put it in another way, part of the problem in India has always been and will always continue to be-barriers to access quality healthcare for the majority of rural population. So, while the central bureaucracy for a majority of the 1990s and early 2000s focused their energies on the daunting task of reinvigorating a dysfunctional primary healthcare system in the country, there was a parallel move by the private healthcare sector to channel their interests on delivering acute care to patients in urban and semi urban areas. “Although this did start for most institutions as a marketing exercise, it has quickly transformed in to a quality differentiator and a source of competitive advantage. Many institutions now have specific budgets allocated for development and recruitment within the Emergency Departments. Further, there are significant investments being made in to procuring technological advances from point of care testing to diagnostic imaging equipment dedicated for the EDs,” explains Jain. In theory, some of the most significant changes in the Indian EM scene have come in EM education. The Medical Council of India (MCI) approved emergency medicine as a speciality in 2009. There is also transition in both the type of specialists-development of the specialist emergency medicine physician instead of untrained MBBS or cross trained anaesthesia and critical care physicians- and the content of their training (development of comprehensive EM residency programmes instead of shorter training courses focusing on basic resuscitation skills). “There continues to be a dominance of joint residency/training programmes crafted with universities from outside of India and perhaps a dilution of the skill and competence of physicians who have practiced and developed emergency medicine at the frontlines in India itself. The introduction of DNB and MD Emergency Medicine courses should hopefully help us to course correct in that direction. Many young graduates today are more aware about the global scope of emergency medicine and pursuing this as an active career choice,” says Jain. Interestingly, it’s the desire to overcome issues of access in healthcare that gave birth to the idea of using IT in emergency departments. “While the latter half of the last decade saw an increasing focus on electronic medical records systems, there is a significantly increasing focus from the health information industry towards the development of an IT backbone to support clinical decision making and research activities within the Emergency Department, as well as resource planning and management in the EMS sector. There is also a growing focus on e-Health and Telemedicine to support outreach during medical emergencies, strategies that are perhaps essential to overcome access blocks that exist in our country,” adds Jain. Perhaps, the best way to understand emergency medicine is to see it through the eyes of those who see it most clearly- as a clinical issue. Venugopal PP, chief of emergency medicine at Malabar Institute of Medical Science (MIMS) in Calicut is a man who has experienced best and worst of trauma care in private healthcare sector. “In order to chart a better course for our future, we should focus on community based initiatives. Our laws and blind spots have created conditions that lead to the death of thousands of citizens every year,” says the physician. Through his initiative Active Network Group of Emergency Life Savers (ANGELS),Venugopal had created a network of bureaucrats, physicians, medical students and ambulatory care providers to offer pre-hospital care to the citizens. In doing so, he tapped in to the community, and led to the development of a not-for profit trust, which won several international accolades including the Asian EMS award. Today the range of services offered by ANGELS includes ambulatory care to training for volunteers as well as emergency technicians who are absorbed for the network. “The core issue at the heart of emergency medicine in India is shortage of trained professional to offer the services. Even though Medical Council of India has approved the specialty, it is still in its birth pangs. It will take at least ten years for the specialty to completely evolve,” says the deputy director of MIMS academy. Imron Subhan agrees that community based training can have a huge impact on Indian Emergency Medical Services. “In fact, the Indian Medical Association (IMA) has a 1 year part-time training program in emergency medicine targeted at doctors in PHCs and District Hospitals. Such doctors also choose to enroll for a 1 year Diploma in EM which are conducted by many other institutes,” explains Subhan. No single emergency response number Several experts also suggest that our policy makers need to take a lesson or two from west regarding emergency response number. While other countries had implemented a three-digit number to reach their emergency services several decades ago, Indians still have to call multiple numbers for police, reporting a fire or request an ambulance service. England was the initial pioneer of in 1937 after the fire brigade was unable to be promptly summoned to a 1935 fire where five women lost their lives. And the first 911 system implementation and phone call occurred in Haleyville, Alabama on February 16, 1968. “In modern systems, the level of response required is no longer decided by the call receiver, but by a set of algorithms usually found in a card set the call receiver has in front of them. The call receiver has a set of questions to ask the caller, and based on those answers the algorithm will determine what resources are actually dispatched to the call,” says Dave Koing, in his book ‘You Called 911 for What’. Sudip Bhose is an Emergency Medicine physician in the United States and also a first-generation American whose parents emigrated from India. He strongly advocates a single telephone number as one of the pillars of EM. “As a medical practitioner in some of the busiest emergency rooms in the United States, I can attest that an important aspect of effective emergency care is an EMS system with a standard emergency response phone number such as 911 in the US,” says Bhose, who is also the medical director for local Emergency Medical Services (EMS). “Educating the public through nationwide media will help citizens identify when emergency medical care is needed and publicize the standardized emergency phone number. By establishing a consistent contact number, people across the nation will know who to contact in emergencies, regardless of where they live or travel,” explains Bhose. However, one of the significant strides made by India in the healthcare sector is 108 service provided by government in association with GVK group. According to Subodh Satyawadi, CEO of GVK Emergency Management Research Institute (EMRI) the problem of emergency care to poor is a management issue rather than a medical issue and professional management of services can bring in outstanding results in India as this was neglected and unexplored area. “108 service of EMRI was started in 2005 and within a span of eight years, covers sixteen states. Unique PPP model is the back bone of the model,” says Satyawadi. The requirements of our country in area of emergency services are huge. “To ensure pan-India services with access to all without differentiation on economic grounds a robust framework of operations is essential. Such framework can only be derived from government machinery in terms of investment and continued service support requirements,” concludes Satyawadi. There are, of course those who disagree with the view and suggest some of the funds allocated for projects often do not trickle down. Having braved several challenges including indifference of some of the private hospitals during mass emergencies, the co-founder of ANGELS, PP Venugopal notes that several key schemes of government often does not reach the citizens. He also spills the beans about corruption in allocation of various projects of the government across the country. “There were several media reports about scandals related to allocation of funds for ambulance services in areas like Rajasthan. There is no miracle formula for perfect execution of emergency care. However, a legal framework might bring some order in to the sector,” says the physician. What can the west teach us? So, where should we look for answers for our questions regarding the challenges towards delivery of quality and patient centred care during medical emergencies to patients in India? Does the solution for our problems lie in western models? Today majority of physicians in the specialty of Emergency Medicine in the USA would probably not call the specialty new any longer. That is not to say it isn’t relatively new compared to pillar specialties in the medical arts such as Internal Medicine and Surgery. The specialty really began in the 1960s and as such, a generation has passed such that most of those practicing then are not now. To many who are now practicing, like Gary Starr, it seems in many ways as if Emergency Medicine is well established and even the leader in many areas. “Of course, every specialist has his or her own biased opinion,” adds Starr, an emergency medicine consultant in Greater Minneapolis. Garry was originally trained in Family Practice and then completed a second residency in Emergency Medicine. “Both specialties are ‘newer’ and are less tied to specific procedures in our fee-for-service system. In this light, Emergency Medicine as a specialty will be very challenged in the coming years as we institute major reforms in our health care system. Questions about where emergency care fits into the new payment systems will be difficult. Additionally, the common perception that emergency care is expensive and wasteful is easy to sell to the public and the politic, but is not precisely true,” says Starr. Sharing the criticism about emergency care, he says that it is often branded expensive when seen as a separate expense, but when tied together with the overall cost of a patient’s care over time, the cost of the care provided in the emergency setting can save a patient delay in diagnosis and greater cost later on. Additionally, some care must be performed emergently regardless of discussions about cost. “Finally, the emergency care system must be operable 24/7 and capable of sustaining great flux in patient volume and acuity. This is the “safety net” function. Without this capacity, emergency medicine as a specialty would be unable to adequately provide care in unpredicted disasters. This redundancy or “over-capacity” may seem wasteful at times when argument about financial efficiency takes the stage, but, much like the military we hope we never use, we can’t chose to have it after–the-fact,” adds Starr. A major challenge for EM physicians is in expressing this complex argument to the public and to our elected officials says Starr. “Telling the story of emergency medicine to someone who is not being affected by an emergency is not very effective. Telling this story will be needed though because funding in our system is quickly changing. Our emergency medical care system in the USA unfortunately also serves as our universal health care coverage system. Though the USA does not have such a system in place, the EMTALA laws guarantee the right of all persons to be cared for in the ED regardless of ability to pay. Unfortunately, the government made this mandate an unfunded one – which renders care provided to those with insurance even more expensive so as to cover the financial losses to the system. Since we are at the epicentre of this problem, it remains one of our challenges to try and help solve,” says Starr. It’s no secret that Indian healthcare can still learn few lessons from western models, though we cannot completely emulate them, say experts. “While there are strict proponents of theories that India is a different environment and no systems can be photocopied from the West and put to in place here, there are definite models that we can draw inspiration from,” says Anunaya Jain. If the most clich├ęd argument regarding delivering care in India is physician is the only person deemed eligible to deliver care, successful western models give high priority to training paramedical staff. “The Paramedic and EMT training programmes are important to implement, because a good EMS system is definitely one of the most acute gaps in our healthcare system. Strategic implementation of telemedicine and technology can definitely help to overcome our problems,” says Jain. A study of other EM models also shows that the practice of developing Advance Practice Providers can overcome the shortage of physicians in several areas. “This is especially important for a country with wide geographic variability. APPs could serve as useful front line for delivery of emergency care in rural and semi-urban areas within our country,” says Jain. Thirdly, another aspect of western emergency medicine which can be adopted here is centralization of all hospital capabilities, both private and public. EM is a key area where public-private partnership definitely needs to come to the fore. A centralized network that informs patients/EMS providers about the capabilities and availability of services at the nearest hospitals is essential in our country as well. “Every EMS service in the west has up-to-the minute information on capabilities, certifications, vacancies, ER loads, ICU beds etc for every hospital in the region. There are also routing rules that are prescribed by the state and adhered by EMS providers in these countries, which helps patients to actually get the appropriate level of care when required. Today the choice of hospital during emergencies is almost always arbitrary in our country, and often wastes significant time to get appropriate care. An example of this system has just been initiated in Kolkata. It would be interesting to see how it evolves,” adds Jain. Disaster response planning and training Undoubtedly, disaster response planning and training is also a key component of Emergency Medicine. While there has been a significant effort to develop these capabilities in India, this has not percolated down to the grass roots. Placing the issue in a larger perspective, Anunaya Jain thinks that many institutions in our country even today openly flout fire and safety recommendations. He says that in the west every staff member at every institution is keenly aware of his/her role during an emergency. “The best way to respond to emergencies is to prevent them and have a plan to prevent loss/provide care if they do arise. These exercises need to be undertaken by every healthcare institution, every economic entity and every residential facility in our country. In keeping with the above chain of thought strict regulations and their implementations especially for road safety which are given in the west need to be implemented in India as well,” adds Jain. He also cites accountability for care as one of the best practices that can be replicated in the country. “This perhaps is the Northwest quadrant need for our country, one that has high reward in exchange for high effort input. It crosses specialty barriers for our country. Mortality and morbidity reviews that have meaning, public reporting of outcomes and quality of care delivered, and developing a culture of equality between care providers are some of the essential tenets of accountability of care,” adds Jain. One way of dealing with emergency medicine, is to see it through the prism of an HR manager. As with any new employee within a company, the principal challenge for Emergency Medicine is to prove to other employees and the management that the care they deliver actually makes a difference to patient outcomes and hospitals financial measures/patient satisfaction in a competitive environment. Another challenge that goes hand in hand with this is the ability to convince hospital management to actually continue to invest in a responsive system of emergency care delivery, because every ER will fall short for its demand in about 4-6 years time. “Although not immediately apparent in private sector, Emergency Medicine in our public sector does need to project problems of the future and start to somehow convey to our population the concept of triage, and why some patients are given more priority over others,” says Jain. The country’s influential think that the emergency medicine in public sector hospitals need major overhaul. “I am a believer in the public sector hospitals and in order to improve the quality of care, agencies should invest in initiatives like Code Blue in Thiruvananthapuram,” says Tamarish Kole, president of Society of Emergency Medicine India (SEMI). SEMI conducts workshops for volunteers as well as training programmes for physicians to bridge the gap in the sector. Perhaps one of the most important events in Indian emergency medicine is the decision of Medical Council of India to approve Emergency Medicine as a specialty in 2009. After that lot of young graduates had taken up this specialty. However, experts admit that there are multiple challenges for the new specialty. “Several medical colleges rely on universities to make curriculum for EM. But as per the national board of examination is concerned, we have our national curriculum, which will be implemented from July this year. There are lot of US universities doing programmes in India, where they follow US curriculum with Indian inputs. Clearly, there is a need to constitute national curriculum,” says Kole. SEMI bats for national curriculum for EM Instead of simply expressing their angst over EM, Society of Emergency Medicine India is planning to create a comprehensive curriculum for aspiring EM physicians. “SEMI has started the process to create a national curriculum with the help of International Federation of Emergency Medicine and we will be able to finish it within six months, with inputs from various stakeholders,” says Kole. The chief mentor for this project is Prof. V Anantharaman, the Asian representative of IFEM. Nagi Souaiby, Chief Editor of Med Emergency, the Mediterranean Journal of Emergency Medicine, agrees with Kole. “It is a big challenge to design a curricula adapted to each setting. What’s applied in Europe or the USA can’t be adopted in Asian countries,” says Souaiby. But what’s it like to be an emergency physician? “As EM is a transversal specialty combining medical knowledge and performance of difficult techniques sometimes the first challenge is to train and educate people for a high level and to keep this high level knowing that when professionals become fully efficient they are a little bit old(forties) to continue having the same stressful rhythm,” says Souaiby,. “So we should have a good training early and not to wait till people acquire the experience alone. This is the case when it is fully supported by the academic corps which is not the case in many countries where emergencies are managed by juniors,” explains Souaiby. There is one more thing that Souaiby is absolutely sure of: emergency physician cannot maintain same rhythm for life. “As they approach their fifties, he or she starts to find other ways of evolution if they don’t have an academic position,” says Souaiby. But what should be the game plan for existing physicians, considering EM has already been approved by MCI? “Doctors must be able to identify and effectively treat all types time-sensitive and life-threatening emergencies including heart attack, stroke, traumatic injuries that threaten limbs, brain injuries, and more. Specialized residency training and board certification in emergency medicine will help ensure that these physicians have the skills and knowledge necessary,” says Sudip Bhose. “Equally important is training all specialists such as orthopaedists, neurologists and surgeons to respond to emergencies within their own fields in cases where a patient cannot receive all necessary treatment in the emergency room,” adds Bhose, a former Major in the US Army. Experts also point out the need for a concerted effort by the specialty to convince people about their capabilities as a medical specialty, what individuals should do to get to an Emergency room during acute medical scenarios and who should use/not use an emergency room. Changing Equations in EMS Little did Rajib Sengupta know couple of years ago, when he met his friend Tanmay Mahapatra at his house in Florida, that he would change the rules of the game. The engineering graduate from Jadavpur University was CTO of a Florida based start-up in US, responsible for the deployment of proprietary Healthcare System in the Cloud. After listening to his area of expertise, Tanmay explained his project in University of California Los Angeles which was in Public Health Research in India. He pointed out that due to vast, diverse population in comparably smaller geographic area India is an ideal place for public health research. But the lack of quality health and patient data is big hindrance for any research work. The friends soon realized that it was an issue that worth channelizing their energy and Mission Arogya Health and Research Technology Foundation was born. Rajib Sengupta came to the attention of the healthcare sector, when he launched Kolkata Medical Emergency System (KMES), which gives highly relevant emergency medical data available to all citizens irrespective of social or economic status. KMES is a real-time Emergency System that connects Sense, Reach and Care, the three cardinal principles of medical emergency care. The system is accessible via internet, SMS, phone and operated by an emergency control room. “A medical emergency system consists of three stages: sense, reach and care. The sense is to locate the nearest facilities, reach is to get to the facility under proper-care and the care is handled by the respective facilities upon arrival –often the sense and reach is seen together,” explains Sengupta “But with an unorganized and often without properly equipped ambulance services in India, these two cannot be clubbed into one. It got very evident to us that in Kolkata, the hospitals are doing a great job in the care part, but the sense and reach are the two most important aspects which are severely lagging,” adds Sengupta. According to the co-founder of KMES patients lose lot of time shuttling between hospitals during the golden hour, in search of a vacant bed. KMES provides them information regarding availability of bed in a hospital near their location either over a phone or by accessing their site. Today Kolkata Medical Emergency System (KMES model), which went live on February functions on two cardinal principles. “Instead of introducing new emergency service enhance and strengthen the existing emergency service and empower citizens for crowd-sourced quick response,” adds Gupta. Within a short span of time, KMES has bagged several accolades including the Rockefeller’s Innovation Challenge and Healthcare Innovation award by AIIMS. But what is the USP of KMES? “The USP is instead of introducing new emergency service, we will like to enhance and strengthen all existing medical emergency services, integrate them under a common emergency response centre and empower citizens with information for crowd-sourced quick response to cater critical patients within golden hour of emergency in an innovative yet practical and feasible business model,” says Sengupta. KMES has tie-ups with 15 hospitals in Kolkata and have plans to collaborate with five more hospitals. Being one of the few social enterprises also brings its share of challenges for KMES. “Convincing hospitals to join the network was extremely difficult, as several managements were worried about whether we would highlight a specific hospital by taking more money from them,” says Sengupta. In order to resolve operational hurdles, the team of KMES provides easy interfaces for partnering hospitals. “The only thing that the hospitals need is a good internet connection to be part of our network,” says Sengupta. Budgeting for an Emergency Medical System The question of what EMS will cost and who should bear the cost is indeed a highly debatable one. Defenders of state-funded EMS tell that there are numerous examples in the world that demonstrate the inability of an absolute state sponsored healthcare system. With rising inflation and shrinking employment opportunities, relying on government alone might not be a viable idea. Anunaya Jain points out that it is clear that a tiered system of healthcare delivery that thrives on public-private public partnership is the need of the hour. For instant the frontline levels of care-i.e. primary healthcare, preventive healthcare and emergency pre-hospital care would be state sponsored. This is not an impossible task. The primary reason to have this state sponsored is to remove the access block that would be born otherwise for those located in non-strategic geographies. This also means that the decision making behind hat level of care to seek for the patient is taken out of corporate hands. This would also work in favour of developing a single number for all emergency services. “The real significance of this move is that as the burden of non-communicable diseases rises in our country, it would be in our country’s economic best interest to avoid diseases as much as possible and that is why the investment on preventive healthcare,” says Jain. Then of course-the government would need to budget for developing primary healthcare centres staffed with physicians/nurses/advance practice providers who are trained in basic Emergency Medicine. “This centre would serve more as a triage centre for those who face an access bloc. A responsive EMS service would be essential to make the model work and so the government would also have to invest in developing these ambulance services and train the paramedics/EMTs staffing them. However, there is very little revenue that would actually come out of any of the above and therefore government partnered care is the answer,” says Jain. Some of the other correctives desired by experts are state regulated secondary and tertiary care facilities with a varying mix of state private equity investment. This would be essential to both minimize cost investments required at the governmental level to develop facilities of this level (freeing up resources for investment in primary care and EMS) as well as have revenue sharing arrangements based on equity sharing with private investors. The equity investment by the government would enable the government in many ways-actually buy regulated care at these facilities. The government would control the protocols of care delivery and the procedures for reporting of outcomes are followed. “Adherence to above regulations and performance on quality measures would determine payment scales for insurance companies and patients at each of these facilities. This would push the private facilities to focus on quality of care and accountability over care that is being delivered,” says Jain. It is essential for the government to control the number of facilities being opened up or being credentialed under this system to make this work. This will ensure that the Government is actually able to control development of facilities in any given area, preventing a hospital ‘arms race’ that has driven up costs of care in most developed countries. When asked about budgeting model for EMS, several experts mentioned that it is the responsibility of the state to protect the interests of the economically challenged population. A state sponsored insurance support with a co-pay component that is derived from the annual family income for each insured patient is the need of the hour. “While cost and charge controls do get placed on facilities because of the above, the economically backward classes could still potentially face challenges around receiving care. Hence the requirement to have a state sponsored insurance support (co-payment of which is a factor of the annual family income),” says Jain. “By controlling the costs and charges of emergent care at each of the facilities above, the government would more or less obviate the need for reimbursement/subsidization for care,” concludes Jain.