Initiatives in India

be met,

The development of pre-hospital care (PHC) in India was the focus of a joint workshop held alongside the RCSEd International Conference in Chennai last October. It was delivered by the Faculty of Pre-Hospital Care (FPHC) International Development Lead, David Bruce, and other speakers.

FPHC were invited to support developments in India via the Faculty of Disaster Medicine – India and Nepal (FDMIN), supported by the charity Saving Lives.

India has a mixed healthcare delivery system. Policy recommendations in the 1940s laid the foundation for a governmentfunded, three-tiered public health system to deliver preventive and curative health services. By the 1980s the private sector’s role in health began to gain prominence. Currently almost 70% of all outpatient visits and about 58% of inpatient episodes are provided by either for-profit or not-for-profit private providers1. Central Government coordinates the work of state health authorities, but health is a state responsibility. Each one operates its own facilities and determines how government aims and policies are delivered. This has led to variation in levels of care between states, amplified by variations in geography, population density and access to care.

JOINED-UP APPROACH

Emergency medical services (EMS) are a relatively new concept in India2 and are evolving to reflect a change from a simple transportation system to one in which medical care and resuscitation occur in transit. There are numerous models for EMS capabilities, and systems in India have been described as “fragmented with no uniformity”. An emergency referral transport system was introduced under the National Health Mission and is available in 31 states and union territories. This system is accessed through toll-free numbers 108 (a public-private

David Bruce OBE International Development Lead, Faculty of Pre-Hospital Care

partnership) and 102 (a separate programme aimed at transporting pregnant women and children).

In 2021 there were 19,290 ambulances operating under these schemes, but most do not provide advanced life support, and there are limited data on the quality of care and response times. There are also private ambulance companies and ambulances may be despatched from hospitals. In terms of trauma workload, there were over 155,000 road-traffic deaths in India in 20213 – clearly there are many more serious and life-changing injuries.

Taking The Initiative

Above: Speakers and delegates at the joint FPHC workshop in Chennai, India

It was against this backdrop that the FPHC decided to take advantage of UK speakers being in Chennai for the RCSEd International Conference to cooperate with the FDMIN and the Sri Ramachandra Institute of Higher Education and Research (SRIHER) to deliver a workshop on developing PHC in India.

Peter Patel of the FDMIN and Professor TV Ramakrishnan of

SRIHER invited key speakers from India and Nepal to the event, which was held on 7–8 October. I constructed a timetable with the aims of sharing current PHC initiatives in India, discussing the applicability of UK capabilities, identifying capability gaps, introducing the FPHC Pre-Hospital Trauma Course (PHTC) and providing networking opportunities.

The State Of Play

We had 10 speakers from different Indian states, five from the UK, and one from the Nepal Disaster and Emergency Medicine Centre in Kathmandu. A second morning was added to the workshop for further discussions and the launch of the first edition of the Emergency Services First Aid Drills Aide Memoire. The workshop opened with a remote presentation by FPHC Chair Pam Hardy. Professor P V Vijayaraghavan, Vice-Chancellor of SRIHER, then highlighted the importance of early resuscitative care to survival rates and its impact on longer-term outcomes. Tausif Thangalvadi, former Head of Emergency Medicine and Director of Premier Hospital Hyderabad, gave an overview of ambulance systems and pointed out that India’s first public-service ambulances – 15 vehicles – were only established in Mumbai as recently as 1985. Prior to that, patients were taken to hospital in auto-rickshaws or ambulances sent from the hospital; outcomes were poor. Subroto Das of the Lifeline Foundation spoke about the

Highway Rescue Project he established in 2002 to reduce the number of deaths on state highways. This was after his wife sustained very serious injuries and took 5.5 hours to reach hospital. More recently he has focused his efforts on training the population to provide high-quality CPR in India’s techno-cities and using alternative healthcare practitioners, who are already established in communities. He stated that studies of private ambulance services revealed that there was no regulation, crew training was variable and equipment was either not working or staff had not been trained in its use in 20–70% of cases.

Professor Aruna Ramesh of Ramaiah Medical College, Bengaluru, highlighted that 50% of patients with acute coronary syndrome aged 30–70 years died before reaching hospital. This had prompted her to set up a hub-andspoke system and ECG telemedicine capability to reduce time to thrombolysis. She has also introduced an awareness campaign for stroke and chest pain, allied with CPR training for communities.

Further initiatives were introduced by Professor Vijaysankar of the Government Kilpauk Medical College & Hospital, including a trauma registry, and speedier thrombolysis and triage tools to aid junior clinicians.

Rod Mackenzie, from the UK, described the evolution of PHC, trauma systems and the introduction of the Pre-Hospital Emergency

References

1. Selvaraj S, Karan KA, Srivastava S, Bhan N, Mukhopadhyay I. India health system review. New Delhi: World Health Organization, Regional Office for South-East Asia; (2022).

2. Emergency Medical Service in India: a Concept Paper by National Health Systems Resource Centre (Undated).

3. Accidental deaths and suicides in India from National Crime Records Bureau (2021).

Medicine sub-specialty in the UK. He handed over to Professor Mark Wilson, who outlined technological developments that could aid effective PHC. Pragya Mallick, who trained in Chennai and is a pre-hospital emergency medicine (PHEM) trainee in the East of England, then gave a unique insight into her career. I also introduced the PHTC, which we plan to run at SRIHER in 2023 allied with a Train the Trainers course, with the intention of the course rippling out across India.

Aims And Ambitions

Day One was rounded off by our host, Professor Ramakrishnan, describing the variations in ambulance personnel training and how SRIHER had introduced a four-year degree course, but that most graduates left India as their status and remuneration was much greater in the Middle East. We agreed that a system of paramedic registration and defined scope of practice were important topics for development, but were long-term goals.

Below: Dr David Bruce, left, making presentation to Professor T V Ramakrishnan of SRIHER

On Day Two Rashmisha Maharjan from the Nepal Disaster and Emergency Medicine Centre outlined the nation’s ambulance capability. Two regions have a toll-free 102 service but crew training and equipment are variable. To address this, the Centre has produced a first-aid handbook in Nepali and delivered advanced, community and maternal health first-aid courses to more than 12,000 civilians.

Our Emergency Services First Aid Drills Aide Memoire is based, with permission, on a publication by Major General Tim Hodgetts and had been updated by FPHC and Indian contributors. An initial print run of 500 has been funded by Saving Lives for distribution to trained personnel in India.

In summary, the workshop achieved its aims, and a number of work strands are being taken forward by the FPHC and colleagues in India.