108 Emergency Response Services for Women
Commissionerate of Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Health seeking attitude of the people plays a major role in the safety of the society where affordable healthcare can be accessed by all the citizens throughout the state and rescue can be made available for all within optimum time for positive intervention to minimise the damage caused to the emergent situation right from an injury to safe pregnancy in all the sections of the society. The medical services and attention required to the rural citizens and especially rural women in health and pregnancy cases was the prime focus to the rescue services. The maternal mortality rate in 2006 was 160 (per ’00,000) which reduced to 148 in 2009 (per ‘00000). The services to women related to pregnancy, hospitalization and new born care was a challenge in front of health machineries. Innovation acknowledged and appreciated popularly as “108” was necessitated by the fact that more than 4 million deaths per annum occurred in emergency situations. Many lives could have been saved but were not, for want Emergency Response Service (ERS) in the state. The project aimed at the need of enhancing responsiveness of government to demands and needs of all citizens right to emergency services specially women. India has an estimated 400,000 medical, crime or fire related emergencies per day. Of the 4 Million deaths reported every year, 80% victims are at the bottom of the pyramid and 80% of these deaths occur in hospitals within the first hour of admission after the emergency necessitating the requirement of a service such as 108 which is free of cost to the end user and available at any place, any time. The “108” project was conceptualized and implemented to confront the requirement of • Access (One single toll free number to dial in case of emergency) • Availability (Availability of Life Saving Ambulance to reach victim and transport to nearest and appropriate health facility). • Affectionate Care to be provided on site of emergency by trained paramedics with compassion and focus towards Saving Lives) and • Affordability of the emergency services by every citizen independent of income, religion and community. Accidents and emergencies occur on a daily basis. These are individual emergencies that can be scaled down with proper education and awareness; however, they cannot be eliminated. For a robust health care delivery model, each country requires an organized emergency response mechanism in place. To address this issue of timely assistance, organized approach and appropriate channelizing of resources in an emergency, a streamlined operating service such as 108 initiative was implemented. Science and technology have created a new age today with a world of high speed and reach in every corner; this necessitates in-tandem emergency assistance. The developing countries like ours are grappling with serious issues of emergency handling, maternal and child mortality, epidemics, long standing illnesses, lack of medical aid to those at the bottom of pyramid. Government of Gujarat is actively working for achieving World Health Organization (WHO) supported Millennium Development Goals (MDG). An improvement in these key indices for health development necessitates a reliable emergency response such as GVK EMRI and care system to support the initiatives in this direction.

B. Strategic Approach

 2. What was the solution?
108 Emergency Response Service is a project under Public-Private- Partnership (PPP) between Government of Gujarat & GVK Emergency Management & Research Institute (GVK EMRI), since 29th August 2007 in Gujarat. “108 Emergency Response Service” is a unique innovative Pro-Poor, not for Profit service delivery model to provide Emergency Response and Emergency Health Care Services to every citizen of Gujarat. “108” provides an integrated emergency response 24 X 7 for any type of Emergency -Medical, Police, Fire through easy to remember - Three digits, toll-free number – “108”. “108 Emergency Response Service” follows a simple, yet comprehensive structure of Sense, Reach and Care, emergency is identified (Sense), a life saving ambulance reaches (Reach) and a trained paramedic provides pre-hospital emergency care (Care) to the victim in distress. The project has also promoted the unique initiative in the women care and delivery cases through essential care for women care for newborn, a drop back facility for patient (project ‘Khilkhilat’), early recognition of danger signs, immunization, essential diet, etc. This has helped the awareness and care for rural women health issues. Objective: To provide free of cost emergency response including rescue and transport to hospitals for healthcare especially the pregnant women to reduce the IMR and MMR by promoting the institutional deliveries in the state. Improving health, quality of life and reducing poverty has been the larger vision behind inception of this project. Spearheading the mission of “Saving Lives” and integrating the larger objective of GVK EMRI to provide the “Right to Safety” for common man, “108” project was founded to provide an end-to end solution in the hour of need to the distressed. Target Audience: This project has set path breaking precedent for all in health care domain to innovate, collaborate and implement initiatives effectively, targeted towards community at large immaterial to gender, caste, age and socio-economical status of the people. 2.26 million beneficiaries of the services were women out of which 58.75% cases were pregnancy related and 8.55% includes acute abdomen cases. Having responded to more than 26.9 million calls and handled >4.092 million medical, >58,472 Police & >5,389 Fire emergencies since 29th Aug 2007 till 8th Dec 2013, 108 interventions have saved 296,407 (0.294 million) lives in critical condition across the Gujarat. With Impressive metrics, 108 handled 1 Emergency every 48th seconds and Saved 1 Life every 11th minutes since its inception in Gujarat. • 132 lives saved / day increased institutional deliveries and reduced infant rate • 34.01% cases are pregnancy cases Looking forward towards making these services available to every citizen of Gujarat with equity, empowering people to manage emergencies with a service, by the people, for the people and of the People, GVK EMRI envisages a service delivery with high quality and standards.

 3. How did the initiative solve the problem and improve people’s lives?
a. Unique Integrated Emergency Response Service for Medical, Police and Fire emergencies through single universal toll-free number ‘108’ which can be dialled from any landline or mobile. b. The initiative targeted the rural beneficiaries in providing healthcare services in transit and facilitating transportation to hospital. This has resulted in immense health assistance to Women and especially pregnancy cases. c. 108 ERS - GVK EMRI as Private Partner brings leadership, innovation, execution and technological capabilities with collaboration and Research Intelligence, Training, Knowledge transfer and Quality assurance. d. 108 Service is free of cost to citizen (end user). Burden of

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
• The project was visualized by visiting a pilot project in Hyderabad by a core team to make the project scalable and operational for the entire state of Gujarat in PPP model. • The project was launched within 3 Months covering the activities of integration of all the key stakeholders viz. Hospitals, Telelcom service providers, etc. GVK EMRI has Pioneered Emergency Management in India, wherein 108 evolved as framework of Public-Private- Partnership (PPP) mode with Government of Gujarat showing a way forward for other state governments. • GVK EMRI manages and leverages local government resources for better outcomes to serve the poor with an overall financial burden of Rupee 1 per citizen per month. • Technology an enabler has taken the operations of 108 service to global standards. Public Switching Telephone Network, Servers, Data networks, Computer Telephony Integration, Telephone ERS, GIS database, specialized applications, Voice loggers are utilized extensively for streamlined operating service. • World class equipped advance life support ambulances suited for Indian terrain support in expeditious transport and quality pre-hospital care. • Processes, protocols and set measures ensure uniform qualitative outcomes. • Capacity building with creation of cadre of Emergency medical Technician (EMT) manning the ambulance guided online by the Emergency Response Centre Physician (ERCP).

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
1. Government: “108” has strengthened state governments’ efforts of unified multipronged approach in individual emergencies as well as situations of man-made and natural disasters by providing on scene and en-route care with evacuation of the victims to hospitals. Contribution in increasing institutional deliveries has enhanced progress towards Millennium Development Goals by reducing maternal mortalities. NDMA document and NRHM National Review states 108 Project as a necessity in Indian states An efficient work mechanism with path breaking speed has been endorsed by various government functionaries, bureaucrats and political class. 2. Private Partner GVK EMRI: GVK EMRI is a not for profit organisation having collaborations with globally renowned institutes like Stanford University of USA, Geo-Med, Singapore Health, NENA USA, etc with technology partner M/s Tech Mahindra to create and maintain the latest software application to run 24X7 Emergency Response Services in the state with global standards, processes and protocols. 3. People: 108 has impacted more than 60 million people of Gujarat with fleet of 525 ambulances. >2600 employees in GVK EMRI team identify themselves with mission of saving lives. As on 8th Dec 2013 has responded to 4,092,035 Medical,58,471 Police & 5,389 Fire emergencies and has saved 296,407 lives in critical condition. In >3% of all pregnancy related transports, emergency deliveries assisted on scene and while en-route in ambulance have brought smiles to families of the mother and child. Popularity and mass appeal of 108 is a reflection of the benefit reaped by multitudes. 4. Medical Fraternity: Extending the “window of survival” for victims with effective pre hospital care ensures arrival at hospital in a salvageable condition. Seamlessly linking emergency care from scene to hospital, the medical community has expressed solidarity for 108 in the best interest of Saving people’s lives. GVK EMRI has been termed “Gandhian Innovation” by Management expert Dr. C. K. Prahalad in Harvard Business Review Jul 2010 Issue.
 6. How was the strategy implemented and what resources were mobilized?
108 Emergency Response Service is a project under Public-Private- Partnership (PPP) between Government of Gujarat & GVK Emergency Management & Research Institute. 100% funding for state pertaining Operational and Capital expenditure is provided by Government of Gujarat and the Technology, Leadership, Global standard EMS protocols and processes are born and brought to the state by GVK group. All the assets are bought for and in the name of the Government of Gujarat including the ERC infrastructure to all the moving ambulances and their equipments for the whole project. After attaining the sufficient number of ambulances, the strengthening of services is a continuous process by adding, relocating and replacing the fleet for health operations. 108 Service is free of cost to any citizen (end user). Burden of less than One Rupee / Citizen / Month, if correlated, is lesser than any state or national budget on health. Comparing with advanced countries like the USA, one ambulance trip of GVK EMRI ambulance amounts to 13$ - 16$ as against one ambulance trip in US relating to 600$ to 700$. Poor, under privileged truly benefit from the 108 service.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
1. Reduction in Maternal Mortality Rate to 148 (per ‘00,000) from 160 (per ’00,000) in first year of launch (2007). 2. The project has proved to be most helpful in critical pregnancy cases and neonatal cases attended in Gujarat state. The provision of emergency services was a great challenge in rural area where the hospital reaching time is high. So EMT available in the 108 Ambulances help getting the job done even before patient reaches hospital (Total 41,949 cases). o Deliveries assisted by EMT - On Scene – 12, 827 o Deliveries assisted by EMT team – In Ambulance – 29,122 3. Contribution in reduction of Maternal and infant deaths in Gujarat by expeditious transport of pregnant ladies and safe assisted delivery option while enroute in impending delivery situations. GVK EMRI has thus safeguarded lives of young mothers and babies. Maternal mortality remains one of the most daunting public health problems and reduction in maternal mortality has been identified as a prominent component in the millennium developmental goal. A pragmatic strategy of maximizing institutional deliveries GVK EMRI has enabled the public healthcare system to reduce the MMR & IMR. “Three delays” of delay in deciding to seek care, delay in reaching care, and delay in receiving adequate treatments is significantly reduced through GVK EMRI innovative approaches. GVK EMRI has been instrumental in improving overall health system through utilization of healthcare facility. 4. 108 has impacted more than 60 million people of Gujarat with fleet of 525 ambulances. >2600 associates in GVK EMRI team identify themselves with mission of saving lives. As on 8th Dec 2013 has responded to 4,092,035 Medical,58,471 Police & 5,389 Fire emergencies and has saved 296,407 lives in critical condition. In >3% of all pregnancy related transports, emergency deliveries assisted on scene and while en-route in ambulance have brought smiles to families of the mother and child. Major killer emergencies such as Pregnancy related maternal and child emergencies, Trauma, Cardiac, Respiratory, Poisoning and other EMs are dealt with care, passion, professionalism and patience. 5. Popularity of 108 and mass appeal across all sections of society has made 108 a lifeline for people. GVK EMRI’s 108 Service is a boon to the people. An efficient work mechanism with path breaking speed which has benefited multitudes and is creating value for the society has been appreciated by all sectors of society including Media and public at large. The bureaucratic network has endorsed GVK EMRI’s innovation, recognizing the potential of these services. Diverse entities, International Agencies, Senior Government officials and opinion leaders with independent view of thought have expressed their appreciation for the 108 project. Medical experts have commended the pre hospital care innovation and heralded the advent of revolutionary Emergency Response Services, in Gujarat. 6. Notable appreciation by late Dr. C. K. Prahalad terming GVK EMRI “Gandhian Innovation” in the Harvard Business Review (Issue Jul –Aug 2010) for synthesizing technologies (telecom, computing, medical and transportation) with commitment to serve the unserved has been a feather in cap of GVK EMRI. 7. Receiving accolades from various quarters, Gujarat 108 ERS was recognized in 2011 with E India Award for best Healthcare initiative.

 8. What were the most successful outputs and why was the initiative effective?
a. Partnership with government, domain experts and allied key functionaries to bring in innovations of futuristic value. b. Structured review mechanisms are followed at various levels and periodicity for monitoring the progress and for taking the policy inputs for overall functioning of system. Various reports and bulletins are published and shared with the stake holders to keep them aware about the progress made. c. Research and analytics wing to monitor, forecast and strategize for impending emergencies. Evidence based understanding shared with stakeholders to eventually prevent and control emergencies. d. Distinguished efforts on training and developmental activities to take overall healthcare to next level with capacity building. e. Surging past barriers of cultures, religions, caste, economics and genders GVK EMRI has demonstrated and equitable service model for all. f. Robustly linked Sense Reach and Care model involving technology in all aspects. g. The collaboration and sharing of best practices for knowledge and technology are: o Stanford University USA o Carnegie Mellon University, USA o GEOMED Research o SingHealth (Singapore health services) o American Academy for Emergency Medicine in India o American Asso of Physicians of Indian Origin (AAPI) o Public Health Foundation of India o Shock Trauma Centre, USA

 9. What were the main obstacles encountered and how were they overcome?
a. Integration and active Involvement all sections of government machinery including Police and Fire wings with regular interface and mutual understanding for knowledge sharing. b. Challenge of prompt and even response time for Urban and Rural areas confronted with strategic ambulance placement based on population, load and trend of emergencies in particular area, analyzing time variation and external factors of demands. c. Availability to telecom networks especially the mobile networks and local health infrastructure was a challenge and was met with planned actions with prioritization with concerned stake holders in identified segments. d. Community participation in leveraging the installed resources for their optimum use in case of genuine need without hesitation. e. To develop and maintain the service level and faith of the beneficiaries in health system of the state. f. Creating capabilities in terms of trained manpower for Emergency response centre (ERC) & ambulances with essential knowledge and skills to provide care at par with global standards. g. Public sensitization of 108 number for emergencies was overcome by regular local community awareness demonstrations, activities for information in schools and villages, regular communication at gram panchayat and taluka levels.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
• Size: o 108 has impacted more than 60 million people of Gujarat with fleet of 525 ambulances. >2600 associates in GVK EMRI team identify themselves with mission of saving lives. As on 8th Dec 2013 has responded to 4,092,035 Medical,58,471 Police & 5,389 Fire emergencies and has saved 296,407 lives in critical condition. In >3% of all pregnancy related transports, emergency deliveries assisted on scene and while en-route in ambulance have brought smiles to families of the mother and child. o Out of 4.076 million emergency cases, 2.264 million cases beneficiaries were women. This demonstrates high quality services to women. • Speed: o >99% of calls at 108 are taken in first two rings. o Within 14 Minute in Urban & within 24 Minute in Rural ambulances reached to cater emergencies. • Type of Emergencies & Lives Saved: Since launch till 8th Dec 2013, 108 ERS has handled 4,092,035 Medical Emergencies. Following is the Type of Emergency wise share: o Pregnancy Related -34%, Vehicular Trauma -15%, Acute Abdomen – 8%, Trauma Non Vehicular -6%, Cardiac – 5%, Respiratory – 5%,Animal Bites – 2%, Suicide related – 1%. o 132 Lives saved per day (0.296 million cumulative) & average >2000 people every day received timely, high quality pre hospital care. • Cost: o Cost per ambulance trip $13 to $16 against $ 600 to $700 in USA • Qualitative Outcomes: o Well documented systems, impressive EMT training, high order management competence o A historic landmark in health care delivery system o Built more trust in the health system as a whole o Increased institutional deliveries, reduced mother & infant mortality rates o A model for replication across the Country in any state o Angel of Mercy – 108 Ambulance

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
• Cost effective optimum resource utilization for ensuring sustainable operations. • Managing and leveraging government resources, synergizing strengths of public and private sectors made this unique project being identified with high speed, scale, replicable status conquering challenging geographies, infrastructure, cultures and medical facilities in developing stages. • Processes and standardized protocols for all operational wings. Well defined documentation ensuring precision in service delivery. • Extensive application of technology to provide equitable healthcare to all at all times. • Flat organisational structure enabling employees towards exponential performance. • After launch in Gujarat, various states and Union territories have replicated this model of Emergency Response Service in their states at varying scales. • Government of Gujarat have initiated free of cost Drop back service “KHIILKHHILAT”for mothers and the newborns by leveraging the existing resources of 108 ERS in Gujarat on 4th Sep 2012. There are 78,980 mothers and newborns are benefited in last 15 months by this unique service model where the professional approach and technology is leveraged and is inspired by the success of 108 model in the state towards safe motherhood.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Looking to the outcomes of the services in Rural and tribal remote terrains of the state to the densely populated urban areas, a life saving service working uninterrupted 24X7 throughout the state has created a revolutionary faith and confidence in people towards using government resources with satisfaction. Effective management of the resources can create and provide a global level of quality services using local expertise enabling people for their right to safety and health. In addition to the Emergency Service ambulances- 108 has regenerated “Khilkhilat” project with drop back ambulances for mothers & newborns in Gujarat using government health facilities for pregnancy related treatments and deliveries. Striding the hurdle of speed, GVK EMRI has commenced preparatory work for launching air-ambulance services. Upcoming plans look towards strengthening civil health infrastructure with Emergency and Trauma rooms at strategic locations. High risk newborns require special ambulances and future plans will meet such special needs. Non-emergency health helpline, poison control centres through a centralized response centre can also be yet another future activity. Detailed processes with explicit guidelines and set measurable ensure uniform qualitative outcomes. Periodic auditing with review of performance generates avenues for constant upgrading, further refinement, innovation and development. Extra mile efforts of GVK EMRI have delighted beneficiaries, stakeholders and governments by active involvement in state programs, synergizing to optimize health initiatives of the state and strengthening infrastructure for growth.

Contact Information

Institution Name:   Commissionerate of Health
Institution Type:   Government Department  
Contact Person:   Sunil R Avashia
Title:   Additional Director - Medical Services  
Telephone/ Fax:   079-23253287/ 079-23259900
Institution's / Project's Website:  
E-mail:   dydir-mediser-health@gujarat.gov.in  
Address:   block 5, Jivraj Mehta Bhavan, Sector 19
Postal Code:   382010
City:   Gandhinagar
State/Province:   Gujarat

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