A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Emergencies can happen at any time, to anyone, anywhere. In most cases, they cannot be predicted or prevented. But, they can be managed to minimise losses to life, health and property. Scenario in India before GVK EMRI was born and need for this end to end service 75,000 emergencies occur per day o 80% are at the bottom of the pyramid o 80% deaths occur in hospitals in the first hour 4 million deaths p.a. (cardiac, road accidents, maternal, suicidal attempts, neonatal/infant/pediatric, diabetic related, etc) due to absence of 4As : • Access to a universal toll-free number • Availability of life saving ambulance to reach quickly nearest and appropriate health facility • Affectionate care by trained paramedics (compassion, ability, resourcefulness & energy) • Affordability by every citizen independent of income, religion and community

B. Strategic Approach

 2. What was the solution?
There were ambulance services in India, but it served as mere transport. The idea of a single integrated emergency response service was the brainchild of former Chairman of Satyam Computers Shri Ramalinga Raju. Hence, GVK EMRI was born in April 2005 with a mission to respond to 30 million emergencies and save 1 million lives annually and deliver services at global standards through leadership, innovation, technology and research & training. The vision encompasses India and is a unique innovation for a developing world with similar challenges that India faced prior to 2005. The 108 services was conceived and developed to provide pre-hospital care during the “golden hour” of an emergency so that the chances of survival were high. In India, 80% of the population are below poverty line, and this service was a life line, providing immediate and easy access to quality care through trained emergency medical technicians Dr. GVK Reddy, Chairman of GVK took over management of EMRI in June 2009. He is committed to provide services surpassing global standards with improved transparency, following the modern principles of management and leadership to serve the nation and work towards taking the organization across the country. GVK EMRI strives to contribute to improvement in healthcare across its states of operation through new initiatives. Some key areas of contribution are • Providing pre-hospital care to people in distress • Upgrading skill sets of various categories of health professionals through customised training programs at various levels, aimed at improving emergency care • Dedicated drop back service (hospital to tome) for mother and new born child • Launch of specialized neonatal ambulances in some states • Implementation of Rajiv Yuva Kirana training program culminating in finding suitable placements for the youth. • Implementation of Ashram schools (105) in tribal areas is under process • Monitoring of women distress calls • In dialogue with government for establishment of Trauma Centers across the state of AP

 3. How did the initiative solve the problem and improve people’s lives?
The 108 services was designed and implemented to reach out to each citizen in every nook and corner of the country. Some of the key differentiators are : • Integrated model which responds to any emergency call, reaches out to victim, provides pre-hospital care till person is admitted to hospital. Police, Fire agencies are also informed. • 1-0-8 is a toll free number and the service is accessible to anyone calling from either mobile or landline • The service is also totally free to anyone availing the services • Run in Public Private Partnership mode ensuring accountability from all stake holders • Formal agreement with all private hospitals for 24 hours free stabilisation of victims brought in by 1-0-8 for admission (Refer Annexure 4)

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
An Integrated Emergency Response System through a single toll free number 1-0-8 was developed to provide free pre-hospital care to the citizens of the State. When 108 is called for help in case of any emergency, be it medical, police or fire, professional pre-hospital care is provided to the victim in distress and then handed over to appropriate emergency care at hospital. Every citizen in the state where 108 is operational is entitled to receive free pre-hospital care A brief glimpse of the technology that has enabled successful implementation of this program is given hereunder : Emergency Response System is a complex software that integrates with many critical third-party systems for managing emergencies. It automates all the activities of the call center and support activities of emergency handling, such as medical assistance to critical patients, ambulance management & equipment management. 01. Technical description Emergency Response system is an integrated several vendor-supplied systems to create a single seamless solution including Computer Telephony Integration (Computer Communication Toolkit – CCT), Voice Logger System, Geographic Information System (GIS) / Maps, Global Positioning System (GPS), Automatic Vehicle Location Technology( AVLT), and Mobile Communication. Application architecture is based upon advanced technologies such as Microsoft, ASP.NET, Microsoft.NET and Windows Operating system-based client applications and services. The software is built using highly distributed components that enhance scalability and reliability. Mahindra Satyam as Technology partner has provided the solution for implementing Emergency Response System. 02. Process or flow diagram 03. Presentation of the Solution GVK EMRI was established in 2005 to provide Integrated Emergency Response Services for Medical, Police and Fire emergencies with single universal toll-free number ‘108’, with a vision to respond to 30 million emergencies and save 1 million lives annually by 2011. An emergency response center was established, software was developed by Mahindra Satyam (Technology Partner). All calls to 1-0-8, from landline or mobile are toll free. 04. Evidence of functionality : Description of usage in a real project Telecom Switch with Automatic Call distribution features & IVR facility: When a emergency victim dials the Emergency Response Centre, the call lands on Telecom Switch (PBX). Telecom Switch routes this call to the idlest agent. Some of the features of Telecom switches are: • High end PBX / Telecom switch with inbuilt automatic call distribution feature • support for Voice Over IP • Scalable, distributed platform for seamless growth from 200 to 2000 terminals • Modular client / server architecture • Redundant call processing core for extra reliability in mission critical enterprises i.e. Five – Nines reliability) • 135,000 busy hour call completions • Automatic Identification of Incoming Number Computer Telephony Integration: CTI software helps in generating unique incident Id, with the help of caller line identification wherever available retrieves related information from Telephone directory database and pops up on the Communication Officer screen along with information regarding the number of times the caller called Emergency Response Centre. Some of the features of Computer Telephony Integration (CTI) Server are: • Two-way communications facility that provides the interface between external computer applications and the PBX to achieve computer telephony integration. • Provides APIs to facilitate integration of Telephony Equipment & Applications. • Generates events required for Computer Telephony Integration and Voice Logging. Voice Loggers: All the incoming and outgoing calls to Emergency Response Centre are logged using advanced compression technology. The voice logs can be retrieved and are used for conducting Quality audit and Training personnel. Some of the features of Voice loggers are: • The Voice Acquisition Module (VAM) Records telephonic conversations and sends it to Voice portal server. • Web portal Server maintains recorded voices and provides secure and authorized access to voice logs. Call Center Server (CCS) used for the following: • Skill based routing of calls • Packaged with over 70 standard and customized Management, Historical & Call- by-call statistics reports • Queuing and presentation • When customized scripting and skill-based routing are combined with queuing and presentation preferences, contact centers can provide callers with scalable, innovative and superior customer service • Balanced workload to the agents • Real-time displays GIS and GPS Software – This application enables Dispatch Officer to access the GIS Vector data (maps) provided by Government agencies and identify the incident location, finding the nearest ambulance and assigning the available ambulance. AVLT – Automatic Vehicle Location and Tracking system helps in identifying the exact location of ambulance on real time basis and tracks the ambulance and other Emergency vehicles using the GIS maps and helps Dispatch Officer in dispatching the appropriate nearest available ambulance / vehicle quickly. Various Applications – Communication Officer Application (COA), Dispatch Officer Application (DOA), Patient Care Record application (PCR), Hospital Information System (HIS), Fleet Management Software (FMS) and related databases aimed at automating most of the critical processes of operations. SMS Technologies – Advanced SMS Server helps in quickly sending the information to EMTs from the Dispatch Officer Screen, Fleet management, Feedback mechanism. World class IT Infrastructure –The entire IT Infrastructure is designed to meet the world standards such as ISO 27001 etc. Redundancy is ensured at all levels of Systems and Network. High Availability – All the applications & Infrastructure are designed such that the availability is maintained at 99.9%. 24 X 7 Technology Support – Technology team supports operations team on 24 X 7 bases to ensure the high-availability of Network & Systems. In addition to the above, GVK EMRI uses the following software for support functions: • Customer Feedback Management System • Quality Monitoring System • Knowledge Management Portal • Document Management System • Attendance Management System, Leave Management & Payroll System • Management Reports • Oracle Financials • Oracle Purchase • Oracle Inventory

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The program is run in Public Private Partnership model between GVK EMRI and the respective State Government. While Government provides 100% operational funding and in some states even the capital expenditure including infrastructure is borne by it, GVK EMRI provides for leadership costs, research costs and technology free of cost. There is a review mechanism in place in all states whereby Government is actively involved in 1-0-8 services. At a community level - Brand Awareness of 108 services from GVK EMRI stems from activities conducted by our local trained personnel at grass root level in partnership with media. As a solution to the greater economic challenge in rural India of unemployment and migration to urban areas, GVK EMRI has generated opportunity for the youth to work in vicinity of their native areas and raise awareness and delivery standards of this program. Volunteers In Case of Emergency (VoICE) Volunteerism is a major initiative by GVK EMRI to ensure that no emergencies go unreported and unattended. Hence first responder trainings and community mobilization through village head level interactions are a part and parcel of GVK Emrites’ role which ensures that community is able to respond effectively at critical moments, saving precious lives. Brand recall of 1-0-8 is critical as 1-0-8 is the lifeline to emergency help. Thus every event is publicized through media reminding citizens of key learnings and critical emergency intervention by GVK EMRI 1-0-8 thus raising public safety awareness. A number of awareness generation activities have been conducted by our field personnel in partnership with all key government functionaries at state and district level. Moreover, GVK EMRI volunteers participate with citizens on all major health day events to raise awareness.
 6. How was the strategy implemented and what resources were mobilized?
The program is operated under Public Private Partnership mode with 100% funding by State Governments, based on budget incorporated in the MoU GVK EMRI consistently provides high quality care while at the same time maintaining flexibility at an average cost of less than 1 rupee per citizen per month, a very small fraction of either state or central budgets available for health, while other players charge anything from Rs.600/- upwards GVK Group continues to support and fund significantly in leadership, technology, global collaborations, infrastructure and research and development which has poised this program to remain on the cutting edge of excellence in future. Mahindra Satyam is the Technology partner of GVK EMRI and the software has been designed, customised and provided free of cost.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Size • One Center for 40 M population against one for every 0.05 M population in USA • 600 M population covered in 16 States including 2 Union Territories (increased reach of health care in rural , hilly and tribal areas) have access to quality pre-hospital and emergency care • Trained 86,000+ Medical professionals like EMTs, Doctors, Nurses etc. • 13,500+ emergencies handled per day • 5300+ Ambulances • 27,319 + GVK EMRI Associates Speed • 91% calls taken in first 2 rings ensuring prompt response to an emergency call • Reach time of Ambulances is within ~15 minutes (urban) ; ~ 25 minutes (rural), thus ensuring victim is accessible to prompt pre-hospital and emergency care Type of Emergencies and Lives saved • Major emergency mix nationwide is Pregnancy related - 38%, Vehicular Trauma – 17%, Acute Abdomen – 13% Cardiac – 5%, Respiratory – 4%, Suicidal – 4%, Animal Bites 2% • Avg. 400+ lives saved per day (7.64 lakhs) and approx. 19,500 victims per day receive timely, high quality pre-hospital care Costs • High quality care while maintaining flexibility at an average cost of less than 1 rupee per citizen per month, a very small fraction of either state or central budgets available for health. Qualitative Outcomes • Angel of Mercy – 108 Ambulance • Successful PPP • Well documented systems, impressive EMT training, high order management competence • A historic landmark in health care delivery system • Built more trust in the health system as a whole • Increased institutional deliveries and reduced maternal mortalities by 20 – 25% • A model for replication in any state across the Country

 8. What were the most successful outputs and why was the initiative effective?
Internal Monitoring Quality Control (QC) • ERC Audits • ERO/PDO Call Quality • Coaching and Feedback • ERO/PDO Go-Live Audits • Good & Bad Calls Evaluation • Call Calibration • Field Audits • Ambulance Go-Live Audits • Operational Ambulance Audits • NC Closures • CFMS • SMS – Customer Feedback • Caller Concerns • Caller Appreciations • Caller suggestions • Process Deviations Quality Assurance (QA) • Quality Management System • Process Mapping • Process Documentation • Process Audits • Internal audits • NC Closures • Continuous Quality Improvement Practices • Average Handling Time • ERCP advice utilization • Drift analysis • Vehicle Busy • Failed Transport • SNR Quality Improvement (QI) • Process Improvements : • Process Mapping • Six Sigma • Value Stream Mapping • Training • Quality Basics • Problem Solving Tools • QMS Awareness • Quality Circles & 5S External Monitoring & Review Mechanisms including Performance Audit - Sample Andhra Pradesh Recent Performance Monitoring PPP Memorandum of Understanding between GVK EMRI and state governments clearly defines the monitoring mechanism to be followed. Hence service parameters are a mandatory report submitted to Government on daily, weekly, monthly basis. As an example, given below are the various levels of review and monitoring mechanisms adopted in the State of Andhra Pradesh. At State level : An Advisory Council under the chairmanship of the Chief Secretary will meet at least once in six months to review the Performance / implementation reports and recommendations submitted by the Executive council and recommend to the Government for necessary improvements. At Department level : An Executive Council under the chairmanship of the Special Chief Secretary/Principal Secretary/Secretary, HM & FW will meet once in three months. Performance will be reviewed against service level agreements outlined in MoU, and suggest methods of improvement At District level : A Committee under the chairmanship of the District Collector/District coordinator will meet once a month to review the performance at district level and take necessary steps to revitalize the district administration for effective service delivery. Daily monitoring : A Special Officer appointed by the Government acts as interface between the Govt. and GVK EMRI in ensuring seamless coordination and efficient implementation of partnership agreement. Purchase and Condemnation committee oversees procurement of all major equipment. Weekly reports are submitted basis which periodic reviews and performance/financial audits happen by Government monitoring cell and internal auditors. Monitoring Cell also speaks directly with beneficiaries to ascertain quality and promptness of service rendered.

 9. What were the main obstacles encountered and how were they overcome?
The following were the major challenges that were envisaged when the program was started : • Inadequate awareness among the masses on availability of free 1-0-8 services, when and how to use these services (Public) – through constant brand building and awareness programs into every nook and corner of the states where 1-0-8 operates, GVK EMRI alongwith local district administration is endeavoring to create and raise awareness amongst the masses encouraging them to call 1-0-8 for any emergency. Maternal and infant mortality which is predominant in rural areas especially because of difficulty in reaching appropriate care is also being addressed through such campaigns. Thus a significant number of institutional deliveries are happening with the reach of 1-0-8 into remote areas. • No law to protect confidentiality of EMS patient care records (e.g.,: RTI, IMCA guidelines) (Patients) – Every patient has a right to confidentiality of their health records. However, this issue still remains to be addressed by the concerned system. GVK EMRI however ensures that unless and until absolutely necessary, utmost care is taken to ensure confidentiality of patient information. • No clear provisions for EMS role in disaster management (Partners) - While immediate Emergency Response is a crucial element in situations of distress, it has been restricted only to low key situations. However, Government agencies have recognized the potential in involving EMS agencies also in disaster management, given the incidence of such disasters (be it man made, or natural). Thus GVK EMRI and 1-0-8 services is playing an active role in the area of disaster management. • No indemnity for EMT/Pilot against being summoned to court to give evidence (Legal) – Unfortunately, this issue is yet to be addressed and continues to remain a challenge. There are instances of accidents / serious injuries / medical conditions that 1-0-8 is called upon to handle. Law/Judiciary inferences on suspicious injuries / deaths entail summons to 1-0-8 field staff who have handled a particular case. This not only disturbs the person on duty, but is beyond the scope of their duty and dilutes the service provided by him, especially when attending to several cases in a day.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
GVK EMRI in partnership with state governments operates at unprecedented speed, scale and quality- an emergency is attended to every 8 seconds on an average and every 8 minutes, this service contributes to a life being saved. Following are some of the quantified impacts of this service on common man since inception: Right to Safety : About 600 Million people across 16 States including 2 Union Territories of India can access and avail 1-0-8 world class services- an assured trained help in any emergency medical, police or fire or disasters – anytime/anywhere. Lives Saved : Cumulatively over 22 million victims have received emergency pre-hospital stabilization care and of them 7,64,301 lives have been saved in critical condition since inception as evaluated by clinical assessments. Reduction in Maternal Mortality and Increasing Institutional deliveries : Since inception, 4.8 million institutional deliveries (majority in rural and tribal areas) have been handled by GVK EMRI 108 service and 2,34,881 deliveries have been assisted in ambulance and at scene by trained paramedic securing mother and child health. GVK EMRI has enabled the public healthcare system to reduce MMR by approximately 18% in its current operating states thus helping India bridge to the millennium development goals. Employment Opportunities : With a current force of more than 27,000 employees, more than 95% of staff of GVK EMRI are local and from rural and tribal backgrounds. Implementation of Rajiv Yuva Kirana training program culminating in finding suitable placements for the youth Impact on Knowledge : GVK EMRI has global collaborations with cutting edge research and development organizations in fields of emergency medicine, learning, technology and syndromic surveillance, GVK EMRI has spawned a new line of qualified professionals in this field known as Emergency Medical Technicians (EMT) and has till date trained nearly 80,000 doctors, nurses and paramedics in this field which has built significant capacity on far flung areas to deal with various emergencies.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Piloted in Andhra Pradesh, from a modest 5 towns in 2005, GVK EMRI has now scaled up its operations to impressive heights, covering 16 states including 2 Union territories of India – Andhra Pradesh, Gujarat, Karnataka, Tamil Nadu, Goa, Uttarakhand, Assam, Meghalaya, Himachal Pradesh, Madhya Pradesh, Chhattisgarh, Daman, Diu, Dadra & Nagar Haveli, Uttar Pradesh, Rajasthan and Kerala. From 70 ambulances GVK EMRI are now operating 5300 + ambulances across the above states From being an emergency response provider, the scope of GVK EMRI services has grown to include the following • Implementation of dedicated drop back service in several states of 1-0-8 operation • Launch of dedicated Neonatal ambulance for critically ill new born babies • Provided support for recent international events like COP-11, World Telugu Conference and training organizing /co-ordinating agencies in disaster management for HYMEX • Implementation of Rajiv Yuva Kirana training program culminating in finding suitable placements for the youth • Active role in Disaster Management co-ordinating with other agencies in disasters. In case of disasters (Natural and man Made), mass casualties, Fire, in large scale and any non medical emergencies, people call “108” because of its recall value and confidence in its information dissemination system. • Centralized Dial 100 Command and Control Center established in GVK EMRI campus for enhanced service delivery The model as pioneered by GVK EMRI are also being replicated by many other state governments and corporate who are approaching GVK EMRI for their expertise. GVK EMRI consistently provides high quality care while at the same time maintaining flexibility at an average cost of less than 1 rupee per citizen per month, a very small fraction of either state or central budgets available for health. The main intention is to intervene at the scene of distress and provide expert pre-hospital care. Thus in areas where a 4 wheel ambulance is not able to reach, other innovative methods have been devised – • the boat ambulance in Assam, Gujarat, Uttarakhand • Doli as a main means of transport in hilly terrains and interior areas where there are no proper paths With the expertise/experience gained over the years, best practices imbibed have helped enormously while implementing this service in different states with different geographical conditions. Given the environment in India, GVK EMRI has developed an ecosystem that can adapt to each unique emergency and any cultural or language barriers that may exist.

 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)
During the course of 1-0-8 journey, a lot of practices have been imbibed based on experience in running this program. We would like to walk you through an article written by Dr C K Prahlad and Dr R A Mashelkar in Harvard Business Review, which we would like to walk you through (Annexure 5B pages 7-8)

Contact Information

Institution Type:   Non-Governmental Organization  
Contact Person:   SUBODH SATYAWADI
Telephone/ Fax:   040-2346471
Institution's / Project's Website:  
E-mail:   subodh_satyawadi@emri.in  
Postal Code:   500014
State/Province:   ANDHRA PRADESH

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