Questions/Answers

Indonesia is an archipelagic country consisting of almost 17,503 islands, tectonically lying between the Indo-Australian, Pacific and Eurasian plate, and is one of the most seismically active countries on the surface of the earth. Demographically, Indonesia is one of high population rate countries inhabited by approximately 265 million people with numerous tribes living in huge social-economic inequality. Such facts have put Indonesia at high level of both risks of natural disaster and social conflict. According to the Health Sector Review in 2014, health condition in Indonesia is aggravated by three highest phenomena: cerebrovascular disease, ischemic heart disease and traffic accident. The data of Sample Registration Survey indicates that mortality rate occurring at home is higher than in hospital, respectively 64.5% and 30.1%. The World Health Organization data shows that in 2015 Indonesia became the third highest country of morality rate in Asia below China and India by 38,279 due to traffic accident equivalent to 4 deaths per hour. However, such issues lead Indonesia to the urgent need for rapid and qualified emergency medical service. The Ministry of Health has made a breakthrough by launching an innovative emergency medical service in the form of SPGDT 199 (Integrated Emergency Service System) providing fast response, emphasizing time in life and limb saving while involving the community within 24 hours notably reaching poor people to get the services. The program is called Emergency Medical Service 119.

The initiative of Emergency Medical Service 199 carries some objectives as follow: 1. Introducing a single service number for accessing daily medical emergency to the community through access code 119. 2. Facilitating the community to freely access the service via local or cellular phone. Currently, the community no longer needs to access many health service numbers. 3. Providing free health service especially ambulance service and the information about the availability of hospital bed for intensive service. 4. Preventing death and minimalizing disability by giving any guidance to the victim’s companion via phone. 5. Utilizing information technology to facilitate the integrated service provision in Indonesia.

Poor people feels difficult to access emergency medical service due to cost limit, they prefer use any kinds of available vehicle. The existence of free emergency service 119 greatly helps community to access ambulance and information about hospital bed and intensive room availability. By July 2016, NCC 119 service inaugurated by Ministry of Health of the Republic of Indonesia and presented in Indonesia. Supported by powerful legal basis, the program is expected to stimulate regional government to form PSC 119 integrating with NCC 119 therefore wherever call incoming can be forwarded quickly and accurately. The health human resources involving in both NCC 119 and PSC 119 have gained the competence of emergency training in order to maintain service quality. Poor people being served are not deemed as helpless victim, yet as customer needs for equitable service. The community is trained to comprehend basic life aid thereby their role in declining disability rate and preventing death can be achieved. This national program requires a good system electronically recorded to draw up so it can be evaluated by everyone. The service 119 has gained appreciation from the Ministry of Administrative and Bureaucratic Reform of the Republic of Indonesia for its positive impact.

In accordance with SDGs agenda, the courtesy of good cooperation with police party has led the mortality rate due to traffic accident to decrease from 4393 in 2016 into 3663 by 2017. Paralleling the policy and road safety map in Indonesia in the 5th pillar appointed to the Ministry of Health thus the integrated emergency management system is necessary to build and optimize through NCC 119 by developing and widening the range of call center 119 in the entire are of Indonesia, optimizing the role of PSC 119 in regency and city with fast and responsive service pursuant to the emergency service quality, accomplishing the availability of ambulance 119 with standardized human resource and utility, building and strengthening hospital referral system, developing hospital equipped with the excellent service of trauma center for traffic accident prone area, promoting safety and health culture in the traffic, as well as determining health standard in driving for the drivers in Indonesia.

Prior to the existence of NCC 119 service in Indonesia, ambulance service formerly known as call center 118 in which the service was managed by paid private party with the cost that was unaffordable for poor people. Through regulation of the Minister of Communication and Informatics, access code 119 has been granted to the Ministry of Health. The implementation of the program has greatly helped poor people. Previously, the paid emergency medical service 118 gave no any issue for rich people, yet as the need of community for emergency medical service has increased thus it seemingly stimulated many parties to determine those responsible in the integrated system. Hence the existence of free emergency medical service 119 has obviously and greatly helped poor people and the entire community.

A number of positive impacts that have been gained from the program as follow: 1. Access code 119 is easily known by the public. 2. Poor people can freely access the services notably ambulance service and the other information including consultation for mental health problem. 3. Regional government competes for building PSC 119 integrating with NCC 119 since the community in regional level very yearns for affordable and impartial public health service.

Prior to the existence of call center 119, all community charged by access code 188 for ambulance service, this notably made poor people feel burdensome. PSC 119 possesses ambulance and trained human resource pursuant to the emergency competency standard ready for 24-hours and free. By cooperating with health service facilities available in its working area, PSC 119 maximizes travel time to reach the location where the victim be. A series of meetings held by the Directorate General of Health Efforts involving cross-programs at the Ministry of Health, Vertical Hospital Association (ARVI), Vertical Hospital and DKI Jakarta Health Agency finally initiated the implementation of integrated emergency management system through “Emergency Medical Service 119”. Actions to carry out: 1. Launching access code 119 for Ministry of Health of Indonesia in accordance with Letter of the Minister of Communication and Informatics number 486/M.KOMINFO09/2012 dated September 13, 2012. 2. Issuing Circular Letter of Director General of Health Efforts of Ministry of Health number IR.01.03/I/1996/12 dated October 19, 2012 to build SPGDT network using access code 119. 3. Pilot Project with Governor of DKI Jakarta and also Ministry Hospital on March 1st 2013 Cooperating with PT. Telekomunikasi Indonesia and 9 Telecommunication Providers. 4. Formulating guidelines for the establishment of PSC. 5. Issuing Health Minister Decree regarding Integrated Emergency Management system.

Original. The innovation was purely derived from the recommendation of health community stakeholders concerning about emergency medical services in Indonesia. The Ministry of Health initiated the preparation of unit that was charged with integrating emergency services into more nationally integrated one known as NCC 119. However, this innovation has overcome such problems formerly appeared as expensive emergency medical service, different numbers of emergency service that each area had, frequent miscommunication between primary service and referral to respond when an emergency case occurred nearby.

1. Infrastructure and Service Support The success of this program highly depends on the information technology, internet network, communication tool, and application system. Ambulance unit and emergency kit are also significant for patient handling. 2. Policy and Rules The existence of Presidential Instruction No.4 year 2013, Minister of Health Decree No.19 year 2016, and local regulations, will support regions to replicate and allocate budget for the 119 program. 3. Leadership and Guidance Creative, innovative, and visionary leaders, strong support and commitment from the policy maker. 4. Human and Financial Resources The existence of competent human resources and budget support also greatly affects the sustainability of the program. Every year, the Ministry of Health budgeted approximately 10 billion rupiah equivalent to 750 thousand dollars (1 $ = 13,500 rupiah) including the cost of 32 agents (nurse), 4 doctors and 4 IT experts.

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Furthermore, the access number for emergency service of police is 110, firefighter is 113, the National Board for Disaster Countermeasure is 129, and the National Board for Search and Rescue is 115. The initiative has certainly transferred to other contexts. Through emergency medical services, the Ministries and related institutions have such a similar pattern as national rescue agencies, police, and so on. According to the regulation of the Ministry of Communication and Information, emergency numbers in Indonesia generally do not follow a single number in common i.e. respectively possessing sole access number.

The sustainability of social programs requires constant maintenance since the community already know the access number 119 is a national call number for daily emergency medical service. Moreover, the socialization of this program to community is necessary. This activity should be submitted to local governments yet to establish PSC in its area. Because operational activities require budget, then the local government needs to plan it well therefore the community finds the service more useful. The establishment of PSC 119 for every district/city in Indonesia has been stipulated in the Presidential Instruction Number 4 of 2013 hence each of district/city is responsible for the finance. In addition to the assistance of the Ministry of Health in the form of specific allocation budget, the PSC can also get the assistance of banks, donors and other unbinding parties. PSC 119 established under the rule of law in case of becoming an independent unit whose employees are permanent employees of the government will be more stable in carrying out its activities in the future. While PSC 119 which is still part of the district health office relies on the ability of local government to allocate its budget. By contrast, NCC 119 carrying a strategic plan has been budgeted every year by the Ministry of Health.

Since this program was initially launched in July 2016, there have been many requirements necessary to prepare. The government’s assistance notably the Ministry of Health is crucial in providing emergency services especially for those unable to access such services like ambulance due to high cost. Indonesia is a vast territory of republic hence in order to maintain a good network connection, a consideration of the availability of infrastructure in each region is necessary. Annually, the Ministry of Health targets for establishing the PSC 119 in the entire country. In 5 years the target plans to establish 514 units of PSC 199, it means every district/city will have PSC 119 thus all community can access the service wherever they be. There are three most important things to note: 1. Financial resources The operational fund of NCC 119 and 119 programs come from the Ministry of Health. Other financial supports for PSC 119 are DE concentration Fund, Physical Special Allocation Fund, Regional Budget and CSR. 2. Technical Resources The information software technology equipment consists of call center infrastructure (computer, desktop, headset, handy talkie, etc.), network connectivity, call center applications, medical emergency algorithms, Hospital Online, and other supporting applications. Legal instrument also established namely Minister of Health Decree number 19 year 2016. 3. Human Resources The implementing team is coordinated by Sub-Directorate of Integrated Emergency Service. Currently, human resources at NCC 119 consist of physicians, nurses, midwives and IT supports. While the human resources in PSC 119 tailored to the ability of the region, consists of coordinator, health workers, call center operators and other personnel as needed. For the following year, the Ministry of Health is expected to be able to build its own system both in the form of based-call center and application (for android) easily accessible for all community in Indonesia.

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The NCC 119 and PSC 119 activities are monitored and evaluated by Sub-Directorate of Integrated Emergency Service and also can be monitored directly through a monitoring dashboard at NCC 119, which displays daily call performance data of NCC 119 and real time monitoring of integrated PSC 119. Monitoring and evaluation of Emergency Medical Service 119 program is nationally and periodically conducted by the Sub-Directorate of Integrated Emergency Service. Activities are reported daily in the form of daily reports and sent to program responders on a monthly basis. Evaluation activities are conducted at the end of the year in the form of meetings attended by related parties and documented in the form of reports. At the beginning of the year discussed the sustainability of the program and the future financing and constraints faced for further improvement. So far, the NCC 119 service has officially been evaluated by mere one outsider namely PT Telkom.

Some positive outcomes and impacts of this are as follow: 1. The emergency medical number (119) that is easily recalled and nationally accessible. 2. The community is able to get easier and faster emergency medical services by calling 119 freely. Based on data, the number of incoming calls to NCC from July 1, 2016-July 31, 2017 = 4,676,060 calls with Successful Call Ratio is 95.69%. 3. Integrated Emergency Medical Service 119 between the central and regional through NCC 119 and PSC 119. As of January 2018, it has been replicated by 136 PSC 119. 4. The existence of community participation in emergency services. Communities can participate by calling 119, and provide first aid for the victim/patient pursuant to the guidance from 119 agents. 5. The support for activities in the form of regional financing as well as good cooperation with cross-related sectors. 6. In addition, the expected outcome of this service is the decline of mortality rate notably those occur outside of health care facilities.

The indicator used in the evaluation is the number of incoming calls, the number of calls received, the number of calls responded by the provision of services including ambulance, the number of active PSCs performing the systematically recorded activities, the average length of calls raised, the average travel time the ambulance reaches the location and the type of disturbance experienced by the PSC. 1. Incoming calls – is a call that goes to NCC 119 before the agent is appointed. 2. Calls received – is a call from the moment the agent is lifted to the delivery of the information the patient needs. 3. Calls Responded – is the call received and followed by the delivery of an ambulance to the location. 4. Length of Calls – how long the average time required from the call is picked up until the call is over. 5. Login – to see if a PSC is running system or not. 6. Time to get location – how long the average time it takes to reach the location. 7. Disturbance – to see the constraints faced by PSC for 24 hours a year.

Emergency Medical Service 119 was initiated by the Director General of Health Efforts by involving cross-programs in the Ministry of Health, and Vertical Hospital Association. The Ministry of Health cooperates with the Regional Government in forming PSC 119. PSC 119 is the executor of emergency medical services in area of pre-healthcare facility supported by MOH through Physical Special Allocation Fund for the construction of facilities in PSC. Each municipality provides human resources and operational funds for PSC 119 as well as involves Hospitals and Sub-district Health Center as PSC networks. PSC also cooperates with Jasa Raharja Insurance, Police, Disaster Agency and Fire Fighter. The entire related parties has respectively role supporting each other. 1. Designing - Cross-programs in Ministry of Health, and Vertical Hospital Association play roles in the process of developing integrated emergency system and call center 119 application. 2. Implementing - Local Governments provide support in terms of issuing local regulations regarding PSC 119 and financial supports. Province Health Agencies conduct socialization of PSC 119. Municipality Health Agencies establishes PSC 119. 3. Professional Organization provides support in preparing emergency algorithm. 4. Networking and Tasks - Hospitals, clinics and Sub-district Health Center become networks/partners of PSC 119 in providing emergency services. Ambulances from hospitals, clinics and Sub-district Health Center can be delivered to the scene if necessary. 5. Police and Jasa Raharja Insurance become partners of PSC 119 in case of traffic accident. 6. Community Organizations (medical/nursing/midwifery students, motorcycle taxi driver community, motorcycle community, volunteers) are partners of PSC 119 in providing emergency medical services, they can perform as the first responders

The main lesson learned from NCC 119 is that this program is a big responsibility of the country for providing emergency medical services that are free of charge and easily accessible for anyone within 24 hours a day in the entire region supported by local governments. This program somehow must reach all community notably the poor therefore they can access such services as ambulance and referral to the nearest hospital. Hopefully in line with the increasing number of information and services used by the community, they are able to have awareness and concern about getting involved in providing first aid correctly. Here are the other points of the lesson learned: 1. Strong commitment and support from the government. 2. The existence of legal support at both central and regional level will make it easier for regions to replicate and allocate budgets for the Emergency Medical Service 119 program. 3. The support of information technology, internet network and application are very useful for the success of service. 4. People are educated to be wiser to use this free service by calling 119 if necessary for emergency medical assistance only, not for fun. For future improvement, based on a cross-sectorial meeting, an integrated emergency medical system will be built for both daily emergency, accidents, fires and disasters.