Family Health International – FHI 360
Assessment of Emergency Response Service
(ERS) Performance in Madhya Pradesh
Under
DFID Contract for Technical and Management Support
to Implement the Madhya Pradesh Health Sector Reform
Programme
FINAL REPORT
September 2013
DELOITTE TOUCHE TOHMATSU INDIA PVT. LTD.
TABLE OF CONTENTS
CHAPTER
SECTION
PAGE NO.
LIST OF ABBREVIATIONS
4
1
STUDY BACKGROUND
5
2
IMPLEMENTATION MODEL
SENSE – REACH – CARE
11
2.1
SENSE
13
2.2
REACH
19
2.3
CARE
29
3
SUPPORT FUNCTIONS
35
3.1
HUMAN RESOURCES
36
3.2
QUALITY
47
3.3
SUPPLY CHAIN MANAGEMENT
52
3.4
MARKETING
56
3.5
INFORMATION TECHNOLOGY
61
4
CONTRACTUAL AND INSTITUTIONAL FRAMEWORK
63
5
DEMAND SIDE ASSESSMENT
72
6
ANALYSIS OF COSTS
82
7
SUMMARY OF KEY OBSERVATIONS &
RECOMMENDATIONS
89
8
ANNEXURES
101
ANNEXURE LIST
Selection of Sample Villages
8.1
102
8.2
List of interviews conducted (village-wise)
116
8.3
Comparison of ambulances as per international norms
Roles and Responsibilities of key stakeholders involved in carrying out field
operations
118
8.5
8.6
8.7
Launch Details of Ambulances & Population coverage per district
122
124
125
8.8
8.9
Assessment parameters and tool used for EMT assessment
8.4
8.10
8.11
8.12
8.13
Facility Feedback
Minimum qualifications and recruitment process for EMTs, Pilots and ERO
List of consumables and equipment present in sample ambulances assessed
Comparison of cases handled by 108 and Janani Express Yojana (JEY) in
Sagar District
Financial data submitted by EMRI
Details of year wise parameters for costing ratios – no. of ambulances,
emergencies handled and KMs travelled
Year wise Costing Detail
121
126
130
132
133
135
136
List of Abbreviations
ALS
ANM
AMC
ASHA
AVLT
BLS
CAPEX
CFMS
CME
CMHO
COO
DHS
EC
EM
EME
EMLC
EMT
ERC
ERCP
ERO
ERS
FEFO
FMS
FT
GoMP
GPS
HIS
HR
IEC
IFT
IT-IS
JSSK
KAP
MO
MoU
OLMD
OPEX
PCR
PM
PPP
PRI
QMS
RM
SCM
TL
UA
UAC
VB
Advanced Life Support
Auxiliary Nurse Midwife
Annual Maintenance Contract
Accredited Social Heath Activist
Automatic Vehicle Location Tracking Systems
Basic Life Support
Capital Expenditure
Customer Feedback Management System
Continuing Medical Education
Chief Medical Health Officer
Chief Operating Officer
Directorate of Health Services
Executive Committee
Emergency
Emergency Medical Executive
Emergency Medical Learning Centre
Emergency Medical Technician
Emergency Response Centre
Emergency Response Centre Physicians
Emergency Response Officer
Emergency Response Service
First Expiry First Out
Feedback Management System
Fleet Technicians
Government of Madhya Pradesh
Global Positing System
Hospital Information System
Human Resource
Information, Education and Communication
Ineffective Calls
Information Technology and Information System
Janani- Shishu Suraksha Karyakram
Knowledge Attitude Practice
Medical Officer
Memorandum of Understanding
On-Line Medical Directions
Operating Expenditure
Pre-Hospital Care Record
Program Managers
Public-Private Partnership
Panchayat Raj Initiative
Quality Management System
Regional Manager
Supply Chain Management
Team Leader
Unavailed Cases
Unattended Calls
Vehicle Busy
CHAPTER 1
STUDY BACKGROUND
Assessment of ERS Performance in Madhya Pradesh
Final Report
Background of the Scheme
1.1
The Government of Madhya Pradesh (GoMP) entered into a MoU with GVK EMRI, a not-forprofit organization, to provide integrated emergency response services (medical, police and fire)
through a toll-free number - 108, across the State in a phased manner.
1.2
The services were launched in July 2009 and covered 10 districts with 102 Basic Life Support
(BLS) ambulances till December 2012 – Bhopal, Gwalior, Jabalpur, Indore, Rewa, Sagar, Sehore,
Damoh, Datia and Hoshangabad.
1.3
The 108 service was further extended to the other 40 districts in 2013 with 352 BLS ambulances.
GVK EMRI and GoMP plan to launch another 100 BLS and 50 Advanced Life Support (ALS)
ambulances in the state to increase the depth of service and ensure presence of at least 1 ALS
ambulance per district to handle extremely critical cases.
Context
1.4
Given the context of 108 services in the state of Madhya Pradesh, GoMP sought an external
evaluation of the current status of emergency management services being provided by EMRI to
identify strengths and areas of improvement of the model. MPTAST, who was assigned the
responsibility for this evaluation, contracted Deloitte to carry out the same.
Objectives and Scope of the study
1.5
The Scope of Work of the study is to:

Assess the appropriateness and relevance of the management and implementation
arrangement, such as MoU, roles and responsibilities, network hospital etc.

Assess the quality of infrastructure, services and knowledge, attitude and practice (KAP)
across the Sense – Reach – Care model.

Evaluate the efficiency and effectiveness of model in terms of performance as well as costs
involved in the ERS

Assess user level satisfaction with respect to quality, timelines and effectiveness of the
services being provided and unmet needs

Assess the effectiveness of enroute basic lifesaving services provided by the ambulance
staff

Assess key issues and bottlenecks affecting efficiency and effectiveness of ERS

Provide recommendations relating to aspects such as policy level changes, management
and implementation arrangements and processes to improve staff KAP and scope for cost
reduction and sustainability.
.
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Assessment of ERS Performance in Madhya Pradesh
Final Report
Approach and Methodology
Approach
1.6 The approach adopted by the Deloitte team was aimed at ascertaining both user as well as supply
aspects of the model as illustrated in the following exhibit Exhibit 1.1: Approach followed
1.7
On the supply side, while the focus was to assess systemic and structural issues through discussions
with key staff from GoMP and GVK EMRI, the objective for demand side assessment was to
ascertain responses from users, non-users, field level workers and influencers on parameters such as
awareness, availability / timeliness (whether an ambulance was available and how long the service
took), quality (what was the condition of the ambulance, preparedness of the staff) etc.
Methodology
1.8 An overview of the methodology followed for the study is presented in the following exhibit.
7
Assessment of ERS Performance in Madhya Pradesh
Final Report
Exhibit 1.2: Study Methodology
Sampling plan
1.9 The mechanism followed to finalize the sample has been given below.

Districts and Bocks: Field visits were carried out in 3 representative sample districts of
MP, covering urban and rural areas. 3 blocks per district were visited. The selection of
districts and blocks was based on analysis of data sought from EMRI1 on parameters such
as geographic coverage, years of operations, no. of emergencies handled and response
times. The list of districts and blocks was then finalized in discussion with GoMP and
MPTAST.
Exhibit 1.3: Sample of district and blocks
District
Gwalior

Urban Blocks
No.
Name of block
Gwalior-Urban
2
Gwalior-Rural
No.
Rural Blocks
Name of block
1
Bhitarwar
Sagar
1
Sagar-Urban
2
Banda, Garhakota
Sehore
0
None
3
Ashta, Budhni,
Nasrullaganj
Total
3
6
Villages: For each of the selected sample blocks, villages were categorized as “Frequent”
and “Infrequent” based on the no. of emergencies received from the villages of the blocks
for the period October to December 2012. The methodology used for selection of villages is
given in the Annexure 8.1. For rural blocks, at least 4 frequent and 2 infrequent villages
1
The new 40 districts were not considered for the study as services in these districts have been operational for less than 6
months.
8
Assessment of ERS Performance in Madhya Pradesh
Final Report
were covered. For urban blocks, the overall block level sample sizes were covered without
further geographic categorization.
1.10 Key stakeholders met during the assessment is given below
Exhibit 1.4: Key Stakeholders Met
Level
Key Stakeholder Groups
GoMP
State
EMRI
District
GoMP
EMRI
Block
and
Below

108 Nodal Officer












COO
Sense, Reach and Care teams
Quality team
SCM team
Marketing team
Hospital relations team
Technology teams
Finance and HR teams
Chief Medical Officer of Health
District Programme Manager
District Magistrate (optional)
Operations in-charges (Emergency
Management Executives)

Doctors at Govt Health care facilities (CHC s)

Ambulance staff
o EMTs (paramedical staff)
o Pilots (ambulance drivers)
Users, non-users, Field Level Workers, Influencers
etc.

No. Covered
Total Sample
1
1
28
28
1-2
per district
5
For 3 districts
1 per district
~2 per block
3
For 3 districts
14*
For 9 blocks
2 per block
18
For 9 blocks
~60 per block
559
Total no. Interviews conducted
627
* In 4 blocks only 1 hospital was visited as all cases were taken only to the nearest CHC.
* In addition to the above, 9 ambulances (1 per block) were assessed for sufficiency of infrastructure
*Annexure 8.2 provides village wise list of interviews conducted.
1.11 Detailed assessment tools for various stakeholders to be met were developed for facilitating
structured discussions and data collection. A detailed methodology and analysis plan was then
agreed and shared with MPTAST.
Analysis and Final Report
1.12 An evaluation of EMRI was carried out based on the detailed analysis of information
collected during discussions with various stakeholders. A Draft report was then submitted to
MPTAST which included an overview and analysis of 108 services being provided by EMRI
covering key strengths, issues and recommendations
1.13 This Final report includes analysis of cost data provided by EMRI and feedback received
from GoMP on the Draft Report.
9
Assessment of ERS Performance in Madhya Pradesh
Final Report
1.14 This report has been drafted under the following sections detailing various aspects of the service.
Section – 2
Implementation model of the 108 service: Sense-Reach-Care and assesses
processes followed, key performance indicators and monitoring aspects.
Section – 3
Findings and analysis of all support functions within GVK EMRI.
Section – 4
Contractual and institutional framework of the public private partnership between
GVK EMRI and GoMP
Section – 5
Feedback on the service from users, non-users and field functionaries.
Section – 6
Analysis of cost data in terms of key cost indicators and trend of expenditure
Section – 7
Summary of key observations and recommendations
Section – 8
Annexures
Limitation
1.15 As agreed during the inception phase, the evaluation is limited to data as of December 2012 (102
operational ambulances)2. Thus, the financial and operational impact of the new ambulances
launched in 2013 is not covered in the study (Although, we have attempted to compare operational
costs for the period Jan-June 2013 against financial estimates proposed under Schedule A of the
revised MoU).
2
As agreed with MPTAST in the beginning of the project.
10
CHAPTER 2
IMPLEMENTATION MODEL
SENSE-REACH-CARE
Assessment of ERS Performance in Madhya Pradesh
Final
IMPLEMENTATION MODEL – BACKGROUND AND SCOPE
2.1
The EMRI operational model is based
on Sense > Reach > Care of an
emergency.
The
emergency
transportation, conducted in an
ambulance, is provided free of cost.
The transportation is coordinated by the
Emergency Response Centre (ERC),
which is operational 24-hours a day, 7days a week. In addition, the call to the number 108 is a toll free service accessible from any
landline or mobile cellphone. EMRI ambulance fleet includes Basic Life Support ambulances
(BLS) containing critical drugs and equipment required for handling emergencies.
Exhibit 1.1: Scope of 108 services
Type of Service
Services Provided
Medical
•
•
All medical emergencies and Referrals to higher facilities post ERCP verification
Drop back to home for pregnancies not covered.
Police*
•
All types of police cases, including medico-legal cases
Fire*
•
All types of fire emergencies, including medico-legal cases
* Cases handled through coordination with respective state departments
OPERATIONAL MODEL – EMERGENCY HANDLING PROCESS
2.2
The operational model followed by EMRI is depicted in the following exhibit below.
Exhibit 1.2: Operational Model
2.3 The following sub-sections detail the findings of the evaluation of these core functions – Sense
Reach Care.
12
Assessment of ERS Performance in Madhya Pradesh
Final Report
2.1 SENSE
2.1.1
The Sense function of the ERS works through a 24 X 7 X 365 centralized call centre, also known
as the Emergency Response Center (ERC), located at Bhopal. The ERC is currently staffed with
85 Emergency Response Officers (EROs), 2 Team Leads (TL) and a Manager. The ERO is
responsible for call handling and the Team Leads and the manager coordinate rostering and
monitoring activities.
Scope of Responsibilities
Exhibit 1.1.1: Scope of activities for Sense
Primary role
2.1.2 Receiving calls of 108: The function of sense is to attend to all calls that land at 108, including:
 Emergency Calls - Calls that result into either a medical, police or fire dispatch.
 Effective Calls - Calls that are related to emergencies but do not result in dispatches,
including repeat, follow up, service cancellation and feedback calls.
 Ineffective Calls - Calls that are not related to any sort of emergencies including silent,
wrong, nuisance, no response calls etc.
2.1.3
Dispatching ambulances: On identifying the location of the emergency, EROs coordinate with
nearby ambulances to identify and dispatch the closest available ambulance. In cases where all
ambulances are busy, the ERC has a separate desk to track vehicle busy cases by dynamically
coordinating with ambulances and keeping callers constantly updated of the status.
2.1.4 Coordinating with ERCPs: ERO is also responsible to connect EMTs (Emergency Medical
Technicians in the ambulances) to ERCPs (Doctors at ERC) for Online Medical Direction
(OLMD), if required.
Secondary role
2.1.5 Case Closure – The case closure process mandates ambulance staff to call the ERC on a separate
“manager-on-duty number” to provide additional EM information such as diagnosed EM, reach
times and hospital details, before attending to another case. This information is used for
generating the daily automated report.
2.1.6
48 hour follow-up – This is a customer centric process initiated by EMRI to collect feedback from
all callers on their experience with 108 and status of patient within 48 hours of emergency.
13
Assessment of ERS Performance in Madhya Pradesh
Final Report
2.1.7
Support Services - Apart from the calls mentioned above, ERC provides other support services
such as receiving calls from ambulance staff on updation of vehicle status (off-road, servicing,
busy etc.), registering staff grievances etc.
Assessment Findings: Primary and Secondary functions of ERC
2.1.8
The findings and observations made during the assessment visits are detailed below –
a. Well defined call taking process: A clearly defined process guides the call taking process
which is constantly reviewed and updated in order to improve efficiency and caller
experience. For example, the ERO process was launched only in April as an improvement to
the earlier CO-DO (Call Officer – Dispatch Officer) process, which involved different
officers for call receiving and ambulance dispatch. This change was done to enhance caller
experience by having only one point of contact and to reduce call handle time.
b. Proactive vehicle busy desk: The vehicle busy desk is helpful to better engage with the caller
in distress and reduce waiting times.
c. Good customer feedback process in place: The 48 hour follow up initiative is a good
feedback mechanism for the service. Discussions with beneficiaries also showed that this
feedback was appreciated among callers and contributed to their satisfaction. During the
evaluation, it was observed that due to the sudden increase in EM calls as a result of
new ambulance launches in Jan-May 2013 period and insufficient manpower, while
the follow up was being done, the 48 hour timeline was not maintained.
d. Well-designed Sense application: The Sense application implemented by GVK EMRI for
handling calls is well designed and structure based on the ERO algorithm ensuring minimum
deviations and errors. The application is adequately supported by switches, servers and data
storage hardware.
e. Weak Case closure process: The case closure process also releases the ambulances on the
ERO application, showing them as available for the next dispatch. It was observed during the
assessment visits, due to delays in case closures, ambulances are not released on the online
application. This could lead to longer call handle time as the exact ambulance status is often
not available during dispatches, requiring EROs to call all nearby ambulances to finalize one.
Operational Indicators
Types of Calls
2.1.9 The following table provides a snapshot of the call related data since July 2009:
Table 1.1.2: Operational indicators – Type of calls
Parameters
Total No. of Calls Received
per day
Unattended Calls (UAC) per
day (%)
Jul- Dec
‘09
Jan- Jun
‘10
Jul-Dec
‘10
Jan- Jun
‘11
Jul- Dec
‘11
Jan- Jun
‘12
Jul- Dec
‘12
17,046
33,717
30,983
33,605
22,274
29,019
23,702
199
(1.17%)
373
(1.11%)
162
(0.52%)
227
(0.68%)
127
(0.57%)
146
(0.50%)
253
(1.07%)
14
Assessment of ERS Performance in Madhya Pradesh
Final Report
Total No. of Calls Attended
per day
16,847
33,344
30,821
33,378
22,147
28,873
23,449
EM Calls
%
2.0%
1.4%
2.5%
2.5%
4.7%
3.0%
3.8%
Effective Calls
%
3.2%
1.2%
1.8%
1.4%
2.5%
1.5%
1.7%
Ineffective Calls
%
94.8%
97.4%
95.7%
96.1%
92.8%
95.5%
94.5%
All Data provided by EMRI
*Analysis is limited to Dec 2012 as data for Jan-May 2013 has not been provided
*Certain data gaps were observed in data provided by EMRI on calls attended
Assessment Findings: Call Types
2.1.10 Low percentage of Unattended Calls (UAC) till Dec’12:


Unattended calls are the calls that are missed at the ERC due to busy lines. As can be seen
from the table, unattended calls have constituted approximately 1 % of the total calls, which
indicates well planned capacity to handle the indicated number of calls per day.
However, during the evaluation period, a significantly higher % of UAC was observed at the
ERC. For instance the UAC on 28th May was observed to be approximately 15% on the
Dynamic report displayed at the ERC. Discussions with officials in the Sense and Field
Operations department teams have indicated that this percentage has been more than 10%
over the last 2 months. It is difficult to estimate the actual percentage and the reasons for
increase due to lack of sufficient data.
2.1.11 High percentage of Ineffective Calls
 Ineffective calls constituted approximately 95% of the total attended calls, which is very high.
However, this % ranged between 80-85% in June’ 13 (as observed by the team) due to
increase in EM Calls owing to the launch of 352 new ambulances. Deloitte team conducted a
dipstick analysis of ineffective calls by listening to 60 calls to analyse the composition of
ineffective calls.
Table 1.1.3: Sample of Ineffective Calls evaluated
Call Type
No Response
Wrong Call
Nuisance Call
Disconnected
Missed Call
General Enquiry
call
Silent Calls
Description
After call connection, no response from caller
Wrong number dials
Intentional/ Abusive calls
Disconnection
after
initial
conversation/
connection
Pop up generated on computer screen, but call
not connected to
Deliberate calls enquiring about non 108 matters
Caller cannot be heard
Total
Percentage of
ineffective calls
17.4%
2.5%
65.3%
Calls sampled
(minimum 3)
10
3
33
9.6%
5
0.9%
3
0.6%
3
3.7%
100%
3
60
*Dipstick conducted on 28/5/13
*50 calls were randomly selected based on the above percentage of ineffective calls
*A minimum of 3 calls was taken for each category where there were lower number of calls as per above
bifurcation
15
Assessment of ERS Performance in Madhya Pradesh
Final Report
2.1.12 Key analysis from the above evaluation is presented below  Wrong Categorization: As seen in the following table, the actual percentage of call categories
varies significantly in comparison to the current split. 48% of the sample calls were wrongly
categorized. Appropriate categorization and frequent analysis of varying call patterns would
be important to develop organization level strategies and draw prioritized action plans to
address and reduce each of the call categories.
Table 1.1.4: Comparison of Classified and Actual Proportions
No Response
17.4%
Percentage of
Wrong
categorization
20%
Wrong Call
2.5%
100%
0%
Awareness
Nuisance Call
65.3%
56%
28%
Disconnected
9.6%
40%
19%
Missed Call
General Enquiry
call
Silent Calls
0.9%
67%
7%
Awareness
Technology ,network or
awareness
Shortage of EROs
0.6%
0%
8%
Awareness
3.7%
67%
8%
Technology or network
Percentage of
Ineffective calls
Type

Percentage of total
after correct
categorization
30%
Possible cause
Network congestion
Varying causes of ineffective calls:
- Network related: While the overall percentage of ineffective calls is daunting, over
50% of the calls are possibly due to network and connectivity problems at the source,
which cannot be directly addressed by EMRI.
- Manpower related: The % of missed calls could be a function of available manpower.
This % should be considered by EMRI while planning for their manpower.
- Awareness related: The composition of nuisance calls (including abusive calls) is an
area of concern as the handling time is comparatively longer in these cases, thus
impacting manpower. Nuisance calls should be addressed through appropriate
communication strategies in coordination with the Government.
2.1.13 In MP, given the composition of calls, GoMP and EMRI need to develop strategies to bring down
this number to approximately 50% over the next 2 years. However, this target needs to be
established based on analysis of trends of ineffective calls of States with matured EMRI
operations such as Gujarat and Andhra Pradesh.
Types of Emergencies
2.1.14 The following table provides a snapshot of the dispatch related data since July 2009 :
Table 1.1.5: Emergency Related Information
JulDec
‘09
JanJun ‘10
July-Dec
‘10
Jan- Jun
‘11
JulDec ‘11
JanJun ‘12
Jul- Dec
‘12
Medical Calls Received per day
171
254
392
431
520
459
514
Police Calls Received per day
30
32
31
41
38
39
33
Parameters
Types of Emergencies
16
Assessment of ERS Performance in Madhya Pradesh
Final Report
Parameters
Fire Calls Received per day
Vehicle Busy per period (% of
medical calls)
JulDec
‘09
JanJun ‘10
July-Dec
‘10
Jan- Jun
‘11
JulDec ‘11
JanJun ‘12
Jul- Dec
‘12
0.32
0.31
0.32
0.13
0.09
0.01
-
10
(5.8%)
19
(7.5%)
58
14.8
54
12.5
95
18.3
63
13.7
91
17.7
Assessment Findings: emergency Types
2.1.15 Mostly Medical Emergencies: Over 90% of emergencies reported are medical emergencies.
While the number of medical emergencies handled has constantly increased over time, no
increase in the number of police and fire emergencies has been observed.
2.1.16 High % Vehicle Busy Cases: The vehicle busy % reflects the capacity of the operational
ambulances to handle current number of emergencies. As can be seen from the graph below, the
increasing number of vehicle busy cases is an area of concern. Since the analysis is limited to
December 2012 i.e. fleet size of 102 ambulances (before the launch of the new 352 ambulances),
the impact of the launch of new ambulances on vehicle busy could not be analysed. It is
suggested that GoMP closely monitors the vehicle busy % given the launch of 352 + 102 new
ambulances.
Table 1.1.6: Vehicle busy cases in comparison with total medical emergencies
600
500
400
300
200
100
0
20.0%
15.0%
10.0%
5.0%
0.0%
Jul- Dec Jan-June July-Dec Jan- June July- Dec Jan- June July- Dec
‘09
‘10
‘10
‘11
‘11
‘12
‘12
Medical Ems
Vehicle Busy cases
Monitoring Mechanisms
Monitoring call center operations
2.1.17 The monitoring processes of call centre operations have been observed to be very good. The team
leaders and the manager play a vital role in ensuring that daily operations of the call centre are
well planned and closely monitored. Mechanisms followed by sense include:
 Weekly rostering of EROs based on call volumes followed by hourly tracking of call
variations to ensure optimum availability of EROs. This is also backed by automated
reports tracking the status and efficiency of each logged in ERO.
 Dynamic displays in the ERC detailing current, daily and monthly information relating to
no. of calls being handled, no. of waiting calls, UAC, no. of dispatched ambulances and
types of emergencies
ERO performance
2.1.18 All calls attended by the call centre are recorded through a voice logger. The Quality Team is
responsible for auditing calls for each employee and identifying issues in call efficiency/duration,
language, skill sets and case closing. These audit findings are collated by the team leaders to
17
Assessment of ERS Performance in Madhya Pradesh
Final Report
evaluate ERO performance using parameters such as process knowledge, call quality,
attendance, call handle time and productivity.
Assessment Summary: Sense
 Well defined and clear processes in place guide the call handling process at the ERC backed by wellstructured and implemented hardware and software. EROs was found to be motivated and adherence
to defined process was high. Adequate monitoring systems are in place for call center operations and
well handled by the team leads.
 However, the manpower planning process would need to be more robust. At an organization level, the
high percentage of ineffective calls, unattended calls and vehicle busy cases would need to be
addressed jointly by the management, sense, field operations, and HR and marketing teams. An
initiative to tackle the problem of longer case handle time due to delays in case closures is the current
plan to launch AVLTs (Automatic Vehicle Location Tracking System) in the coming quarter
18
Assessment of ERS Performance in Madhya Pradesh
Final Report
2.2 REACH
2.2.1
This section focusses on the two aspects of the Reach function- Fleet and Field Operations.
FLEET
2.2.2
Currently the fleet of EMRI in Madhya Pradesh consists of 454 BLS ambulances stationed across
the 50 districts of the state. Additional 150 ambulances have been purchased by GoMP and will
be added to the fleet in 2013, 50 of which shall be ALS ambulances.
2.2.3
The fleet consists of smaller vehicles such as Maruti Suzuki Omni, Maruti Suzuki Eeco and Tata
Sumo as well as larger vehicles like Force Traveller and Tata Motors Tata 407. The deployment
of vehicles is finalized in discussion with GoMP after considering factors such as topography,
distance from health facilities, urban-rural split of population etc. The ambulances are stationed at
public health facilities and police stations, which results in strengthening field level relations with
these key stakeholders and in receiving help from them, such as accommodation for ambulance
staff, support for medico-legal cases, office space etc.
Scope of Responsibilities
2.2.4
The Fleet team, consisting of 2 Field Coordinators (FCs) and 5 Fleet Technicians (FTs), is
responsible for managing the procurement and maintenance of vehicles. The key responsibilities
of the team include:

Vehicle refurbishment, registration, branding and insurance

Ensuring scheduled maintenance and any repairs of vehicles

Coordinating contracts with service centers for servicing and tyre changes and with fuel
stations

Accident management

Pilot training
Assessment Findings: Fleet
2.2.5
Relevant equipment in 108 ambulances in comparison to international norms: As part of a
dipstick survey conducted by the Deloitte team, ambulance equipment currently available in
EMRI BLS ambulances were compared to one of the international standards for BLS developed
by the National Association of State EMS officials (NASEO) 3, comprising of American College
of Surgeons, American College of Emergency Physicians, National Association of EMS
Physicians, Emergency Medical Services for Children, American academy of Paediatrics and
National Association of EMS officials. The detailed list and categorization of ambulance is
provided in the Annexure 8.3. An analysis of status of availability of equipment in sample
ambulances has been discussed in the quality section.
2.2.6
The key observations and findings from the survey are Apart from cold packs, hazardous materials reference guide and patient care SOPs the
current list of equipment which are available in the ambulance are sufficient for pre
hospital care provided in the ambulance.
 More specialized equipment like defibrillators, nasogastric tubes, pediatric feeding tubes,
endotracheal tubes, pediatric backboard and splints, infant oxygen masks, large bore
3
Source: http://www.nasemso.org/Councils/PEDS/documents/AmbulanceEquipmentGuidelinesJune2012.pdf
19
Assessment of ERS Performance in Madhya Pradesh
Final Report

hypodermic needles for managing shock and pneumothorax etc. are requirements of higher
level of care which are part of ALS. Since there are no ALS ambulances in place current
training of EMTs also hasn’t included use of these specialized equipment.
Most equipment like protective gear, helmets, TRIAGE tags etc. which are listed in the last
‘Not Relevant’ group are either required in case of Mass Casualty Incidents (MCI) for
which EMRI are in the process of developing SOPs for (mentioned in SOPs shared with the
evaluation team) or are not relevant to the level of care provided by the EMTs in the current
setting.
2.2.7
Well established Vehicle Maintenance process: Vehicle maintenance,
related to periodic servicing and accidents, is undertaken by EMEs
(district level operations managers) in coordination with the fleet team.
During the assessment visits it was observed that in each district, the fleet
team has very strong vendor tie ups, resulting in early turn-around times
of the 108 ambulances. Also, to help EMEs and pilots better monitor
vehicle servicing, a detailed picture manual for servicing and formats for
accident claims have been designed by the state fleet team and
distributed. These are good initiatives to ensure high levels of compliance
to processes
2.2.8
Online Fleet Management System to monitor uptime – In order to ensure maximum uptime, the
fleet team uses a well-designed online application, called the Fleet management System, to
continuously track on-road and off-road status of ambulances and analyse vehicle performance.
This application is also linked to the sense application to dynamically update status of
ambulances.
2.2.9
Stringent Fuel and Tyre Management: Refuelling of vehicles is done through fuel cards recharged
at the state level. In cases where fuel cards are not available, the EME is responsible for
negotiating credit facilities for the vehicles at local fuel stations. Purchase of tyres is done at the
state level through a tender process, while the delivery is done in the districts. Both these
processes ensure better monitoring of utilization and costs. However, an area of improvement is
that the current daily limit of INR 1,500 per ambulance was found to be insufficient for filling the
vehicle to its capacity leading to frequent refuelling. This rate is currently being reviewed by the
state fleet team by conducting a thorough analysis of key fleet parameters.
Operational Indicators
2.2.10
The details of operational indicators of the Fleet are presented below:
4
Jul-Dec
‘10
Jan- Jun
‘11
Jul- Dec
‘11
Jan- Jun
‘12
Jul- Dec
‘12
Jan- Mar
‘13
Total number of
ambulances
Avg. No. of Trips per
Ambulance per Day
Jan-Jun
‘10
Parameters
Jul-Dec
‘09
Table 2.2.1: Operational indicators- Reach4
55
55
87
94
99
102
102
286
3.9
4.4
4.8
4.3
4.9
4.0
4.3
3.3
Source – Data provided by GVK-EMRI
20
Jul-Dec
‘09
Jan-Jun
‘10
Jul-Dec
‘10
Jan- Jun
‘11
Jul- Dec
‘11
Jan- Jun
‘12
Jul- Dec
‘12
Jan- Mar
‘13
Assessment of ERS Performance in Madhya Pradesh
Final Report
Avg. Distance Travelled
per Ambulance per trip
26.33
26.155
29.31
30.67
31.19
32.79
32.29
35.15
Fuel Efficiency (per KM)
9.05
9.33
9.27
9.32
9.31
9.31
9.08
9.95
Ambulance Uptime %
98.32
98.44
98.12
99.07
98.55
98.32
97.97
98.03
0
0
0
0.08
0.09
0.2
0.25
0.12
Service adherence %
100
100
100
100
100
100
100
94.6
Average tyre mileage
achieved
NA
NA
45,299
43,948
45,253
44,603
45,310
47,281
Hours of training per pilot
1.38
2.59
2.3
3.48
1.71
1.03
1.36
2.21
Parameters
Ambulance breakdown rate
%
Apr ‘10 - Mar‘11
Apr ‘11 - Mar‘12
Apr ‘12 - Dec‘12
26:43
28:21
29:18
23:40
26:07
27:34
29:01
29:52
30:29
Avg. Time taken per
Ambulance* (Base to
Scene) - in mins
: Urban
: Rural
* Data for reach times was provided for different time periods – Annual April to Mar
Assessment Findings: Fleet performance
2.2.11
5
The following findings summarize the above table 
Increase in fleet sizes: The number of ambulances has increased from 55 to 286 from July
2009 to March 2013. 5

Good adherence to scheduled servicing: Service adherence has been 100% until January
2013, which corresponds with the low ambulance breakdown rate. However a dip in service
adherence during the period Jan-Mar 2013 could be because of the fleet and field teams
being engaged in the launch of new 352 ambulances. It would be important to ensure that
service adherence is back on track w.e.f. May 2013

Varying fuel efficiency due to launch of smaller ambulances: Fuel efficiency remained
stable around 9.3 km/l, though it reduced slightly in the period July-December 2012,
possibly due to the increasing age of the vehicles. In the period January-March 2013, the
fuel efficiency peaked to 9.95 km/l and this can be attributed to the deployment of new
small vehicles.

Varying trips per ambulance due to launch of new ambulances: The average number of
trips per ambulance per day steadily increased, peaking at 4.9 in the period July-December
2011. While this figure fell to 3.3 in the period January-March 2013 due to launch of new
ambulances, it will take some time for the operations to stabilize in the new areas being
covered by the service.
In relation to data available for fleet. Currently EMRI has 352 operational ambulances
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Assessment of ERS Performance in Madhya Pradesh
Final Report

Increasing distant travelled per trip: The increase in distance covered per trip before
January 2013 could be attributed to better coverage of 108 services including more remote
villages owing to increasing awareness. The sudden increase from Jan – March 2013 could
possibly be due to more spread population and dispersed health facilities of the newer
districts. A detailed analysis could not be done as district-wise data for launches in the new
40 districts is not available.

Base to Scene time6: The rural base to scene times meet the international standards of 40
mins; however the urban reach times are more than the standard of 20 mins. However,
observation of urban cases during field visits and discussions with the state fleet team
indicate that this high reach time could be attributed to the fact that most urban ambulances
serve cases in the peripheries of the city / urban area thus resulting in longer reach times.
FIELD OPERATIONS
2.2.12
Field operations are managed by 1 Regional Manager (RM) and 6 Program Managers (PMs) at
state and regional levels, 23 Emergency Management Executives (EMEs) at district level, and
1095 Emergency Management Technicians (EMTs) and 1140 Pilots (Drivers) at the ambulance
level.
Exhibit 2.2.2: Structure of field operations team
Scope of responsibilities
2.2.13
Field Operations team at the state, district and field level are required to interact and liaison with
a number of internal and external stakeholders to ensure efficient functioning. The exhibit below
highlights the scope of responsibilities of the field operations team –
6
“ Ambulance Response Time in Developing Emergency Healthcare Systems” – Jochen Schmidt
22
Assessment of ERS Performance in Madhya Pradesh
Final Report
Exhibit 2.2.3 – Scope of Responsibilities
2.2.14
The detailed roles and responsibilities of key stakeholders involved in carrying out field
operations are mentioned in the Annexure 8.4. The following section highlights key findings of
the field operations.
Findings: Field Operations
2.2.15
Good population coverage: EMRI targets to follow WHO benchmark of deploying one
ambulance per one lakh population7 based on factors such as district coverage, average reach
time, average trip distance etc. However, till Dec 2012 with operations only limited to 102
ambulances across 10 districts, this benchmark was difficult to achieve (population per
ambulance was 1,56,503). With the launch of additional 23 ambulances in these 10 districts the
ratio has reduced to 1,27,706.
7
Source – “Publicly Financed Emergency Response and Patient Transport Systems Under NRHM” by NHSRC
report
23
Assessment of ERS Performance in Madhya Pradesh
Final Report
Exhibit 2.2.4 – Population Coverage per Ambulance in Initial 10 Districts
(Dec’12 vs. May’13)
2.2.16
For the newly added fleet of 352 ambulances, the focus was entirely on district coverage. As
shown in Annexure 8.5, currently the entire population of Madhya Pradesh (64,54,55,485; Census
2011) is covered by 454 ambulances, making the population per ambulance is 1,42,171. With the
state planning to add another 150 to make the total ambulances 602, the population coverage
would almost meet the target of 1,00,000.
2.2.17
Inadequate liaising with District administration: As per the MoU, GoMP has the responsibility of
providing base stations and shelter for the ambulances. For the recent launches(like in Sehore),
EMRI officials – Program managers and EMEs, effectively coordinated with District
administration i.e. District Collector, CMHO and Superintendent of Police to identify appropriate
base stations either at local police stations or at health facilities.
2.2.18
As per MOU, each district is required to hold quarterly District committee meetings chaired by
the District Collector along with other members such as Superintendent of Police, CMHO,
District Fire Department Head, and EME etc. to review 108 operations. However, none of the
districts assessed were holding the quarterly district committee meetings. It was observed that
none of the district officials were aware of the need and objectives of the district committee.
There is a need for more formal and frequent communication from the state to districts informing
them of the requirements of the MoU and monitoring their adherence.
2.2.19
Hospital Tie-ups: EMRI has defined a process to capture details of services, specialties, resources
and infrastructure available across health facilities in each of the districts. EMEs play a vital role
in coordinating with hospitals, collecting information, forwarding information to the EMRI state
office and monitoring relationship with each of the hospitals. EMEs also provide advocacy to the
Chief of Hospital on the importance of stabilizing critical EM patients before referring them to
any other facility when required. Data collected from hospitals is then entered into Hospital
Information systems (HIS) application which is linked to the case closing application of SENSE,
in order to allocate each emergency to the corresponding hospital.
2.2.20
Across the initial 10 districts, the HIS survey was filled for 1,266 hospitals. However, collected
data of partner hospitals has not yet been made available to the ambulances, which could help
ambulance staff in advising relevant hospitals to beneficiaries. The process for enrolling hospitals
for the new districts is underway.
24
Assessment of ERS Performance in Madhya Pradesh
Final Report
2.2.21
There is a need for EMRI to transition from collecting hospital information to maintaining
hospital relationships with network hospitals in order to maximize the utilization data collected.
Some of the findings and issues include –

District EMEs also did not have periodic data to analyse the number of cases being taken to
each of the hospitals, which could help them analyse and conduct hospital discussions to
increase hospital readiness.

No relationship building initiatives with the hospitals were undertaken to ensure acceptance
of cases by partner hospitals, increase usage of vital information recorded in the PCRs or
enable field level trainings at partner hospitals.
2.2.22
Field Level HR: The EME at each district is responsible for managing field HR i.e. EMTs and the
pilots. The EMTs and pilots directly report to the EME of each district. Discussions with EMTs
and pilots indicated a high level of confidence and trust on their respective EMEs. Overall a high
level satisfaction amongst field staff on the role and capabilities of the EME. Exhibit below
depicts field related activities undertaken by EME for the ambulance staff
Pilots
EMTs
Exhibit 2.2.5: Field Activities undertaken by EME
•
•
•
•
•
•
•
Prepare Duty roster
Track vehicle performance through daily discussions with
ambulance staff
Checks on any issues and grievances of ambulance staff
Monthly Rewards & Recognition
Periodic events such as the EMT day, Pilot day
Performance appraisal
Grievance Redressal
2.2.23
Regular Drug indenting sand equipment checks: For each ambulance the EMT is required to
conduct a regular drug indenting and equipment check and raise a monthly indent for the required
drugs. EMEs are also required to conduct bimonthly stock checks of each ambulance. In addition,
quarterly vehicle audits are conducted by the quality team.
2.2.24
During our assessment it was found that overall Basic living saving equipment and drugs were
found to be present in the ambulances except for some minor equipment gaps due to ongoing
repairs.
2.2.25
All non-compliance issues as indicated by the quality team are addressed in coordination with the
SCM team. This process keeps a constant check on compliance of ambulances to recommended
guidelines.
2.2.26
Spreading Awareness: The most frequently undertaken awareness building activities are Demos-Demos are conducted in every village in the district by gathering people, informing
them about 108 services and how to use them, showing the ambulance equipment and how
EMRI can be helpful in case of any emergency.
 Follow-up with ASHAs - EMEs are in constant contact with ASHAs who keep a track of
pregnant women for planned deliveries and this provides an opportunity to spread awareness
among the potential users.
 News Articles- Given the popularity of the scheme, details of special cases, ambulances
launches of pilot and EMT days are well covered by the district level print media. This is also
an important form of district level marketing to spread awareness of the service.

25
Assessment of ERS Performance in Madhya Pradesh
Final Report
2.2.27
During the assessment it was observed that very few demos were undertaken across all the
sample districts over the last 6 months due to the increasing number of cases.
Good Practices observed in Sehore District

EMTs and Pilots have developed good linkages and rapport with the district authorities and local
people in their respective coverage areas through high level of interactions with village influencers
as part of IEC/BCC activities.
 The EME in charge has also taken an initiative to contact local movie theatres for playing slides on
availability and scope of 108 services before the start of every movie
2.2.28
Interaction with Sense: As discussed
in the Sense section, the field
operations team interacts with the
Sense team for sharing three types
of information – Case closure,
Vehicle busy and off road vehicles.
2.2.29
While the vehicle busy and off road reporting mechanisms are being implemented well, delays
have been noticed in the case closure process mainly due to the increasing number of cases. This
leads to free ambulances being reflected as busy and longer dispatch times at EROs level.
However, EMRI is now planning to launch the AVLTs (Automatic Vehicle Location Tracking
System) in the coming quarter in order to address above issue.
Monitoring mechanisms for the Reach (fleet and field operations) Function
2.2.30
The following exhibit describe the existing monitoring systems in place:
Exhibit 2.2.6 – Monitoring systems implemented by the Reach team
State Level
Fleet & Field
Ops
District Level
Programme
Manager
Field Level
• Regional Manager - Monitors and analyses operational and non-operational details
including expenditure reports
• Fleet Head - Defines performance parameters and monitors key fleet processes such as
vehicle maintenance, service adhrence, fuel and tyre management etc.
• Regular conference calls and monthly meetings with EMEs and PMs
• Programme Manager and Emergency Management Executives responsible for monitoring
at regional and district level
• EME receives and collates Daily Vehicle Checklist from Pilots. Also receives details on
number of cases, servicing, fuelling, distances and expenditures
• PM Analyses data shared by EME for each district
• At the field level, the pilot fills out a Daily Vehicle Checklist. This is shared with the
EME.
• The pilot keeps the EME informed about servicing, refueling and ambulance breakdowns
• The EME also gives operational and non-operational details to the EME on a daily, weekly
and monthly basis
26
Assessment of ERS Performance in Madhya Pradesh
Final Report
Assessment Findings: Monitoring systems of Reach
2.2.31
COO review: All EMEs and PMs are required to attend a monthly meeting organized at the state
level. The aim of this meeting is to discuss issues faced at the field level and any performance
improvement parameters. However, these meetings had not been conducted between November
2012 and May 2013 due to the organization being busy in the expansion of services in 40 new
districts. The monthly meetings have resumed since June 2013.
2.2.32
State level monitoring: State level monitoring of the reach function is done by the fleet head and
the regional manager. Comprehensive daily and monthly reports are submitted by the EMEs and
are collated & analyzed by the state teams. The following exhibit highlights the monitoring
mechanisms in place.
Exhibit 2.2.7 – Existing Monitoring Mechanism
2.2.33
Field level monitoring: Each vehicle is supposed to maintain the following registers which are
filled by the EMTs and Pilots on a regular basis and shared with the EME. These registers are
well maintained at the field level checked by the EME and quality teams during their ambulance
audits. Key registers include:

Vehicle checklist

Vehicle log book/Trip sheet

Stock Register

Attendance Register

Handing over Register

Pre Hospital Care Records
27
Assessment of ERS Performance in Madhya Pradesh
Final Report
Assessment Summary: Reach
 The Reach processes are well defined, implemented and managed by the fleet and field teams. Strong
district-level vendor tie-ups and a comprehensive vehicle performance tracking mechanism drive
vehicle efficiencies. Initiatives such as the servicing manual, accident reporting formats and the fleet
management system improve adherence to protocols. Some areas of improvement include more
frequent analysis of reach times and distances to address the increasing trends and introducing
variable daily financial limits for fuel refilling based on urban/rural base station, trip distances and
proximity to fuel stations.
 The field operations team manages and handles staff and operations reasonably well. EMTs and
pilots reflect a high level of confidence and motivation in carrying out their daily tasks. Areas of
improvement include delays in case closures, un-planned field marketing activities, weak liaising
with district administration and weak hospital relationship processes.
 Overall, the reach function has clear implementation and monitoring processes. The team would need
to better liaise with both external (partner hospitals and district administration) and internal
(marketing and hospital relations) customers.
28
Assessment of ERS Performance in Madhya Pradesh
Final Report
2.3 CARE
2.3.1
The CARE component of the EMRI operational model consists of providing pre-hospital
emergency medical attention to the patients. It consists of three sub components – CARE cell at
the ERC, Pre-hospital Care Record Cell and Emergency Learning Centre, led by the Head
(EML&C). It essentially entails services provided by trained Emergency Medical Technicians
(EMT) in ambulances equipped with basic life support equipment to tackle any type of
emergency within the first “Golden Hour”.
Exhibit 1.3.1: Organisation structure of the EML&C
CARE - ERC
Scope of Responsibilities
2.3.2
The CARE function at the State level comprises of Emergency Response Care Physicians
(ERCPs), who are located in the ERC. The ERCPs are qualified MBBS graduates, preferably
with prior clinical experience. The following exhibit depicts their roles and responsibilities:
Exhibit 2.3.2: Roles and responsibilities of an ERCP
29
Assessment of ERS Performance in Madhya Pradesh
Final Report
Assessment Findings: CARE - ERC
2.3.3
Well defined SOPs in place: GVK-EMRI has detailed Standard Operating Procedures (SOPs) in
place to ensure the level and quality of care is maintained in all ambulances.
2.3.4
Provision of good OLMD: Trained medical technician in a mobile and well equipped set up along
with 24*7 telephonic assistance support a qualified physician are the key strengths of the 108
EMRI care model. This ensures that quality of care is maintained at all times, especially in the
‘golden hour’ of an emergency. However, it was observed that there was high dependency of
EMTs on ERCP advice and there were several instances of the ERCP line being busy due to
insufficient number of ERCPs.
2.3.5
Inadequate field visits: ERCPs are required to visit the ambulances to understand the field
conditions and challenges faced by EMTs and guide them. While these periodic visits are
effective initiative to evaluate EMTs, the last round of ambulance inspections by ERCPs was
conducted in November-December 2012. Since then, no further assessments have been carried
out by the ERCPs, owing to the significant increase in the volume of emergency calls.
Emergency Learning (EML)
Scope of Responsibilities
2.3.6
Emergency Medicine Learning Centre is responsible for training EMTs and Emergency Response
Officers on the Care component. A brief snapshot of the EMLC department’s responsibilities is
as follows:
Exhibit 2.3.3: Activities conducted by EMLC
2.3.7
2.1.2
EMT Preparatory training: New EMTs are mandated to undergo the EMT Preparatory Training
Program. This is a phase wise program as detailed in the table below. EMRI has documented
treatment protocols / Pre Hospital Care Standing orders for clinically addressing various
emergency conditions in collaboration with the Stanford School of Medicine. Each protocol
enlists steps to handle a particular emergency before connecting with the ERCP. This is an
integral part of the EMT Preparatory Training.
The training program was originally used to be held for 60 days. However, due to the increase in
number of EMTs in the system (352 ambulances added between January and April 2013), since
January 2013 the training program has been modified for new recruits and is now completed in a
period of 35 days itself.
30
Assessment of ERS Performance in Madhya Pradesh
Final Report
2.3.8
Given below is a brief comparison between old and revised training schedule:
Exhibit 2.3.4: Activities conducted by EMLC
Training sessions
Institutional training for
theoretical concepts and skills
Ambulance phase training
Hospital phase training
Leave
Evaluation including
remediation**
60-day training program
28 days with 4-day ambulance
posting and 2-day ERC visit (+1
day leave)
10 days (+1 day leave)
10 days (+1 day leave)
1 day
8 days
35-day training program*
15 days with no leaves
10 days with reduced duration
10 days with reduced duration
Included in the above schedule
* Prepared by national CARE team of GVK EMRI after prioritizing critical areas to be covered. Revised training format already
piloted in Uttar Pradesh
** Evaluation (written +oral viva) conducted by professors from medical institutions in MP with 60% marks as qualification
criteria
2.3.9
Mentor EMT Program: Considering that the revised format of EMT preparatory training could
impact quality of pre-hospital care being provided by the new EMTs, EMRI has designed the
following methods to continue to improve the knowledge and skills of the EMTs :

Mentor EMT program: This program was initiated in April 2013, wherein older EMTs (1
per district) have been designated as mentor EMTs to provide on-field handholding support
to new EMTs.

Refresher trainings every 6 months
2.3.10
Certification Training by National Care Team: In addition to above, a refresher training program
for 5 days was held in Hyderabad for existing EMTs (102) under the Global Certification
Program (GCP) which includes training on Basic Life Support (BLS) and International Trauma
Life Support (ITLS).
2.3.11
Refresher Training by State Care Team: This training is conducted annually once for 3-5 days at
the State training center in Bhopal. This training is mandated for experienced EMTs, on specific
needs identified through various evaluations and monitoring mechanisms which are in place. For
the newer EMTs, it is planned to be held twice a year.
Assessment Findings: EM Learning
2.3.12
Shortened EMT preparatory training – It was observed and reiterated by some EMTs that the
shortened duration of the EMT preparatory training affected their level of retention of knowledge
and confidence in handling patients. However, variation in this was observed during Deloitte’s
field evaluation of EMTs. 2 EMTs who were trained in the older training module also had poor
technical knowledge. The effectiveness of the shortened training duration of the EMT Preparatory
training is yet to be formally evaluated to see any impact on knowledge retention and care
provision by the EMTs.
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Assessment of ERS Performance in Madhya Pradesh
Final Report
2.3.13
Irregular Refresher Trainings: Refresher training / certification programs for EMTs are a good
initiative to increase their confidence and motivation. However, no comprehensive plans,
detailing training schedules, numbers and dates, are in place currently to initiate the bi-annual
refresher plan at least for the new EMTs.
2.3.14
Monthly CMEs for EMTs: EMLC conducts Continuous Medical Education (CME) activities for
EMTs including circulation of medical emergency-based questionnaires among all EMTs on a
monthly basis. Responses are mandated to be filled in and forwarded to the EMLC for evaluation.
This activity has been designed to encourage the EMTs to provide inputs on training needs,
revisions required in training and course material. This initiative is appreciative and promotes
knowledge among the EMTs.
2.3.15
On-field handholding support through Mentor EMT program: The objectives and the
implementation mechanism of the mentor EMT program were not clear among EMEs. As shown
in the table below, there is variable understanding and implementation of the mentor EMT
program across districts visited. Given the criticality of the program, it would be important for
EMRI to institutionalize standard mentoring guidelines for EMEs, design a skill assessment tool
for EMTs and share a proposed development plan for identified EMTs based on the areas of
improvement.
Table 2.3.5: District Level variations in Implementation and understanding of
Mentor EMT program initiative
District
Observations
Mentor EMT Duration
Target EMTs
Covered ambulances with both old and new
EMTs.
Sehore
2 days at each location
Gwalior
Minimum 2 days at each location.
Duration could differ from EMT to EMT.
(Mentor EMT interviewed was at the
same location for over 10 days).
Covered only ambulances with new EMTs
Sagar
1 day at each location
Covered ambulances with both old and new
EMTs
Pre-Hospital Care Record Cell (PCR Cell)
Scope of Responsibilities
2.3.16
For all cases handled, EMTs are required to submit a copy of the filled PCR form to the receiving
hospital. The second copy is retained in the ambulance and a third copy is sent to the PCR Cell at
the State EMRI headquarters. This cell is involved in documentation, analysis and storage of
these PCR forms received from the field. The PCR cell activities and process followed is shown
in the exhibit below:
32
Assessment of ERS Performance in Madhya Pradesh
Final Report
Exhibit 2.3.6: Activities of PCR cell
Assessment Findings: PCR Cell
2.3.17
EMT feedback through critical case evaluation: The filled PCR forms of all emergencies are sent
to the PCR cell by the EMTs, which are then sorted to identify critical cases based on standing
order given by the ERCPs.to identify missing/fake PCR forms. The critical cases are then
evaluated by the ERCPs for appropriateness of care provided and its criticality in saving the
patients’ life. The process helps ERCPs evaluate and monitor quality of pre-hospital care being
provided by EMTs. Key findings from the EMT evaluation are also used to identify training
needs.
2.3.18
Currently, feedback is given to the EMT only in case of any observed error either in provision of
care or documentation. However, this process could be improved further by clearly determining a
fixed number of PCRs to be evaluated per EMT for periodic feedback.
2.3.19
Lives Saved: CARE generates a monthly report on ‘lives saved’, which is defined as the total
number of critical cases with aberrant vitals which were provided appropriate care by the EMTs.
Factors that decide lives saved are: critical cases, provision of appropriate care, well documented
PCR and stable patient condition within 48 hours of emergency. The total number of “lives
saved” by 108 EMRI services since the commencement of the service is as follows:
Table 2.3.7: Activities of PCR cell
Period
Jul 09 –
Mar 10
Apr 10 –
Mar 11
Apr 11 –
Mar 12
Apr 12 –
Dec 12
Lives saved
4,080
7,213
9,456
7,183
Total lives saved
(From Inception - Dec
2012)
27,932
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Assessment of ERS Performance in Madhya Pradesh
Final Report
Facility Feedback
2.3.20
As part of the evaluation, Deloitte team visited two facilities each per ambulance where the
patients were commonly referred to. The team interacted with the doctors and got feedback on
quality of care provided by EMTs using a pre-designed structured tool. A snapshot of the
facilities visited along with feedback from doctors is provided in the Annexure 8.6.
Assessment Findings: Facility feedback
2.3.21
MOs satisfied with quality of prehospital care: Most facility doctors were appreciative of the
services provided by EMTs. As shown in the table, doctors were satisfied with service quality
(especially for trauma and pregnancy cases), response time and quality of PCR documentation.
2.3.22
Areas of Improvement: Some of the areas that need further improvement as suggested by the
doctors at health facilities include:
 Reducing unnecessary ERCP OLMD in few cases, availability of ALS care at least in
some ambulances and better patient handover by ambulance staff were the key areas
identified by the doctors as areas of further improvement.
 It was observed that the PCR copy was not stored in all health facilities. Of the 13
facilities visited, the PCR copy was maintained as a practice only in 6-7 facilities.
Information in the document was not used by the attending doctors in any facility visited.
Many doctors were not even acquainted with the PCR form and did not use any of the
critical information it contained. There seemed no special effort by the EMTs in
educating the doctors and ensuring its use in treating the patient. This could be worked
upon and improved.
Assessment Summary: Care
 Availability of well-defined SOPs, 24*7 online medical support from ERCP, availability of trained
medical technicians in all ambulances as well as their good knowledge on systems and adherence to
protocols are the key strengths of the CARE function. Appropriate training programs and innovations
like the mentor EMT program and HIS data base creation are also appreciable.
 Areas of improvement that need to be addressed by EMRI include shortage of ERCPs for OLMDD,
inadequate processes for evaluation of care provided by ERCP and EMT and poor coordination with
government health facilities. Additionally, EMRI needs to conduct a comprehensive evaluation of the
effectiveness of the revised preparatory training schedule to identify specific skills gaps.
34
CHAPTER 3
SUPPORT FUNCTIONS
Assessment of ERS Performance in Madhya Pradesh
Final Report
3.1 HUMAN RESOURCES
Organization Structure
3.1.1 The GVK EMRI operations in MP is headed by a Chief Operating Officer (COO), who is
responsible for the overall functioning of the scheme, liaising with GoMP and adherence to
service level parameters. The organization structure adequately represents both core and support
functions: Core functions – Sense, Reach and Care, and key support functions – HR, Finance,
Quality, Marketing, SCM and IT-IS. The function heads report to the COO, who closely monitors
their operational plans and progress on a monthly basis.
Exhibit 3.1.1: Organization Structure8
Role of HR
Scope of Responsibilities
3.1.2 Key responsibilities of the HR function include:

Manpower planning

Recruitment

Training

Appraisal and Retention

Grievance Redressal
8
Based on the understanding of the evaluation team, exact structure not shared.
36
Assessment of ERS Performance in Madhya Pradesh
Final Report
Manpower Planning
3.1.3 There are close to 2400 employees working at EMRI-MP currently. Human resource capacity
plans are developed at the beginning of the financial year, in accordance with the requirement of
state operations and manpower ratios decided at the national level, by the state HR head, the state
COO and the national HR team.
3.1.4
The following table provides staffing details of EMRI with respect to existing staff and
recruitment plans for the year given the expansion of services.
Exhibit 3.1.2: Current vs. Planned Manpower at EMRI
Employee
Ratios ( if any)
developed by
National HR
team, EMRI
Current
Manpower
(A)
Additional
Planned
(B)
Total
(A) + (B)
55
2
57
122
4
1
127
1095
400
1495
1140
400
1540
23
6
1
5
2
2
2273
17
2
1
819
40
8
2
5
2
2
3092
Sense
ERO
TL
Manager
Sense Total
67
2
1
70
Reach
EMT
Pilot (per ambulance)
EME
PM
RM
FT
FC
Operations
Reach Total
2.4-2.5 /
ambulance
2.4-2.5 /
ambulance
1 per district*
1 per 5 EMEs
1 per 300 ambys
Care
Physicians
PCR Cell
EMLC trainers
Care Total
7
2
9
6
6
4
4
17
2
19
Support Functions
Human Resources
6
6
SCM
4
4
IT/IS
4
4
IEC
1
1
Quality
4
2
6
Finance
3
3
Support Total
22
2
24
Total
2382
880
3262
*40 EMEs are planned for 50 districts. 10 EMEs shall manage two districts each due to smaller sizes of
identified 10 districts
37
Assessment of ERS Performance in Madhya Pradesh
Final Report
Assessment Findings: Manpower Planning
3.1.5 The process for annual manpower planning followed by EMRI is comprehensive and well
adhered to at the state level. Discussions with the HR head and the COO also highlighted that the
national team regularly reviews adherence to the plan and deviations, if any, which is a good
monitoring mechanism in place. However, an area of improvement is the process followed to
derive required number of EROs, which was not developed in concurrence to annual call and
emergency forecasts.
3.1.6
Some of the findings with respect to sufficiency of staff in comparison to the requirement are
given below:
 Sense EROs: Discussions with the sense and HR teams and the COO have highlighted
that the number of EROs for the current call volume is insufficient, thus contributing to
the high levels of unattended calls.9
 Sense- TLs: The current number of 2 TLs and 1 Manager is not sufficient to handle the
24/7 ERC for 3 shifts. While recruitment plans are in place, to enable a more structure
planning process for sense TLs, HR could evaluate defining a TL: ERO ratio.
 EMEs: During field visits, it was observed that to effectively monitor ambulance
operations, the average number of ambulances that an EME could effectively monitor is
15. With EMRI planning to have 40 EMEs for 602 ambulances, this ratio would be
sufficient.
 Ambulance Staff: The current ratio of pilots and EMTs per ambulance is 2.4 and 2.5
respectively, which has been developed by the national HR team based on the 6 day
working week on field and the current staff leave policies. Field visits have shown that
these ratios are adequate with respect to the current scale of operations. However, in case
EMRI plans for more village-level demos and refresher trainings, these ratios might have
to be revisited for the state.
 Support Manpower: Broadly, the current manpower is necessary for the various support
and operational functions to work efficiently. There is a need to hire more support staff in
the quality function to enable periodic audits of all 602 ambulances.
Recruitment Process
3.1.7 Recruitment for field level staff takes place at the state office through open advertisements with
clearly mentioned qualifications and requirements. Efforts are made to hire local people for the
field level positions to ensure retention. The minimum qualifications and recruitment process for
EMTs, Pilots and EROs has been mentioned in Annexure 8.7. It is to be noted that in states such
as Andhra Pradesh and Karnataka, the salaries of EMTs and Pilots have been found to be low and
are currently being revisited10. An analysis of the same could not be done for MP due to lack of
data.
3.1.8
For senior positions, the recruitment process involves interviews with state and national
functional and HR teams. This 2-step recruitment process ensures monitoring quality of new hires
and adequate negotiation of compensations.
9
Ineffective calls were observed to be high in May 2012 due to a sudden increase in emergencies and shortage of
manpower
10
http://www.deccanchronicle.com/130807/news-current-affairs/article/how-can-108-staff-live-such-low-payhigh-court
38
Assessment of ERS Performance in Madhya Pradesh
Final Report
Training
3.1.9 The responsibility of organizing trainings for all employees lies with HR. While HR plans and
schedules trainings, and conducts modules on organization orientation, HR processes and soft
skills, all technical and process related trainings are carried out by respective core functional
teams.
3.1.10 EMT Training: As discussed in the Care section, the Emergency Medical Learning team (EML)
under the Care function is responsible to conduct trainings for EMTs. The 60 day preparatory
training is conducted based on pre-hospital care protocols developed by the national Care team in
collaboration with Stanford school of medicine. The training was found to be comprehensive and
well-structured. In MP, to meet the EMT requirement for the launch of 502 new ambulances, the
training duration was reduced to 35 days, the effectiveness of which is yet to be estimated.
3.1.11 Pilot Training: The Pilots undergo a 5 day foundation course which consists of 8 days classroom
training and 2 days on-job training at their posting. During this training, tips to increase
ambulance mileage, tracking mechanisms to ensure timely maintenance of the ambulance and
defensive driving techniques are provided. 2-3 day refresher training programs are also organized
on a need basis for pilots identified by EMEs. Additionally, FTs and FCs also provide on-site
training at the ambulance during their scheduled field visits. This training was found to be
sufficient for the pilots as only experiences drivers are hired as pilots.
3.1.12 ERO Training: The EROs undergo a comprehensive 21 day training programme where they are
trained on process, geography of the state and typing skills. As part of the training programme,
EROs are also provided training through screening of live calls and call simulations. This training
program is delivered by the Quality team, Sense manager, Sense team leads and senior EROs, to
ensure a good understanding of the various processes related to EROs.
Appraisal and Retention
Appraisal
3.1.13 EMRI follows an annual appraisal process. The appraisal process starts with self-evaluation by
each employee. This is followed by a technical evaluation of each employee by his/her immediate
supervisor. A performance rating is given to each employee on the following parameters:

Technical Knowledge

Process Knowledge

Planning and Organization

Communication

Customer Orientation/Service
3.1.14 Increment slabs are decided by the State and National HR and Finance teams based on budgets
approved by the government for the respective year. Field visits have shown that while EMTs and
Pilots were very motivated about the tasks, there is a general dissatisfaction on the level of
remuneration currently being given.
Retention
3.1.15 A number of recognition programmes are being implemented by EMRI, especially for the field
staff. Some examples include:
 Monthly Reward and Recognition programme, where nominations for best
performers are made from the field and a certificate and token gift is given to one
EMT and one Pilot every month
 Sports activities for the field level staff on a regular basis
39
Assessment of ERS Performance in Madhya Pradesh
Final Report

Field celebrations of festivals and special days such as Pilot day and EMT day, where
contributions of pilots and EMTs are highlighted and celebrated.
Sports activities and celebration of special days for the field level staff
3.1.16 Overall the organization recognizes the importance of retention and mostly uses non-monetary
retention and motivation techniques.
Grievance Redressal for staff
3.1.17 V Care: EMRI has launched a Grievance Redressal mechanism called VCare in 2013, which
requires EROs to register staff grievances onto the application and provide complainants with
unique grievance ids. The grievance data is then accessed by the related function - HR, Quality,
Finance, SCM or Fleet, who are then required to address the issue within 24 hours of its receipt
through detailed discussions with the complainants. An awareness campaign was initiated by HR
to ensure all field level employees were made aware of the VCare facility for grievance redressal.
3.1.18 This is a good initiative by the organization to better address staff grievances. The process is still
new and needs to stabilize. For example, a common issue observed is poor communication
between the related function and the complainant on the grievance closure process The HR and
quality teams need to audit some VCare complaints to further improve the resolution process
Evaluation of Knowledge-Attitude- Practices (KAP)
3.1.19 The following section highlights the findings of KAP analysis of key operational staff:
 Sense – EROs
 Reach – Pilots
 Care – EMTs
EROs
3.1.20 An evaluation of 10 EROs was undertaken by Deloitte to assess their knowledge and practices.
The parameters used for the evaluation include:
Empathy towards caller measures the ability of the call taker in clearly recognizing and
understanding the situation of the caller and nature of emergency being reported.
Process knowledge measures the call officers proficiency of prescribed SOPs
Responsiveness measures the effectiveness of the call officer in addressing the needs of the
caller in a timely and appropriate manner.
Communication skills measures the ability of the call officer to collect and share correct
information with all involved stakeholders – caller, ambulance staff, doctors at the call
centre, police dispatch officer etc.
40
Assessment of ERS Performance in Madhya Pradesh
Final Report
3.1.21 The following table summarizes the findings of the evaluation:
Table 3.1.3: Summary of ERO evaluation
ERO 10
ERO 9
ERO 8
ERO 7
Sehore
ERO 6
ERO 5
ERO 4
Sagar
ERO 3
Parameter
ERO 2
ERO 1
Gwalior
Empathy towards caller
Process knowledge
Responsiveness
Communication skills
Good
Average
Poor
3.1.22 Overall, it was found that all EROs were confident about the process and adhered to the laid
down process for all calls and conversed with callers patiently to understand and gather all
required information. While being guided by the main process, EROs also exercised enough
flexibility to handle variations posed by each emergency. All EROs were good in Hindi and all
other dialects of the state. Experienced EROs were also observed to provide handholding support
to new staff by constantly guiding them on the process. The motivation level of EROs was very
high resulting in an energetic and positive environment in the ERC.
EMTs
3.1.23 This section highlights findings on EMT assessment. As detailed earlier, 9 EMTs, 14 facilities 11
and 36 PCRs were evaluated across the 3 districts.
3.1.24 The table below highlights the profile of the EMTs interviewed. Effort was made to interview
both old and new EMTs.
Table 3.1.4: Summary of EMT Profile
3 months
3 years
EMT 3
-In EMRI
EMT 2
5 years
EMT 1
3 months
EMT 3
-Total
EMT 2
EMT 2
DMLT
BSc, MSc
(ongoing)
Educational
Qualification
Sehore
EMT 1
EMT 1
EMT
Profile
Sagar
EMT 3
Gwalior
BHMS
BSc,
DMLT
BSc
(Paramed
pathology
)
DHCP,
DCA
BHMS
BSc
DHCP
5 years
6 months
1 year
3 years
2 years
4.5 years
2 year
18 months 6 months
1 year
Experience
11
9 months 5 months 4.5 years 9 months
Some facilities visited were common as most cases were referred to same facilities.
41
Assessment of ERS Performance in Madhya Pradesh
Final Report
EMT 1
EMT 2
EMT 3
Sehore
EMT 3
EMT 2
EMT 1
Sagar
EMT 3
EMT 2
EMT
Profile
EMT 1
Gwalior
30 days
60 days
60 days
60 days
30 days +
10 days
(ITLS,
BLS,
BLSO)
55 days
55 days
No
-
No
-
-
No
-
Once (8
days)
No
Once
(ITLS and
BLS)
No
No
Once
(ITLS)
Once
(4 days
ITLS)
Trainings
-Joining
30 days
-Refresher
-
-National
trainings at
Hyderabad
No
55 days
Yes – 5
days
Twice (3
& 5 days)
–ITLS,
BLS,
BLSO
3.1.25 Key findings:
 All EMTs met the required qualifications as defined by HR (Annexure 8.7)
 All EMTs underwent the preparatory program implemented by the EM Leaning team
 The older EMTs underwent ITLS and BLS certification program at the national level
from certified trainers. This process is beneficial as these EMTs could now be places in
the 50 ALS ambulances.
 Only 1 of the 4 EMTs with more than 1 year experience in EMRI went through refresher
training, highlighting the need for more frequent and better planned.
EMT Evaluation Parameters
3.1.26 The EMTs were evaluated using a pre designed structured schedule which was designed based on
the EM SOPs provided by EMRI to the evaluation team. Annexure 8.8 details the assessment
parameters and the tool used for the assessment. The broad domains used for evaluation are given
in the below exhibit. For technical knowledge, each EMT was evaluated on general protocols and
2 of the three specific protocols related to medical, trauma and pregnancy.
42
Assessment of ERS Performance in Madhya Pradesh
Final Report
EMT assessment findings
3.1.27 Given below is a snapshot view of the overall impression of the assessment of Emergency
Medical Technicians.
Table 3.1.5: Summary of EMT Profile
Assessment
Domains
EMT
1
Gwalior
EMT
2
Sagar
EMT
EMT
EMT
3
1
2
Technical Knowledge
EMT
3
EMT
1
Sehore
EMT
2
EMT
3
General
Medical
Trauma
Pregnancy
Others
Systems
Documentation
* Where possible, direct handling of cases was also observed to check adherence
Good- Correct response without
probing
Average-Response fair with
probing
Poor-Poor/Incorrect response with
probing
Technical Knowledge
3.1.28 The following table highlights key findings:
Table 3.1.6: Key findings of EMT evaluation of technical knowledge
Type of
Protocols
Areas of assessment
General
protocols
Patient assessment and
components of history
taking and assessing
vitals
Medical
protocols
Management of
medical emergency
cases like seizures,
cardiac arrests etc.
Findings
• 6 out of 9 EMTs had average to poor knowledge of the general
protocols.
• Six out of nine EMTs showed excessive dependence on ERCPs
even at the stage of patient assessment.
• All EMTs were aware of lifesaving and assessment protocols
like CPR, GCS, BLS and AVPU.
• Five of the nine EMTs interviewed were confident and
spontaneous in providing complete information about these
protocols
• Overall, one EMT had good knowledge, 3 had average while 2
had poor knowledge in this area.
• All EMTs, needed probing in specific areas like observations
required in anaphylactic reactions and ideal patient position
knowledge in a case of seizures.
• The EMTs were not very conversant with the details and
standard procedures for managing medical emergencies.
• The dependency on the ERCP’s advice in managing medical
emergencies was high among most EMTs interviewed.
43
Assessment of ERS Performance in Madhya Pradesh
Final Report
Type of
Protocols
Trauma
protocols
Pregnancy
Related
cases
Areas of assessment
Findings
• Overall, two EMTs each had good, average and poor knowledge
in this area.
• Four EMTs were able to confidently answer questions on
Management of
conditions in which they had to actively manage cases like
vehicular and nonamputations, poisoning, bleeding etc.
vehicular trauma cases
• Most EMTs interviewed needed probing in theoretically
detailing out management protocols, signs and symptoms of
shock, head injury and abdominal injuries etc.
• Overall, five EMTs had poor knowledge in this area.
Considering that pregnancy related emergencies constitute a
significant proportion of all emergencies, this is an area of
concern.
• On extensive probing basic management protocols of
emergency child birth and basic management of placenta were
Handling
pregnancy elicited from most EMTs. However, overall knowledge of other
related emergencies.
pregnancy related emergencies was very poor, including PPH,
spontaneous abortions, prolapsed cord, and pre-eclampsia.
• The % of pregnancy related calls received by 108 ambulances is
the highest as compared to others. However it was observed in the
evaluation that the technical knowledge level in EMTs regarding
this was the poorest in comparison to other areas like medical
emergencies and trauma cases.
3.1.29 Overall, the EMTs were conversant with standard management protocols of conditions they had
attended themselves and not with those which they are mandated to be aware of theoretically. The
Operating manuals were not available in all ambulances nor were most EMTs aware that they
should be having it as a ready reference in their vehicles.
3.1.30 Also, it was observed that the EMTs trained in formal paramedic courses like DHCP and BSc
(Paramedical) or with at least 1year of experience were relatively better equipped to handle
emergency cases and had a higher level of overall conceptual clarity. Thus, there is a need to
regularize refresher training as gaps in the understanding of basic EM protocols were found
amongst the newer EMTs. No clear difference in EMT skills between the two types of
preparatory training undergone could be drawn.
Systems knowledge
3.1.31 All the EMTs interviewed had good and consistent knowledge of systems and processes to be
followed with respect to call handling, patient handover, drug and equipment indenting and
demos.
3.1.32 An issue which was highlighted by some EMTs and also observed by the team was the absence of
the ERCP advice in the filled PCR forms. This was due to the line being continuously busy or
there being no connectivity. The PCR copies which were scrutinized by the team also had no
mention of the ERCP names in a large number of them and contained common instructions like
O2, V.M. and LLP.
Documentation
3.1.33 The team checked and verified records and registers which were mandated to be maintained by
the EMT, including patient/clinical (PCR, patient data etc.), inventory (stock of drug, equipment,
44
Assessment of ERS Performance in Madhya Pradesh
Final Report
Bio-medical waste etc.), vehicle checklists (fleet and quality related etc.) and administrative
(attendance, demos etc.) documents.
3.1.34 Considering the large amounts of documents which are mandated to be maintained by EMTs, the
overall quality of documentation in all ambulances was found to be satisfactory. Most EMTs had
records updated up to the same day of interview or the previous day. Exceptions include :
 3 continuous cycles of vital monitoring is sometimes not done as mandated but information
on the same is filled in the form.
 Stock registers were not updated in some ambulances
 Demo registers were not available
.
General observation
3.1.35 Overall, it was observed that EMTs were courteous and sensitive to the needs of the patients.
They received calls and answered the patients politely and tried solving their queries regarding
ETA (expected time of arrival) or any first aid if required. The EMTs also tried alleviating the
callers’ anxiety in the best way possible and counseled them on any immediate pain alleviation
techniques for e.g. immobilization, using a tourniquet for arresting blood flow or cold
fomentation if required in some cases. Additionally, they provided counseling on schemes like
JSY in government facilities to pregnant women en route to the facility.
Pilots
3.1.36 An evaluation of 9 Pilots was undertaken by Deloitte to assess their knowledge and practices. The
parameters used for the evaluation included:
Process Understanding measures the level of operational and technical understanding the pilot has with
regards to the processes defined by the fleet team.
Records maintenance measures the completeness and correctness of documents and records that are
required to be filled by pilots
Vehicle Maintenance measures adherence of pilots to processes related to maintenance of vehicles,
including scheduled servicing, refueling, tyre management, accident management etc.
Medical Equipment measures initiatives taken by pilots to ensure availability of required equipment and
timely indent of non-functional equipment, in coordination with EMTs. Pilots were also measured for
timely filling of oxygen cylinders in the ambulance
3.1.37 The following table summarizes the findings of the evaluation:
Table 3.1.7: Summary of Pilot evaluation
Assessment
Parameters
Gwalior
Pilot Pilot
1
2
Pilot
3
Sagar
Pilot Pilot
4
5
Pilot
6
Pilot
7
Sehore
Pilot
8
Pilot
9
Process Understanding
Records Maintenance *
Vehicle Maintenance
Medical Equipment –
Availability & Maintenance
* As detailed in the ambulance checklist
Good – Consistence Adherence of
SOP
Average –Adhoc implementation of
SOP
Poor - No implementation of SOP
45
Assessment of ERS Performance in Madhya Pradesh
Final Report
3.1.38 Following are some of the key observations of the assessment:
 Process Understanding: Process understanding among pilots was reasonably good. 7 out of
9 pilots had an excellent understanding of fleet processes including vehicle maintenance,
accident management, insurance recovery, fuel management, tyre replacement etc.
However, 2 pilots were found to be average in their process understanding skills.
 Records Maintenance: Documentation levels were observed to be excellent with pilots
clearly maintaining records of daily vehicle usage information related to no. of trips,
distance traveled, quantity of refuel, break down details, accident information, if any etc.
 Vehicle Maintenance: All pilots assessed were found to be good in maintaining the vehicle
as required by SOPs defined by the Fleet team. The scheduled service timelines were being
adequately monitored and adhered to, supported by strong on-field vendor. The pilots were
observed to be especially good at implementing local initiatives to increase tyre efficiency
like rotation of Tyres, ensuring and optimum pressure. The fleet handbook distributed by
the state fleet team was found to be very useful to the pilots.
 Availability and maintenance of medical equipment: In 7 out of 9 ambulances, the pilots
played an active role in constantly monitoring the status of equipment and oxygen in the
ambulances, by ensuring timely indenting, reporting non-functionality to EMEs, attempting
local repairs , where possible etc.
Assessment Summary: Human Resource
 HR processes: The planning, recruitment and annual appraisal processes are robust and are well
handled by the recruitment team, supported by comprehensive review mechanisms by the national
HR team. The state has also implemented good non-monetary performance, retention and grievance
redressal measures, resulting in high levels of motivation among staff. An area of improvement is the
manpower planning process for sense which should be done based on call and emergency forecasts,
and trends of call handle time.
 KAP of staff: Overall, EROs, EMTs and Pilots were observed to be very good in processes, empathy
towards beneficiaries and documentation. Staff was found to be very motivated about the tasks being
undertaken.
 EROs, were found to be adept at the call handling process
 EMTs were conversant with standard management protocols of conditions they had attended
themselves but not with those which the EMTs were mandated to be aware of theoretically. They
also required frequent ERCP advice for some infrequent conditions. Thus highlighting the need
for more robust mechanisms of refresher trainings, especially for new EMTs.
 Pilots were found to be very good in process knowledge, vehicle maintenance and
documentation. There was limited need for any kind of an exhaustive refresher training program
as most pilots had prior driving experience
46
Assessment of ERS Performance in Madhya Pradesh
Final Report
.
Scope of Responsibilities
3.2.1
3.2 QUALITY
The Quality team in EMRI, comprising of 4 members, is responsible for driving and monitoring
service quality and process adherence through clearly defined processes and periodic review
mechanisms. The following exhibit details the scope of activities currently undertaken by the
team.
Exhibit 3.2.1: Current responsibilities of the quality team
ISO Certified Quality Management System
3.2.2 At the core of the quality function of GVK-EMRI is its Quality Management System (QMS),
certified in ISO 9001:2008, which consists of processes defined across core and support functions
.As part of this initiative, the organization has a long term quality policy statement to guide the
policy initiatives of the state. The policy also clearly shows the vision the organization has in
establishing systems and policies.
Exhibit 3.2.2: Quality Policy of GVK-EMRI
We are committed to ‘Sense, Reach and Care’ every Emergency in the
state, with the best in the world standards, ensuring delight to Customers,
Associates, Partners and Investors through
― Visionary leadership
― Continual improvement by innovation and technology
― A suitable , scalable, and replicable business model
3.2.3
The quality function is responsible for periodic up gradation of all processes, monitoring of
process adherence and review of status of the organization with respect to the defined vision.
Ambulance Go-Live Audits
3.2.4 The quality team is responsible to conduct pre-deployment audits during the launch of new
ambulances after completion of all fleet and supply chain related activities, such as vehicle
47
Assessment of ERS Performance in Madhya Pradesh
Final Report
procurement, refurbishment, registration, and drug and equipment stocking. The following exhibit
shows the stage of quality go-live audits in the life-cycle of new ambulance procurement.
Exhibit 3.2.3: Stage for New Ambulance Go-Live Audits
3.2.5
As part of the Go-Live audits, the quality team checks whether new ambulances meet the
required compliance standards in terms of equipment, drugs, records, vehicle documents etc. If
the vehicle meets the required standard, the quality team transfers them to the field operations
team for deployment; else they are sent back to the SCM team to address identified gaps.
Sense
3.2.6 Key activities undertaken by the quality team with regards to the Sense function have been
detailed in the following exhibit.
Exhibit 3.2.4: Scope of Sense related Quality Audits
48
Assessment of ERS Performance in Madhya Pradesh
Final Report
ERO Evaluation
3.2.7 The quality team conducts periodic audits of all types of calls (EM calls, 48 hour follow- up and
case closing), either through retrospective listening of recorded calls or through live call barging.
The EROs are evaluated on process adherence, handle times, language and skill sets. Feedback
based on findings is then shared with the EROs either monthly or bi-monthly.
Analysis of Vehicle Busy and Unavailed Cases
3.2.8 This is a recent initiative of the quality team where one of their team members dynamically tracks
Vehicle Busy (VB) and Unavailed12 (UA) cases as they occur. Once they are intimated by Sense
of the occurrence, they are in constant touch with the VB help desk and the respective field
operations team to understand issues faced, operational errors, if any and possible mitigation
steps that could be implemented. They also provide real-time telephonic training advising EMEs
on more efficient tracking systems that could be implemented for UA and VB cases.
Analysis of ineffective calls
3.2.9 The main process in place for addressing ineffective calls (specifically nuisance calls) is the
periodic identification and blocking of frequent callers. A dynamic frequent caller report
generated by the IS team is used for identifying frequent callers.
Custodians of the Operational support Desk
3.2.10 The quality team is also the custodian for four applications that are integral to the sense and reach
operations.
Sense
Reach
VCare for grievance handling
E Visit for recording visitor feedback at the state level
Fleet Management System (FMS)for monitoring vehicle uptime
Customer Feedback Management System (CFMS )for 48 hour follow-up
Reach – Ambulance audits
3.2.11 All ambulances are audited by the quality team once a quarter based on a checklist covering
manpower, fleet, operations and supply chain management.
Care
3.2.12 Currently, the team does not conduct particular audits related to provision of care by EMTs and
medical direction by ERCPs.
 EMT audit: The plan is in place to launch care audits. Audits on EMT care shall be done
by integrating with the existing process followed by ERCPs to evaluate EMT care based
on PCR evaluation of critical cases. Feedback shall then be provided to all EMTs in a
more organized manner.
 ERCP audit: ERCP audits would be conducted on the lines of ERO audits where the
CARE lead shall a fixed number of audits of medical direction and IFT calls and provide
monthly feedback to them. It is important for this initiative to launch as soon as possible
as care provision is the backbone of the 108 services
12
Unavailaled cases are cases where the ambulance is dispatched for the call, but it is not utilized by the caller either
because the caller transports the case through other means instead of waiting for the ambulance or due to a fraud EM
call made
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Supply Chain Management
3.2.13 Periodic supply chain audits are undertaken by the quality team to track indent vs. disbursal of
consumables. The team also conducts physical audit of stock vs. stock recorded on Oracle
software.
Assessment Findings: Quality
3.2.14 Reasonably good adherence to defined processes: With respect to implementation of the policy
and the processes, broadly the evaluation of all functions of EMRI shows that most processes are
consistently followed by the teams owing to skilled, experienced and motivated functional teams
driving implementation. Adherence is also driven by constant review and monitoring by the
national functional teams of GVK EMRI. This additional check on processes is a sure strength to
the system. With regards to the state quality team, while there is adequate focus on driving core
functions, they play a limited role in ensuring process adherence for support functions.
3.2.15 Inadequate internal auditing processes: The ISO certification requires the organization to
identify quality champions and train them to be internal auditors, who would be responsible for
periodic audits of defined processes and ensuring high level of compliance with processes.
Currently, the quality team has identified only 3 people as internal auditors for all the functions,
which are inadequate considering the number of processes would be in excess of 50. There is also
no clear plan of internal audit, defining periodicity, responsibility and documentation formats.
The last internal audit for support functions was done in September 2012, the findings of which
were not shared with the evaluation team, making it difficult to comment on the
comprehensiveness of the earlier done audits.
3.2.16 Exhaustive Go-Live Audits: The quality team has exhaustive and well-defined checklists,
covering various aspects of the Go-Live audits, including medical and general consumables,
equipment, documents, extrication tools, oxygen requirements etc. The process was followed
meticulously for the recent launch of 352 ambulances, where the team also developed a launch
tracker to monitor progress. This also helped the team identify and address critical paths in a
timely manner.
3.2.17 Good ERO Evaluation processes: This evaluation is done regularly by the Quality team and is a
critical factor impacting adherence to call taking processes at Sense. EROs also expressed their
satisfaction with the process and the benefits of sharing periodic feedback. The findings of the
quality audit are also included by the sense team leads into the EROs’ monthly performance
evaluation chart.
3.2.18 Analysis of VB and UA cases: This is a commendable initiative by EMRI as VB and UA cases
should be focus areas as these are emergencies that EMRI could not handle (except UA cases due
to false reporting of emergencies). The importance of the initiative is reiterated by the large
proportion of UA and VB in comparison to medical dispatches (4.3% and 17% respectively for
the period – July-Dec 2012)
3.2.19 Inadequate monitoring of ineffective calls: While this activity has the potential to be an important
step towards addressing the large number of ineffective calls in the ERC, the issues are

The process was only implemented till February. It has since been very sporadic and
infrequent, as the team was engaged in go-live audits for the 352 new ambulances

There is inconsistency with respect to understanding of the process by the various
management and operational stakeholders , indicating that it is not a focus in the system
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3.2.20 No other data analysis on ineffective calls is done to come up with exact action plans. It is
important for the quality team to carry out monthly analysis of ineffective calls (like the Deloitte
dipstick study) to identify possible causes and actions that could be taken.
3.2.21 Comprehensive and periodic ambulance audits: A recent initiative by the quality team was also
to train a number of state EMRI officials on the ambulance checklist to conduct a comprehensive
audit of all 454 ambulances. The audit was completed in April 2013 and the team is now
following up with the supply chain, fleet and field ops teams to close ambulance wise noncompliances. This initiative is an important step in ensuring complete availability of drugs,
equipment and infrastructure in ambulances. However, documentation of periodic progress of
closure was found to be weak.
3.2.22 Ambulance audits done by Deloitte have shown minor unavailability of equipment (as shown in
Annexure 8.9). However, replacement process for non-functional or missing equipment identified
during the above audits was already underway.
3.2.23 Irregular SCM audits: It was observed that these audits were only conducted till December 2012
since the team was engaged with the launch of the new 352 ambulances. It is important for the
quality team to resume this activity as the store team does not conduct any physical audits, which
could lead to gross mismatches between the online system and availability of physical stock.
3.2.24 Operational Support Helpdesk: The applications are being adequately used and monitored by the
quality team, which coordinates with the technology team in case of any required modifications.
3.2.25 Minimal Data Analytics: While the team is responsible for driving process adherence, there is
minimal focus on evaluating the impact of processes through exhaustive data analytics. Fleet was
the only function observed to be conducting in-depth analysis of data to drive operations. Quality
team should be the custodian of both processes and performance of key parameters. It is thus
suggested that the team has a dedicated associate to produce periodic multi-functional periodic
analytical reports in constant coordination with the IS team.
Assessment Summary: Quality
 The quality department plays a critical role in the monitoring of internal processes. With their Quality
Management System certified in ISO 9001:2008, processes are well defined for all core and support
functions. Audits for all core functions are done diligently by the quality team; including newambulance go live audits, evaluation of sense manpower – skill, attitude and process knowledge,
audits on vehicle busy and unavailed cases and on-field ambulance audits.
 There is a need for the team to increase its focus on monitoring and auditing support functions.
Currently no internal audits are done by the team to track and drive process adherence of support
functions. Other areas of focus for the team need to be audits of medical direction and ineffective
calls. Overall apart from the processes, the team should also champion driving service parameters
through thorough analyses of existing data.
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3.3 SUPPLY CHAIN MANAGEMENT
Scope of Responsibilities
3.3.1
The 108 operations involve frequent procurement of capital and operational items such as:
 CAPEX
― Vehicle related: Ambulances, refurbishment, equipment, AVLTs, mobile phones etc.
― Office and infrastructure related: Call center equipment, office furniture, computers,
software requirements etc.
 OPEX
― Vehicle: Tyres and repairs and maintenance of vehicles
― Ambulance infrastructure: Drugs, Consumables, Equipment maintenance and
stationery
3.3.2
The supply chain team, comprising of 4 members, is responsible for all procurement and state
level inventory management related activities of EMRI. Scope of activities of the state supply
chain team includes:
 Procurement Related
o Managing the procurement process
o Liaising with national SCM for specifications and national tenders
o Organizing and driving procurement committee meetings for all tenders

Store Related
o Stock management and
consumables and stationery
distribution
for
ambulance
equipment,
Procurement
3.3.3
Processes for procurement are defined and monitored by the National SCM team of GVK EMRI.
The state SCM team then customizes the same for the state, if required and implements the same
for all its procurement related activities.
3.3.4
Exhibit 1.3.1 shows the current procurement process in place.
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Exhibit 3.3.1: Snapshot of the Procurement process
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Assessment Findings: Procurement
3.3.5
Comprehensive annual budgeting plans: The process of estimating and budgeting all OPEX and
CAPEX that require procurement on an annual basis is guided by a preapproved plan that is
developed by the state teams and reviewed at the national level. This process helps the
procurement and finance team better monitor procurement with respect to improving cost
efficiency.
3.3.6
Adequate review of procurement requests: During the year, any procurement that is required to be
done is thoroughly reviewed by the SCM and Finance teams, post discussion with the requesting
department on the need, specification and cost of the item to be procured. The recommendation is
then shared with the national procurement for a quick review. For large value items, a summary
of the recommendation is also sent to GoMP. The national procurement team plays an important
role in closely and constantly monitoring state procurement processes.
3.3.7
National procurement for economies of scale: Since EMRI is operational in over 12 states, to take
advantage of economies of scale, the national procurement team issues national tenders for
frequent or high cost items. This is done only for states which agree to follow the national tender
route for specific items. The EMRI-MP team periodically submits letters to GoMP seeking their
opinion and approval for planned national tenders. On approval, the final list of nationally
tendered items, prices and vendor details are shared with states. This is a valuable benefit that
GVK EMRI brings to the partnership as it has the potential to significantly reduce costs for the
state.
3.3.8
Good procurement process in place with detailed documentation: In cases of items that are not
tendered nationally, the state SCM team procures them depending on the value of the item or
service required to be procured. All tender committee meetings and tender openings are
adequately documented by the state SCM team (as observed during document review). The
document clearly covers details such as members involved, list of bidding organizations, reasons
of disqualification, details of bidder wise technical specifications, qualified technical bids, list of
selected vendors etc.
3.3.9
Use of Oracle for monitoring procurement: The use of Oracle’s purchase module enables better
online monitoring of the procurement process. Since this model is also linked to the finance
module, the process ensures that payment to vendors is made only on satisfactory compliance of
delivery as per the issued purchase orders, thus enabling the finance team better monitor
procurement related costs.
3.3.10 GoMP monitoring: While the internal processes at EMRI appear comprehensive, the level of
GoMP monitoring is inadequate. Given the high quantum of annual procurement, the MoU does
not state any procurement guidelines. In order to monitor and drive cost efficiencies, there is a
need for GoMP to strengthen monitoring processes for both national and state level procurement.
Store, Indenting and Stock management
Store Management
3.3.11 All consumables (general and medical), repaired equipment and record formats to be sent to the
ambulances are stocked in the store handled by store staff reporting to the SCM head. Staff at the
store, comprising of 1 store manager and 2 associates, are responsible for periodic physical
checks of the stock, receipt and verification of vendor goods, dispatch to ambulances and raising
timely stock demands.
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Indenting and Inventory Management
3.3.12 Ambulance indents: Ambulances indent required consumables and equipment on a monthly basis
in the form a hard copy format provided by the SCM team, consisting of date of indent, current
stock, previous month consumption and required stock. The store staff then analyse each indent
based on the information furnished by the ambulance on monthly consumption and available
stock. Ambulance wise indents are then stocked and packaged to be delivered to the ambulance
site.
3.3.13 Documentation of indent dispatch: Ambulance wise indents are entered onto an excel tracker
once every 7-10 days by the store staff. Monthly consumptions are calculated for all consumables
and compared with available stock to finalize batch sizes of consequent lots.
Assessment Findings: Store Management
3.3.14 Inadequate tracking of ambulance utilization trends due to absence of a computer at the store:
The store does not have a computer and printer which are important to implement proper
inventory management processes. The same would also enable the store manager better track
ambulance wise utilization trends of consumables.
3.3.15 Good store arrangement practices: Drugs, equipment and documents in the store are organized
based on recommended store management guidelines including alphabetic sorting and FEFO
(First Expiry First Out) principles.
3.3.16 Timely fulfillment of ambulance indents: The indent management process at the store has been
observed to be good. Indents are fulfilled in a timely manner which is important given the
criticality of service being offered by the organization.
3.3.17 Manual inventory management processes: The current process does not clearly define minimum
stock, stock holding time or economic order quantities. It is calculated by the SCM team only
based on monthly consumptions. While no apparent stock outs were observed, the current process
is manual and time consuming. Skills of staff would need to be enhanced to address the current
gap in assessing exact demand. While the organization uses Oracle for purchase process, the same
is not used for inventory management. Using some inventory management module for the same
would be beneficial for the organization in more accurately tracking consumption and indents.
Assessment Summary: Supply Chain Management
 The supply chain management function of GVK EMRI is an important function of the organization.
The strength of the function is its clearly defined processes and close monitoring exercised by the
national supply chain team of GVK-EMRI. In MP, adherence to these processes was found to be high
along with high standards of documentation. The use of Oracle helps the SCM and finance teams
better monitor related processes. While store and ambulance indents are managed very efficiently by
the team, inventory management is an area of improvement.
 At the policy level, better review mechanisms by GoMP, of both state and national procurements,
would strengthen the current procurement process and drive cost efficiencies.
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3.4 MARKETING
Scope of Responsibilities
3.4.1 The marketing function of EMRI is responsible for the following activities:
 Brand management of GVK EMRI, 108 and GoMP
 Public relations at the state and district level, including press releases
 Planning ambulance launch events
 Spreading awareness of the service through appropriate communication strategies
Assessment Findings: Role of Marketing
3.4.2 Till December 2012, EMRI was responsible for handling all IEC/BCC activities for the ERS in
the 10 districts where services were operational. However as per the renewed MoU, the
responsibility to promote public awareness in emergency response lies with GoMP in
consultation with GVK EMRI, which has been given limited annual budgets.
3.4.3
Due to limited annual budgets for marketing, it leaves very less scope for EMRI to promote
awareness activities in the state. This often leads to EMRI requesting for special approvals from
GoMP for additional budgets.
State level Marketing
3.4.4 The marketing in-charge develops annual plans detailing campaigns and major events to
be conducted at the state level in discussion with the COO and the national marketing
team, which are then discussed with GoMP and implemented.
3.4.5
At the state level, the various media used by the team has been described in the exhibit below –
Exhibit 3.4.1: IEC/BCC activities undertaken by EMRI
IEC/BCC Activities undertaken by EMRI
•
•
•
•
•
•
•
•
•
Ambulance branding
Media coverage- print media, TV ads, radio spots, interviews on
Doordarshan,
Demonstrations in schools, colleges,
Pledge to Save Lives Campaign
Wall paintings
Hoardings
Stickers on buses
Posters and pamphlets
Water tank paintings
Field level marketing
3.4.6 The plan for field level IEC/BCC activities is drawn up in consultation with the EMEs and PMs.
As discussed in the Reach (Field Operations) section, the most frequent awareness mechanisms
used on the field include demos, news articles on cases handled and ambulance launches in local
newspapers and coordination with ASHAs for using the service for planned deliveries in the
absence of JEY.
3.4.7
On an average, 3-4 demos are required to be conducted per district per day. The EMTs and Pilots
are also trained on aspects of IEC/BCC activities during their induction period.
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Assessment Findings: State and Field level marketing activities
3.4.8
Significant activities during launches: Ambulances launches are a major means of spreading
awareness of the scheme. EMRI has developed detailed processes guiding teams on procedures to
be followed for launches including recommended chief guests, panel guests, speakers,
involvement of stakeholders and press messages. The marketing function plays a significant role
during the launch phase in spreading awareness of the number through press releases and, event
and ambulance branding.
3.4.9
Lack of clear target messages: The annual marketing plans are not developed with objectively
formulated target messages for various user categories across the state. Analysis of impacting
factors such as geography, social status, morbidity patterns, proximity to health facilities etc. are
not used to analyze the need and customize target messages. No. of emergency calls received
during a period is sparsely used to plan demos in some regions.
3.4.10 Absence of a strategic marketing plan: During the state level meetings with EMRI, it was noticed
that there is absence of a strategic communication strategy which details clear marketing
objectives and related implementation plans. The current process only lists down annual
requirement of marketing material such as badges, caps, posters etc.
3.4.11 Target Campaigns: Very few implemented campaigns target critical awareness needs such as
 Low awareness levels of fire and police services
 Low awareness levels of medical emergencies, other than pregnancies and trauma
 High % of ineffective calls.
It was observed that no topic or target message based demos were conducted across the state.
3.4.12 District and Village plans: To develop current demo plans for districts and villages, data from
Sense and Reach functions is not adequately analyzed to understand specific issues and prioritize
demo locations.
Good Practices from the Field
3.4.13 The following section highlights some good practices observed at the state and district levels,
which could be scaled up on a regular basis.
Radio Campaign at the state level: Indore, Jabalpur and Bhopal Districts
3.4.14 EMRI in collaboration with 92.7 FM conducted a radio campaign ‘Pledge to Save Lives’ in
Indore, Jabalpur and Bhopal during the Road Safety Week to spread awareness in urban areas on
the need to report a trauma emergency as quickly as possible and to give way to ambulances on
busy urban roads.
Demos to increase emergency cases: Hoshangabad District
Need of the campaign
3.4.15 An analysis of data from the field indicated that the number of emergency cases being handled
per ambulance per day was much lower in Hoshangabad district compared to the average of 10
districts.
Demography
Average number of trips per
ambulance per day
Hoshangabad
10 districts average
*August-December 2012
2.4*
4.3**
**July-December 2012
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Assessment of ERS Performance in Madhya Pradesh
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Implementation plans
3.4.16 Targeting influencers: In order to raise awareness about the 108 service and to increase the
number of emergency cases, a comprehensive IEC/BCC plan was drawn up for the district. The
aim was to target those who are viewed as decision makers and influencers as well as the general
population.

ASHAs - As part of the strategy a number of demos were held at schools, public health
facilities and at the ASHA training centre. These demos showcased the ambulances, the
equipment available to manage emergencies, the pilots and EMTs knowledge and
experience of managing emergencies. The process of calling a 108 ambulance was also
explained.
IEC/BCC activities undertaken in the field

Panchayats - Efforts were also made to work along with Panchayats to raise awareness
levels of the community. A chopal was held at the Gram Sabha in Panjakarla village
where the Sarpanch and 100 villagers took an oath to call the 108 helpline for any
emergency. The reach of the chopal goes further than just the 100 villagers covered. The
Sarpanch acts as an influencer and at the time of an emergency would encourage the
people to call 108.
Community level
awareness programme
Impact
3.4.17 Due to the targeted marketing efforts undertaken the number of emergencies per ambulance per
day rose from 1.46 in August 2012 to 3.68 in February 2013.
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Assessment of ERS Performance in Madhya Pradesh
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Strict action leads to reduction in hoax calls: Indore District
Need of the campaign
3.4.18 There were a number of hoax emergency calls being received by the ERC which were traced to
Indore district. The callers would request an ambulance to be sent to a specific location to attend
to emergency. However, when the ambulance would reach the site they would find that there was
no emergency to attend to, thus leading to an increase in the number of unavailed dispatches.
Implementation plan
3.4.19 Print media: To reduce these hoax calls, a targeted IEC/BCC campaign was undertaken. Using
the print and electronic media, awareness was raised about how by responding to fake calls
ambulances were missing genuine emergencies.
Use of Print media to cut down hoax calls
News Coverage on pinning down of fake callers
3.4.20 Coordination with Police: The marketing team worked along Sense and Field operations to
identify the source of the hoax calls. As part of the strict measures taken to reduce the fake calls,
3 arrests were made of people making numerous fake calls. Media coverage of these arrests
stressed the importance of using the 108 helpline only to genuine emergencies.
Impact
3.4.21 The ERC saw an immediate reduction in number of hoax calls from Indore following this
IEC/BCC campaign.
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Assessment Summary: Marketing
 The marketing team continues to play an important role at the state level in brand building and
developing annual communication plans. The team also monitors demos being conducted at the field
level. However, the team needs to focus on following a more strategic approach towards its
communication strategies w.r.t identification of target messages, development of need based plans
and addressing key gaps such as ineffective calls and medical emergencies in addition to trauma and
pregnancies.
 At a policy level, the Government would need to decide the way forward for marketing activities with
respect to the current arrangement of GoMP being responsible for spreading awareness. GoMP and
EMRI would have to evaluate developing joint IEC/BCC plans and define mechanisms for review of
additional budgets required for the same.
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Assessment of ERS Performance in Madhya Pradesh
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3.5 INFORMATION TECHNOLOGY
3.5.1
The Information Technology and Information System (IT-IS) function is responsible for the dayto-day oversight and management of all IT enterprise system implementation within the
organization as shown in the exhibit below. The team is also responsible for implementing
processes to constantly streamline and redesign various technologies and business systems across
all functions to improve system efficiency. This section aims to give a very brief snapshot of the
scope of services and highlight some broad technology challenges, if any. The section does not
evaluate detailed technical specifications of the solutions being used at EMRI.
Exhibit 3.5.1: Responsibilities of IT-IS Team
Software
3.5.2 A list of key software applications being used in MP operations by EMRI are ERO application (Sense)
 Care application to provide OMLD (Care)
 Daily Automated Reports (Sense)
 Customer Feedback Management System (HR)
 V Care for grievance redressal (HR)
The applications are detailed in the respective sections on their usage.
3.5.3
Development of Core applications: The national IT team of GVK-EMRI monitors the
development and changes to any of the applications being used. These applications have been
developed by technical partner, Tech Mahindra. The national team adequately tests and evaluates
applications before launching them for use in the states.
3.5.4
Maintenance of Core applications: The IT team’s main responsibility is to ensure 100% uptime
of all core 108 applications which include the Sense (all related applications - call taking and
ambulances dispatch), case closing and fleet applications, since this affects the organization’s
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Assessment of ERS Performance in Madhya Pradesh
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main service of handling 108 calls that land on 108. With the current server uptime being more
than 99.9%, the IT team does a commendable job of undertaking adequate preventive steps to
keep a check on downtime.
3.5.5
Report Generation: While EMRI stores all call and EM data, the IT-IS team member is
responsible to ensure that all planned and automated reports, both internal and to the Government,
are generated on schedule as is the case currently. The team also collates other adhoc report
formats submitted to them by the various functions based on an evaluation of their criticality and
approval of the COO.
3.5.6
Other software- The team is also responsible for defining specification of all other software
required to be procured for the staff and renewing required licenses.
Hardware
3.5.7
All hardware specifications and application design is coordinated and monitored by the National
IT-IS team. The benefit is the incorporation of best practices and efficiencies collated from all
GVK-EMRI’s implementation states.
3.5.8
The state IT-IS team ensures timely procurement, preventive maintenance and issue redressal for
all hardware involved in the system, including
 Data storage discs for information and call recording.13
 Nortel communication system at the call center
 Voice logger at sense
 All other admin and application servers
Assessment Summary: Information Technology
 The IT-IS systems of GVK- EMRI are well designed to enable efficient call handling, safe data
storage and data analysis. This support function is a mainstay for smooth functioning of 108 services
in the state. Through its partnerships with Tech Mahindra to develop core application, EMRI designs,
reviews and updates its IT systems nationally.
 The state IT team does a commendable job of ensuring more than 99.9% uptime and undertaking
adequate preventive steps to keep a check on the same. Overall technology and data are definitely
some of the key strengths of the organization. However, there is scope to increase the level of data
analysis done at the organization.
13
Data is store in three places – Storage Area Network (SAN) with mirroring in the call center, external hard drives
in the EMRI building and in the EMLC.
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CHAPTER 4
CONTRACTUAL AND INSTITUTIONAL
FRAMEWORK
Assessment of ERS Performance in Madhya Pradesh
Final Report
Introduction
4.1
As discussed in Chapter 1, the 108 service functions through a Public Private Partnership (PPP)
model between GoMP and GVK EMRI. GVK EMRI has been appointed as the nodal agency to
provide emergency response services. The current MoU14 between GoMP and GVK EMRI is
valid for a period of 5 years (November 2012-2017).
Scope of Responsibilities
4.2
Under the MoU, EMRI is responsible for providing technological, leadership, strategic,
managerial and operational support for the project. The role of EMRI as per the MoU includes:

Provide technological, leadership, administrative and managerial support to produce
mutually agreed outcomes

Operationalize and maintain fully equipped ambulances on a 24x7x365 basis

Ensure 24x7 services at the call centre located in Bhopal

Procure ambulances and get them insured and equipped as mutually agreed.

Ensure that each ambulance has at least one pilot and one EMT present at any given
point of time to provide patient-stabilization, first aid and other pre hospital care

Recruit, train and position qualified and suitable personnel for implementation of the
project at various levels.

Maintain financial transparency in terms of financial planning, disbursal, accounting
and auditing

Ensure proper and timely monitoring of the services
4.3
On the other hand, the state government is responsible for all capital and operational expenditure
of the project including procurement and refurbishment of vehicles, call centre related capital
costs, ambulance related operating costs, salaries of staff15 etc. The role of the Government as per
the MoU includes:

Disbursal of OPEX quarterly and CAPEX on completion of required tender processes

Formation and proper execution of state and district committees

Review and approve guidelines and procedures for operation of ambulance services

Provide parking spaces for stationing ambulances across the state

Conduct regular monitoring and evaluation of project activities based on reports
submitted by the private provider and review meetings

Promote public awareness in consultation with GVK EMRI.
Institutional Structures
4.4
The MoU mandates setting up committees at the state and district levels to advise and monitor the
functioning of the scheme according to defined clauses. The following table gives a snapshot of
the members, role and current status of each of these committees.
14
Signed on 27th December, 2012.
GVK EMRI is required to bear the salaries of senior management placed at Bhopal whose salaries exceed Rs. 12
lacs per annum. In the current situation, only the COO gets a salary greater than the current cap.
15
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Table 4.1: Committees to be formed as per MoU
Name of
Committee
Advisory
Council
Executive
Committee
Members
Responsibilities
Chairman: Chief Secretary
To meet at least once a year
GoMP: Principal Secretaries
and Commissioners of Health,
Finance and Home, MDNRHM
GVK EMRI: CEO and COO of
MP operations
- Strategic review of
performance/ implementation
plans and reports submitted by
EMRI and review of
recommendations submitted by
Executive Committee.
Chairman:
Secretary, DoHFW
-To meet at least once a
quarter
Principal
GoMP: Commissioner Health;
MD-NRHM; Directors, Health
Services, Medical Education,
Fire Services, Finance; IG
Police;
Special
Officer
appointed for ERS MP
-Review SOPs, status of service
parameters, release of funds,
reports submitted and fund
utilization.
Issue
special
guidelines, where required.
Current Status
(Findings from Field Visits)
- The Council is required to
meet once before December
2013. As of June ‘13, the
council meeting had not been
convened.
- No formal EC meetings had
been convened till June’13.
However, EMRI constantly
communicated
with
the
DoHFW Principal Secretary,
and MD and Commissioner
NRHM to convey process
updation,
extra
budgets
requirements and launch plans.
GVK EMRI: COO of MP
operations
District
Committee
Special
Officer
-Chairman: District Collector
-To meet once a quarter
GoMP: District Collector;
CMHO;
Superintendent,
Medical
College,
Civil
Surgeon- District Hospital;
Chief Municipal Officer;
District Heads of Fire and
Police Depts.
-Review district operations of
108 services – trends of
emergencies and reach times,
ambulance uptime, awareness
activities,
launch
progress,
feedback on Govt hospitals,
Grievance redressal etc.
GVK
EMRIDistrict
Emergency
Management
Executive – EME)
Appointed by the MD, NRHM
- To liaison with GVK-EMRI to
periodically review their
operations, reports, and
adherence to budget caps and
service parameters.
- In all three sample districts,
the committees were not in
place. Adhoc reports on
emergencies handled were
submitted to the district office.
In Sagar and Sehore, Collectors
and CMHOs conducted
frequent reviews mainly during
launch of new ambulances in
the district
- A Deputy Director under
NRHM has been the 108
Special Officer since June
2011 and is well informed
about the scheme with respect
to its funding, processes and
performance.
* Mutually decided nominees (including relevant Deputy Directors and Joint Directors) are also part of the
committees.
Assessment Findings: Institutional Structures
4.5
Well defined institutional structures: The new MoU details out the required institutional
structures with respect to roles and responsibilities of each of the stakeholders as well as
committees at various levels. It is envisioned that the advisory, executive and district committees
would advise and review EMRI with regards to its strategic and implementation plans.
65
Assessment of ERS Performance in Madhya Pradesh
Final Report
4.6
However, as indicated in the table, committees defined in the MoU have not yet been formally
implemented. In most of the cases, either the meetings are not being held or are being held in an
informal settings. These meetings are important to ensure continuous appraisal of performance of
the services at various levels and help coordination between various stake holders. Infrequent
meetings often leads to issues such as:
- Lack of integration with police and fire departments, leading to absence of
coordinated response as required in medico-legal cases and spreading awareness of
108 for police and fire cases
- Inadequate mechanism of reporting to and monitoring by Govt. officials, leading to
non-redressal of issues such as high ineffective calls, insufficient audits of support
function processes, weak technical knowledge of EMTs, non-adherence to agreed
service parameters etc.
- Lack of coordination for marketing strategies involving joint communication plans
Funding
4.7
As per the MoU, GoMP bears all OPEX and CAPEX costs. This section seeks to briefly analyze
the funding requirements of the MoU. A detailed analysis of the same could not be carried out
due to lack of data.
4.8
OPEX: The MoU details out limit per ambulance per month for various budget heads as shown in
the following table
Table 4.2: Estimated OPEX per ambulance per month
S.No
1.
2.
3.
4.
5.
6.
Item
Ambulance Running and Maintenance
Salary
General office/Administrative Expenses
Recruitment Expenses
Marketing Expenses
Miscellaneous, inc Traveling Expenses
Total
Limit per
ambulance
per month
(in INR)
30,800
57,500
4,400
2,800
400
1,800
97,700
%
31.5%
58.9%
4.5%
2.9%
0.4%
1.8%
100%
4.9
Operational expenses borne by the Government includes all expenses related to 108 operations in
Madhya Pradesh. Salaries of senior management of the national operations of EMRI,
headquartered in Hyderabad, are not considered as OPEX and are borne by the private partner –
GVK-EMRI. The government pays 100% of the OPEX on the basis of quarterly Utilization
Certificates (UC) submitted by GVK EMRI. Any expenditure beyond the limit mentioned in the
MoU would have to be approved by the Advisory Council. EMRI submits quarterly audited
Utilization Certificates to the GoMP detailing funds received during the previous quarter, budget
head wise utilization of funds, account balance and estimated budget for the following quarter.
4.10
CAPEX: As stated in the MoU, the Government also bears all capital expenditure including
ambulance procurement and fabrication, medical equipment, IT/networking equipment, GPS and
adequate space and equipment to run the Emergency Response Centre. The costs for CAPEX do
not have a cap, but are on actuals on receiving GoMP approval before procurement and following
a structured tender process. The CAPEX for each year is estimated at the beginning of the
financial year.
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Assessment of ERS Performance in Madhya Pradesh
Final Report
Assessment Findings: Funding and review
4.11
Budget Cap for monitoring cost efficiency: The revised MOU has included cap on each of the
budget heads, which has enabled GoMP to monitor expenses incurred by EMRI. These caps were
decided on analysis of previous expense trends in discussion with EMRI. However, it would be
important for GoMP to analyze actual expenditures at least bi-annually to revise the caps in a way
to drive better cost efficiencies. Trends of other states could also be sought from EMRI and
analyzed to fine tune the targets.
4.12
High Opex per ambulance per month compared to the MoU cap: Based on available data, the
provisional OPEX per ambulance per month for the year 2012-13 is INR 1,15,244/-. For EMRI,
to meet the MoU cap of INR 97,700 for the year 2013-14, budget heads in excess of the given
heads would need to be identified and initiatives that could drive required cost efficiencies would
need to implemented.
4.13
Quarterly and Annual audits mostly complied with by EMRI: As required by the MoU, EMRI
submits annual and quarterly reports of audits conducted by external chartered accountants to
GoMP. The formats of submitted UCs, which contain the findings of quarterly audits, have been
observed to be in accordance with the recommended formats of Schedule B of the MoU.
However, delays in submission of quarterly UCs have been observed in 2013.
4.14
Costing details to be included in the UCs: While the UC is in concurrence with Schedule B and
provides details of the expenses incurred, related costing parameters and details of expenses are
adequate. Expense heads that could be further included in the UC as annexures include:
 CAPEX – Details of items procured, no. of units and unit costs
 Salaries and other allowances – Division of expenses based on staff type and number
for the quarter being considered, for EROs, EMTs, Pilots, EMEs, Team Leads and
Managers of Sense, Reach and Care and support staff.
 Ambulance Running Expenses – Apportioning expenses based on no. of operational
ambulances for the quarter being considered
Assessment Observations: Procurement
4.15
The 108 operations entail frequent procurement of capital and operational items including
ambulances, refurbishment, equipment, medical consumables, ambulance stationery, Tyres etc.
As described in Chapter 3.3, EMRI follows an exhaustive procurement system with respect to
preparation of annual budgets, periodic national reviews, established procurement committees
and defined tender process and documents.
4.16
EMRI also follows a national tender process to take advantage of economies of scale across its
operational states. On getting approvals from concerned state governments, the national
procurement team issues national tenders for frequent or high cost items. The EMRI team in MP
periodically submits letters to GoMP seeking their opinion and approval for planned national
tenders. This is a valuable benefit that GVK EMRI brings to the partnership as it has the potential
to significantly reduce costs for the state.
GoMP Monitoring
4.17
While EMRI’s internal procurement processes are comprehensive, the level of GoMP monitoring
is low given the absence of GoMP representation in the procurement committees designed by
EMRI and procurement guidelines in the MoU. In order to drive cost efficiencies of both
national and state procurements, there is a need for GoMP to strengthen monitoring processes for
both national and state level procurement.
67
Assessment of ERS Performance in Madhya Pradesh
Final Report
Review and Monitoring
Service Parameters
4.18
4.19
4.20
The inclusion of service parameters in the MoU is an important step taken by GoMP towards
monitoring operational performance of the service. Currently, the MoU stipulates 9 service
parameters to be adhered to by GVK EMRI. The review of performance of EMRI with regards to
these parameters starts 6 months from the date of signing the agreement.
Broadly the parameters are divided into the following categories:
 Milestone based (indicated as
) – Parameters which are dependent on achievement of a
particular milestone. These parameters would have to be constantly reviewed and updated
based on the dynamic operational plans of the service
 Ongoing target based (indicated as
) – Parameters which are based on operational
targets of performance indicators. While the parameters would be applicable for consecutive
years, targets would need to constantly update based on achievement levels of EMRI.
The following table presents an evaluation of the current service parameters along with our
recommendations.
Table 4.3: Evaluation of Service Parameters for 108 services in MP16
S.No
Service
Parameter
Current
Threshold
Category
Reason for Change, if
any
Possible change
: EMRI has achieved this
milestone with the launch
of 352 new ambulances
For the next year this
parameter could be changed
to include district wise
population per ambulance.
Existing
1.
2.
3.
4.
16
Geographic
coverage of the
district with
EMRI services
Average number
of emergencies
to be attended by
one ambulance
per day
100%
4.2
: With the state launching
new ambulances this
target is still good, for the
newer ambulances to
stabilize.
(Actual achievement for
July-Dec 2012 is 4.3 and
Jan-Mar 2012 is 3.3)
Average time
taken to reach
the scene after
the call (Rural)
20-30
minutes
Average time
taken to reach
the scene after
the call (Urban)
15-20
minutes
: Target to continue as
international standards
require reach times to be
40 minutes for urban and
20 minutes for rural5
(Performance between
April and December 2012
- Urban - 27m 24s and
Rural - 30m 25s)
: The definition of rural and
urban needs to be clarified. :
Currently EMRI classifies
urban cases on the basis of
base station location. This
leads to reporting of higher
urban reach time as urban
ambulances also serve
periphery locations of the
city/town
: Urban cases should be
classified based on the
location of emergency site
and not the location of
ambulance handling the
emergency.
“ Ambulance Response Time in Developing Emergency Healthcare Systems” – Jochen Schmidt
68
Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
5.
Service
Parameter
District wise
vehicle busy
calls
Current
Threshold
Not more
than 7.5%
Category
Reason for Change, if
any
: Target to continue.
However the denominator
for calculating the ratio is
unclear. Suggested to be
defined as No. of vehicle
busy cases / Total no. of
medical
dispatches
Possible change
: This target could start with
7.5% for the first year and
then reduced to 5% for the
next year.
(Value for Jan - Jul 2012
ranging from 14% to
18%).
6.
7.
8.
9.
17
Introduce GPS
tracking for all
vehicles (subject
to timely
clearance by
state
government)
Address
ineffective calls
Introduce
Quality
Management
indicators for
skills and
equipment
Average % of
on-road vehicles
per day should
not be less than
100%
within 6
months of
signing
MoU
Reduce by
15%
: To Continue. Clear
target month to be
mentioned if not already
in place.
:None of the ambulances
had AVLTs at the time of
study
: Target period not clear.
: Unclear parameter. Does
not give any activity based
target.
100%
:This would require the
Executive Committee to
define Quality
Management indicators
and approve their targets
: Target To Continue.
95%
(Performance as of March
2013 - 98%.
:Target period should be
clearly specified
: As discussed in the Sense
section earlier, ineffective
calls should be reduced to
50% over next 2 years from
the current level i.e. 95%17 .
However, this target should
be finalized based on
analysis of trends of
ineffective calls across more
mature states such AP and
Gujarat.
Could be changed to " Biannual sharing of internal
audit findings of all
processes and adherence of
performance to approved
skill and equipment quality
indicators"
Target could be increased to
97% based on further
analysis of current status,
given the launch of new
ambulances.
As of Jul-Dec 2012 data provided by EMRI
69
Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
Service
Parameter
Current
Threshold
Category
Reason for Change, if
any
Possible change
New
10
Monthly average
of % Unattended
Calls should not
be more than
: This parameter evaluates
the effectiveness of the
call center in ensuring that
almost all EM Calls are
picked and attended to.
1.5%
(As per data submitted by
EMRI for all months till
Dec 2012, this % has
never crossed 1.2%)
Target Value could be 1.5%
for the first year. Once
services in new districts
stabilize, target could be
revised to 1%
Reporting Mechanisms
State level
4.21
The MoU requires EMRI to submit periodic reports to GoMP covering operational parameters of
the service, including number of trips per ambulance, number and types of patients etc.
Daily and Monthly Reports
4.22
In this regard, the following exhibit gives a snapshot of the daily reports shared by EMRI 18with
GoMP.
Table 4.4 –Format of Report submitted to the GoMP
Daily Format - State wise
Today
Current Month
Launch till Date
Call Type
 Emergency
 Effective
 Ineffective
Dispatches
Type of emergencies
 Pregnancy related
 Vehicular trauma
 Etc.
Monthly Format - State and District wise
Month till Date
Year till Date
Launch till Date
Call Type
Type of emergencies
Reach Times
Lives Saved
Deliveries in Ambulance
District Level
4.23
At the district level, currently EMEs submit adhoc monthly reports covering no. of emergencies
and reach times to the district offices.
18
Based on formats shared with the evaluation team
70
Assessment of ERS Performance in Madhya Pradesh
Final Report
Key Findings
4.24
Need to strengthen periodic reporting to be submitted by EMRI at the state and district levels: It
was observed that EMRI submits daily reports to GoMP at state level consisting of essential data
to get an overview of the operations. However, reports at state level could further be improved to
include the following parameters based on recommendations from the executive committee.
Daily
― Sense : UAC, call handle time, no. of vehicle busy cases, no. of unavailed cases
― Reach : No. of off-road ambulances, base to scene reach time (including urban and rural
split)
― Care : No. of cases given OLMD, No. of IFT (Inter Facility Transfer) cases, no of partner
hospital
Monthly
― Status of agreed service parameters, along with detailed remarks of non-compliances, if
any
― Findings of core process audits : key findings (strengths, non-compliances and issues) of
quality audits of ERO calls and ambulances
― Findings of support function audits: key findings (strengths, non-compliances and
issues) of all support functions including SCM, Marketing, state-level fleet, marketing,
IT-IS etc.
― Status of District Committee meetings : Status of adherence to quarterly plan of district
committee meetings across districts, district wise summary of minutes – strengths, issues
resolved, any state-level escalations required etc.
― Findings of population based feedback, if any
4.25
At the district level, details on ambulance wise emergencies handled, reach time, demography of
cases handled, patient feedback, IEC activities undertaken, case studies, best practices
implemented and issue should be submitted by the EME every month to the District Committee.
4.26
Inadequate review of reports: Overall, it was found that even with the current level of reports
being submitted by EMRI, the data is not adequately reviewed by the state and district
administration. However, it is important to monitor reports timely or at least review the same
during the committee meetings to be appraised of the good practice and areas of improvement of
the service
Assessment Summary: Contractual & Institutional Framework
 The new MoU signed on 27th December 2012 is well documented and clearly details the roles and
responsibilities of GoMP and GVK EMRI. In comparison to the older MoU, this MoU also specifies
service parameters and budget caps to enable GoMP to monitor operational and financial
performance. The operational service parameters could further be improved to increase objectivity of
the parameters.
 However, the level of monitoring could further be strengthened by ensuring regular meetings of
defined committees at various levels and improving the reporting requirement and their analysis. This
would help GoMP to constantly supervise EMRI’s implementation plan and provide input for
performance improvement
 Improving these monitoring systems would help both partners develop a shared vision of the service
in the state and dynamically define areas of focus as per mutually identified service gaps, which could
include addressing ineffective calls, increasing tribal coverage, reducing response times, establishing
systems for pre-arrival instructions etc.
71
CHAPTER 5
DEMAND SIDE ASSESSMENT
Assessment of ERS Performance in Madhya Pradesh
Final Report
Introduction
5.1 As part of the study, Deloitte conducted a demand side assessment to identify strengths and areas of
improvement of the 108 service by ascertaining responses from users, non-users, field level workers
and influencers on key parameters including:
(A) Awareness of 108 services
(B) Call Experience and Ambulance Reach time
(C) Perception of Quality of Care and hospital handover
5.2
The total sample interviewed in the three sample districts for the assessment is as follows –
Category
Users
Non-users
FLWs and PRIs
Total Interviewed
299
148
112
5.3
Annexure 8.2 gives details of village wise list of interviews conducted.
5.4
The table below represents the observations and responses made in the sample districts.
(This Space has been left intentionally)
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Assessment of ERS Performance in Madhya Pradesh
Final Report
S.no
Responses
Parameter
(A)
1
Overall
awareness
2
Sources of
awareness
3
Awareness of
usage of 108
for police and
fire
emergencies
Awareness of 108 service
Users
 98% of the users interviewed were aware of 108
 2% of the unaware users were all women and while they were not
aware themselves, someone in their family was aware of the
service e.g. mostly husband, father-in-law.
Non-Users
 75% of the non-users were aware of 108. While this shows high
levels of overall awareness, it also indicates scope of improvement
Field Functionaries and PRI members
 All the Field functionaries and 90% of the PRI members
interviewed aware of 108 services.
 The most common sources of awareness are:
- Word-of-mouth (mostly from other users and field level
workers)
- Observation of ambulance while serving some other
emergency in the village
- Official communication / announcements
- Posters.
 In Gwalior, particularly, television was the major source of
awareness as it is the most urban district of the three.

Overall, less than 50% of the respondents across different groups
were aware of the use of 108 for police and fire emergencies.

Comparatively, frontline workers and PRIs were more aware.
Yes
No
6
299
38
113
Users
Non-Users
0
59
6
51
Field
Functionaries
PRI
74
Assessment of ERS Performance in Madhya Pradesh
Final Report
S.no
4
Parameter
Awareness of
JEY
5
Awareness of
Emergencies
for which 108
could be
utilizes
6
19
Awareness of
role of
frontline
workers
Responses
 JEY awareness was higher amongst ASHAs and PRI members whereas
awareness amongst users/ non users was lower
- Ashas: More than 85% of the ASHAs in all the three districts were
aware of JEY and were using the service for pregnancy cases,
mostly for drop backs.
- PRIs: Awareness among PRI members was more than 75% both in
Gwalior & Sehore, while in Sagar it was less than 50%.
- Users: In Gwalior & Sagar districts, less than 35% of the users and
less than 25% of the non-users were aware of JEY services due to
its irregular functioning, whereas more than 60% of the users & non-users were aware of the JEY services in
Sehore District.
 As shown in the graph below, normal deliveries and accidents have the largest recall for 108. The graph also indicates
the need for GoMP and EMRI to spread awareness on the usage of 108 for the other medical emergencies.
19
 It was particularly observed that ASHAs and ANMs were informed from official communication channels (mostly
CMHO) of the use of 108 was only for pregnancies, which is only limited information about the service. This could
have had an impact on field awareness.
 More than 80% of the respondents were aware of the role of ASHAs/ AWWs in their village with respect to 108
operations. This included spreading awareness of 108, calling 108 and accompanying patients to the hospital
 However the urban blocks had the highest proportion of respondents who were not aware of any of the roles of
the Frontline workers.
Deloitte conducted a brief comparison cases handled by 108 and Janani Express Yojana (JEY) in Sagar District. Refer to annexure 8.10
75
Assessment of ERS Performance in Madhya Pradesh
Final Report
(B)
S.no
7
Parameter
Refusal of 108
services
Call Experience and Ambulance Reach time
Responses
 91% of total users interviewed responded that they were never refused 108 services.
 Where refused, reasons were:


Engagement of vehicle in another emergency. However, in all such cases the respondents informed that they were
told the approximate time the vehicle would take to complete the engagement and reach that location, and hence
asked to wait if possible.
Unavailability due to jam or breakdown of vehicle
8
Mobile network
connectivity
 In 82% of the cases, callers reported not having issues with regards to mobile network connectivity while calling 108.
 The 18% calls with network issues could be a cause for the no-response and silent calls reported at the ERC
 Mobile network problems were more common in urban blocks because of network congestion than in rural blocks.
9
Call response
 76% of calls answered in the 1st attempt, indicating the efficiency of the Sense function of
EMRI.
 24% of calls being responded beyond 1 attempt could correspond to the call center’s unanswered
calls (UAC) during their first attempt.
10
Ambulance
reach time
No. of attempts
1 attempt
2 attempts
3 attempts
4 attempts
% calls
76%
16%
7%
1%
 In over 90% cases across districts, ambulances reached as per expectations of
respondents
 96% of the callers/ users reported being told of an indicative time.
 In most cases, ambulances reach between 10-20 mins.
 Reason for late arrival of ambulance is often cited as engagement at another emergency
76
Assessment of ERS Performance in Madhya Pradesh
Final Report
(C)
S.no
11
Parameter
Availability of
Medical
equipment in
ambulances
Perception of Quality of care20
Responses
 Most users and attendants identified key equipment and infrastructure
available in the ambulances, including stretchers, first aid kits, oxygen
cylinders etc.
13
261
243
27
21
Others
Does not
Know
*Respondents were probed only for equipment that are easily visible and not equipment
such as BP instruments, suction machines etc. that may be either difficult for the users to
identify.
12
311
Stretcher
First Aid
Oxygen
cylinders
Attendants
accompanying
patients
Presence of
EMT in
ambulance
 No cases have been reported where attendants were not allowed to travel with the patient to the facility
 On an average 2-3 attendants per patient have been allowed by the ambulance staff
Physical
examination
/Investigation of
patients
Physical
examination/
Investigation
conducted in
various cases
 62% of total respondents reported receiving some medical attention/examination in the ambulance.
 8% of respondents were not aware or could not comment on the medical attention they received in the ambulance.
 In 98% cases, attendants/ callers/ users were aware of the presence of the EMT in the ambulance.
 Only 2% of respondents in Gwalior and Sehore each reported that they were not aware of the EMT’s presence.
 Possible reasons for users/ attendants not knowing about the presence of the EMT was be due to the fact that the EMTs did not
get off the vehicle to assist the attendants in taking the patients to the ambulance
14
15
*It is important to note that in 35% of pregnancy cases, no care was provided as in most cases, users reported not requiring any care as the
ambulance was called for transportation of a normal delivery.
 In pregnancy related cases: Users reported the following care provided
- 47% : Usage of BP machine
- 46% : Usage of Stethoscope
- 34% : Physical Examination
- 27% : Enquiry of obstetric history
 Vehicular Trauma cases : Users reported the following care provided
- 39% : Application of tourniquet / pressure
- 24% : Usage of injection of IV drip
- 22% : Usage of BP machine
- 20% : Usage of stethoscope
- 18% : provision of oxygen mask
 Non-Vehicular Trauma cases 21– Users reported the following care provided
- 73% : Usage of stethoscope
- 71% : Usage of BP machine
20
As discussed with the MPTAST team, an attempt was made by the evaluation team to estimate the user’s perception of quality of care. However, the limitation is that the user is
mostly unaware of both the equipment available and the care being provided. Thus this section is only indicative of quality of care as perceived by the user.
21
Includes fall from the roof, consumption of poison, burn etc.
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Assessment of ERS Performance in Madhya Pradesh
Final Report
(C)
S.no
Parameter
Perception of Quality of care20
Responses
-
16
EMT Behaviour
17
Choice of health
facility
18
Handover at
facility
 78% of the respondents have indicated that the EMTs were empathetic and helpful. They handled the cases well, and were
patient in understanding the complaint of the user. EMTs would escort the users from the site of emergency to the vehicle and
ensure their comfort in the ambulance before proceeding towards the hospital.
 The major complains of users not satisfied with EMT behavior included not helping attendant bringing the patients to the
ambulance.
Type of Hospital
 Over 95% of the respondents were taken to government facilities (usually the closest CHC) in emergency cases.
 The other 5% were mostly taken hospitals located in the District Headquarters or Bhopal (in case of Sehore).
Choice of Hospital
 Across districts, 94% of the respondents were satisfied with the choice of health facility.
 Across blocks, in around 60% of the cases, the facility the patient was to be taken to was decided by the user/ attendant.
 In most cases where the EMT/ Pilots decided the facility, it was understood to be the closest CHC in the area and the respondents
concurred with this decision. In the cases that weren’t satisfied, since the choice of facility for more than 60-70 Kms, EMTS
dropped the cases at the closest CHCs.
 Over 90% of the respondents stated being handed over at the facility in a convenient manner.
Payment for
services
provided
In most cases respondents were satisfied with the EMT’s level of empathy and involvement during handover
including transfer to hospital stretcher and waiting upto the completion of admission formalities.
In the rest of the 10% of cases, issues raised included
- EMT did not brief the nurse during handover
- EMT/Pilot did not assist the attendant in hospital admission
98% responded free of charge
2% of interviewees were asked for payment (6-7 cases of ~INR 50) either at the health facility or at the ambulance
These cases were observed in the urban blocks of Gwalior and Sagar
-

19
31% : Administration of oral medicine or IV drip



78
Assessment of ERS Performance in Madhya Pradesh
Final Report
Overall Rating: Demand Side Assessment
5.5
Apart from the above responses, the study also involved capturing respondent rating on the
services utilized for the following parameters:

Call process

Ambulance reach time

Ambulance cleanliness

Care provided

Attitude of staff

Handover at health facility
5.6
The ratings were based on the following scale:
User Rating
Corresponding points awarded22
Very Good
Good
Average
Poor
Very Poor
5.7
5
4
3
2
1
On a scale of five, the overall rating as given by the users for each of the parameters has been
summarized below:
Districts
Gwalior
Sagar
Sehore
Overall

Call
process
Ambulance
reach time
Ambulance
cleanliness
Care
provided
Attitude
of staff
4.13
3.99
4.08
4.07
4.07
3.94
4.01
4.01
4.11
4.07
4.06
4.08
3.91
3.95
3.69
3.85
4.04
4.00
4.02
4.02
Handover at
health
facility
4.03
3.93
3.99
3.98
While the user gave good rating to the call process, ambulance reach times, ambulance
cleanliness, attitude of staff (EROs, EMTs and Pilots), clear areas of improvement include care
provided in the ambulance and the handover support at the health facility. These have also been
reflected in the user response discussed earlier.
22
Response styles of users and attendants varied with respect to the service rating. Responses could be marginally
biased with respondents not differentiating between “Good” and “Very Good”
79
Assessment of ERS Performance in Madhya Pradesh
Final Report
Summary
(A) Awareness of 108 services
 The overall awareness levels of the service and the number-108 are high, mainly due to the onfield impact of the service, resulting in awareness through the informal word-of-mouth channel.
Field workers (mainly ASHAs) and PRIs have also been observed to play the role of information
agents at the village level, counseling villagers to utilize the service in case of emergencies.
However, there is still low awareness with respect to utilization of 108 for medical emergencies,
other than accidents and pregnancies, and police and fire cases

Thus, it is important that GoMP and EMRI target these awareness gaps while designing statelevel communication strategies to increase service utilization. Comprehensive information on the
scope of 108 services should also be provided to village influencers, through formal
communication channels to ensure spread of correct messages in villages.
(B) Call Experience and Ambulance Reach time
 Users have appreciated the round-the-clock availability of call services, simplicity of call process,
attitude of call taking officers and negligent refusal of ambulance requests. In most cases, all
users were completely aware of the process, and often gave the required information even before
being asked, thus reducing the call handle time. In 76% cases, the call was answered in the first
attempt; however the other 24% could correspond to the unattended calls at EMRI’s end which
could be addressed by manning adequate EROs.

The timely arrival of 108 vehicles usually within a short time regardless of the time of the day has
led to user confidence in the service. Further, in cases of delay, the ability of the ERO to
communicate this delay to the caller makes the service quality even more appreciated by the
respondents.
(C) Perception of Quality of Care and Hospital handover
 Provision of care provided by the EMT and availability of equipment in the ambulance was
appreciated by the respondents to be pain relieving/ lifesaving in nature. However, in 22% cases,
respondents expressed concerns on either the support provided by EMTs to transfer patients to the
ambulance or the lack of any enroute care or counseling. This is a concern that would need to be
addressed by EMRI. Given the limited knowledge of the respondents on the care required to be
provided, the sufficiency and effective of pre-hospital care is difficult to estimate.

Patients were satisfied with the choice of health facility, even though in 60% cases, the EMTs
decided for them. However, 10% of the respondents highlighted issues concerning handover at
the facility by the ambulance staff. These may be looked into and the process further streamlined
for better service in this regard.
Overall
 The respondents expressed high reliability and trust on the service, which has been formed due to
consistent timeliness, service quality, and helpful attitude of staff, as can be seen from the ratings
discussed in the previous section.
80
Assessment of ERS Performance in Madhya Pradesh
Final Report
Beneficiaries Speak
“Marij Aspataal jaldi pahuch jaata hai. Turant uska upchar shuru ho jaata hai. Turant pahuchne ke
karan seva jaldi mil jaati hai”
(The patient is quickly taken to the hospital. The treatment is also provided instantaneously. With the
advantage of reaching the health facility timely, the treatment is also provided timely)
- Geeta , GH Birla, Gwalior
“Tatkal aa jati hai (The service is quick). Ab Aspatal jaane mein koi dikkat nahi hoti”
- Pirambal, Sorai, Sagar
“Treatment is given on the way. It comes very fast. They are available 24X7.
Especially in villages where there is no mode of transport, it helps to reach the facility”
- Girdharilal, Sagar Urban
“It is fast and comes on time. At the call center, they don’t disconnect the call. 48 hours after the
emergency, they call to enquire and take feedback on EMT/pilot.”
- Krishna Uika, Bayan, Sehore
“Emergency service takes less time. There is timely treatment. It saves money and time.
It is free for all. There is no distinction among patients”
- Sunil Kumar, Ron, Sagar
“If the vehicle was not there, I wouldn’t be alive.”
-Gyanbai, Chourai, Sagar
“Very happy with the services. Being from a tribal community,
I was glad that someone was there to take me to the doctor without any bias”
-Ramvathi Adhivasi, Girwai, Gwalior Rural
“Patients get care on time. Transportation is quick and money is saved.
Ambulance has requisite facilities”
-Archana Mishra, ASHA, Gwalior
“Achha kaam kar rahe hain. Din ho ya raat, woh kabhi mana nahi karte.”
(They are doing a good job. They never refuse to come, whether day or night)
81
CHAPTER 6
ANALYSIS OF COSTS
82
Analysis of Costs
6.1 This chapter consists of analysis of costs of EMRI 108 operations in Madhya Pradesh over the last
4 years of operations
6.2 The 108 service in Madhya Pradesh has been operational with 102 ambulances till December
2012 in 10 districts. It was further decided to extend the service to the remaining 40 districts in
2013 and accordingly, 352 ambulances were launched between January and May 2013, and
another 150 ambulances are planned to be launched before the end of the year, covering all 50
districts.
6.3 Hence, the current phase of expansion is yet to complete and stabilize in terms of operations. This
kind of an expansion phase is typically characterized by an increase in operational staff, their
trainings and other launch related activities (marketing, IEC, procurement of medical
consumables, etc. for new ambulances), thus resulting in increase in operational expenditures.
6.4 Considering that the above expansion phase is still on-going and operations are yet to stabilize,
our financial/ costing analysis is primarily limited to data upto Dec’12, although we have also
attempted to compare data for operational costs for the period Jan-June 2013 against financial
estimates proposed under Schedule A of the revised MoU (under Section II, below).
6.5 Broadly, the analysis has been divided into two sections:
SECTION I : Analysis of Operational Costs - Year-wise trends of key cost indicators and
select expense heads
SECTION II : Comparison of operational expenses per ambulance per month for the periods
Apr – Dec 2012 and Jan – Jun 2013 with the limits provided in Schedule A of the
current MoU.
SECTION I - ANALYSIS OF OPERATIONAL COSTS
Basis of Costing
6.6 Costs incurred by GVK EMRI for the 108 operations since its launch in July 2009 upto
December 2012 were collated and analyzed. The following table details the key cost components
on which data from EMRI was collected.
Exhibit 6.1 : Components of Costing Analysis
Ambulance Running and Maintenance related expenses
 Covers fuel, tyre replacement, vehicle repair, maintenance and insurance, equipment repair and
maintenance, and drugs & consumables
Human Resource related expenses
 Covers salary of line and support staff including basic salary, HRA, PF, mobile reimbursement and
other employee benefits, and training
Communication and Tech Support related expenses
 Covers telephone expenses including landline and mobile of the call center and ambulances, internet,
equipment maintenance including AMCs and other hardware and software tech support
Administration related expenses
 Covers Office maintenance expenses such as rent, electricity, housekeeping, courier to ambulances
etc., staff related expenses such as staff travel, motivation events, uniforms etc. and other admin
expenses related to auditing, recruitment, tendering etc.
Marketing related expenses
 Covers marketing including content creation and state and field level implementation of media and
IEC activities
Note : Annexure 8.11 provides the details of data provided by EMRI
83
Analysis of Key Cost Indicators
6.7 Key cost indicators were calculated to analyze year wise trends and enable comparison of
EMRI’s performance in MP with other mature EMRI states such as Andhra Pradesh, Assam,
Rajasthan. The indicators covered for this analysis include:
 Operational expenses (Opex) per ambulance per month
 Operational expenses (Opex) per emergency handled
 Operational expenses (Opex) per km travelled
Exhibit 6.2 : Performance of key Cost Indicators
(Amounts in INR)
Parameters
2009-2010
2010-2011
2011-2012
Apr to Dec 2012
No. of operational months
9
12
12
9
No. of ambulances*
48
69
97
102
Average Kms per trip
17
36
38
40
No. of emergencies handled
50,599
116,048
148,467
114,857
Total Operational Expenses#
572 Lakhs
1,063 Lakhs
1,261 Lakhs
1,001 Lakhs
Key Costing Indicators
Operational expenses per
132,478
128,448
108,347
109,084
ambulance per month
Operational expenses per
1131
916
849
872
emergency handled
Operational expenses per km
65.53
25.81
22.47
21.80
travelled
Source
: Based on data provided by EMRI.
*
Weighted Average of month-wise operational ambulances has been considered, since the number of
operational ambulances varied on month-on-month basis due to phased launch of ambulances, (Details of
calculation provided in Annexure 8.12)
#
See Annexure 8.13 for detailed head wise breakup of operational expenses
Key Observations
 Opex per ambulance per month: There is an overall declining trend - Operational expenses per
ambulance per month have decreased from INR1,32,478 (launch) to INR 109,084 (December
2012), indicating that GVK has been able to manage the operational costs effectively with
stabilization of operations over the years.
 A comparison of the above indicator with AP model (the first state with 108 services) also suggests
that the MP model is in line with the costs achieved in AP after the first 3 years of operations (INR
1.09 Lakhs in MP in comparison to INR 1.05 Lakhs in AP). This is despite significantly lesser
number of operational ambulances in MP as compared to AP, and without considering the impact of
inflation between the two reference periods.
Exhibit 6.3 : Comparison of Opex / Amby / Month between MP and AP
at the end of 3 years of operations
Indicators
Launch Month
No. of ambulances at the end of 3 years
Kms per trip
Opex per ambulance per month
Andhra Pradesh*
April 2005
652
29
INR 1.05 Lakhs
*Source: “Study of ERS – EMRI model” : National
Madhya Pradesh
July 2009
102
40
INR 1.09 Lakhs
(FY 2007-08)
(Apr – Dec 2012)
Health Systems Resource Centre (NHSRC, 2009)
84
 Opex per Emergency handled : In MP, the Opex per emergency handled has also been decreasing
from INR 1,131 in 2009-10 to INR 872 in 2012. While this reflects improvement in operational costs
per emergency by 23% over three years, the cost per emergency handled in AP (after 3 years of
operations) was significantly lower i.e. INR 56523 in 2008, as reflected in NHSRC study. However, it is
important to note that the total number of emergencies handled per day in AP during the study period
was approximately 350023, while the average number of cases handled per day in MP during the period
Apr – Dec 2012 was only ~ 400 per day. Also since the number of ambulances was significantly higher
in AP, the fixed costs of the services are apportioned over more ambulances and thus emergencies.
Also, the higher Kms per trip in MP (as compared to AP) could also have an impact on this ratio. Given
the expansion of 108 service into 40 new districts in MP with 502 new ambulances, this ratio is
expected to reduce further.
 Opex per Km travelled : The Opex per Km travelled in MP has decreased from INR 65.5 in 2009-10
to INR 21.8, including a major expected drop in the 1st year due to increase in the cases covered and
kms per emergency handled. This is comparable to cost per km across EMRI operations in states such
as Assam and Rajasthan which recorded Opex per Km travelled of INR 2524 and INR 22 respectively
after around 3 years of operations.
Analysis of Select Expense heads
6.8 The following exhibit highlights trend of the key expense heads over past three years and relevant
ratios.
Exhibit 6.4 : Select expense heads and Relevant Ratios
(Amounts in INR)
Financial Year
No. of operational
months
No. of ambulances*
No. of emergencies
handled
Average Kms per
emergency
Salaries
Ambulance repair,
maintenance and
Refurbishment
Fuel Cost of
ambulance
09-10
10-11
Analysis
Ratio
11-12
Analysis
Ratio
Apr-12 to
Dec-12
9
12
12
9
48
69
97
102
50,599
116,048
148,467
114,857
17
36
38
40
29,565,936
880,510
5,962,079
Medical
consumables
2,201,048
Communication
expenses
2,303,201
Administration and
Travelling
9,207,215
Training
Analysis
Ratio
2,461,774
68,439
Per amby
per month
2,038
Per amby
per month
117.8
Per
Emergency
handled
43
Per
Emergency
handled
46
Per
Emergency
handled
21,313
Per amby
per month
5,698
57,080,117
3,527,578
17,270,747
4,443,428
3,232,531
15,546,029
2,463,078
Per amby
per month
68,937
Per amby
per month
4,260
Per amby
per month
148.8
Per
Emergency
handled
38
Per
Emergency
handled
28
Per
Emergency
handled
18,775
Per amby
per month
2,975
Per amby
per month
71,817,566
4,886,225
21,229,723
3,718,297
2,368,533
12,735,041
3,993,947
61,698
Per amby
per month
4,198
Per amby
per month
143.0
Per
Emergency
handled
25
Per
Emergency
handled
16
Per
Emergency
handled
10,941
Per amby
per month
3,431
Per amby
per month
56,468,057
5,697,555
15,184,944
2,887,343
1,667,034
10,661,811
3,143,267
Analysis
Ratio
61,512
Per amby
per month
6,206
Per amby
per month
132.2
Per
Emergency
handled
25
Per
Emergency
handled
15
Per
Emergency
handled
11,614
Per amby
per month
3,424
Per amby
per month
*Weighted Average as detailed in Exhibit 6.2
23
24
“Study of ERS – EMRI model” conducted by National Health Systems Resource Centre (NHSRC, 2009)
“Publicly Financed Emergency Response and Patient Transport Systems under NRHM” - conducted by
National Health Systems Resource Centre (NHSRC, 2012)
85
 Salaries: Although, overall salary costs have increased (in absolute terms) over the period considering
expansion of services, cost of salaries per ambulance per month has decreased from INR 68,439 in
2009-10 to INR 61,512 in 2012 (i.e. ~10% decrease). Most of this decrease could be attributed to the
fact that as the number of operational ambulances increase, while ambulance staff increases
accordingly, the no. of support staff (non-ambulance staff25) does not increase proportionally.
 Ambulance repair and maintenance: The repair, maintenance and refurbishment expenses per
ambulance per month have increased significantly from INR 2,038 in 2009-10 to INR 6,206 in
2012. This could be attributed to the aging of ambulances. Since the ambulances are already in the
4th year of operations, a significant number26 of ambulances had to go through the recommended
vehicle refurbishment procedure, usually involving a complete overhaul of the engine, interiors,
brake systems and other important vehicle components. This cost is expected to be high for the
older ambulances over the next few years as the maintenance cost would continue to increase in
order to attain fuel efficiency and maintain vehicle condition despite their aging.
 Fuel: The fuel cost per emergency handled for the year 2010-11 shows an increase in comparison
to 2009-10, which could be attributed to the significant increase in distance travelled per
emergency during this period. While the distance travelled per emergency has further increased in
subsequent years, fuel costs per emergency handled have come down indicating implementation
of efficiency measures undertaken by EMRI with respect to optimum utilization of vehicles and
well-monitored refueling processes.
 Medical Consumables: The cost of drugs per emergency handled has been consistently
decreasing. This has been achieved by focusing on procurement efficiencies, optimum indenting
of drugs and strict monitoring by field managers and the quality team.
 Communication: Similarly, there has been a substantial decrease in the cost of communication
per emergency handled. As shared by EMRI, this could be achieved due to periodic (almost biannual) negotiations with telecom providers on optimum call plans based on detailed analysis of
provider wise composition of calls made and received at the call center and the ambulances. Also
constant attempts are made to ensure an optimum mix of telecom providers for PRI lines (Primary
rate Interfaces, which provide multiple call lines for the call center) to reduce overall
communication expenses.
 Administration: The administration expenses per ambulance per month have been decreasing
with a marginal increase in the period April - December 2012. These expenses cover:
 office maintenance expenses - including rent, housekeeping, courier to
ambulances, diesel for power back up, security, electricity etc.
 staff related expenses - including travel of field staff & support staff, staff
motivation events and uniforms
 other expenses - including auditing, tendering, recruitment etc.
As shown later in Exhibit 6.5, administration expenses currently account for ~8.5% of overall
operational expenses and this share is expected to reduce post the launch of new ambulances as
the fixed costs would be apportioned across all new ambulances.
 Training: The training costs for 2009-10 have been observed to be the highest owing to related
EMT and pilot preparatory training programs required to be undertaken for new ambulance
launches. The costs have stabilized in 2011-2 and 2012 post a slight increase in comparison to
2010-11, owing to fixed number of refresher trainings being conducted annually. However as
discussed in Section 3.1, the current level of refresher trainings being conducted is insufficient,
and this cost is expected to increase in case more robust classroom and on-field refresher trainings
are undertaken.
25
Salaries of non-ambulance staff usually account for 30%. This is based on salary breakup data provided by EMRI.
However an analysis of the actual trend could not be carried out due to non-availability of data for the rest of the years
26
Exact number of ambulances not available with EMRI
86
SECTION II – PERFORMANCE IN COMPARISON TO MOU ESTIMATES
Analysis and Findings
6.9 The following section compares the overall and head wise Opex per ambulance per month for the
periods Apr – Dec 2012 and Jan – Jun 2013 with the estimates provided in Schedule A of the
current MoU in MP.
6.10 However, it is recognized that since the new 502 ambulances (planned to be launched for 2013)
are not yet fully operational, this comparison only indicates how the current costs are comparable
to the future estimates decided and identify indicative key areas where costs could be considered
for reduction to achieve the targets. This exercise would be more meaningful once all 604
ambulances are launched and have stable operations.
6.11 The following exhibit provides the details of the cost components covered in the MOU format.
Exhibit 6.5 : Comparison of Opex per Ambulance per month
S.No
Item
No. of Ambulances
Ambulance Running and
Maintenance
Fuel Cost of
1
ambulance
2
Tyre Expenses
Ambulance repair,
3
maintenance and
Refurbishment
4
Vehicle insurance
5
Medical consumables
Salary
6
HR Expenses
General office
/Administrative Expenses
Communication
7
expenses
IT/Equipment
8
maintenance and Tech
support
Administration
9
Expenses and
Travelling
Recruitment Expenses
10
Training
Target for 2013-14 as per
MOU
Opex per
amby per
%
month (in INR
lakhs)
604
(As per the MoU)
Expenses for Apr-Dec
2012
Opex per
amby per
%
month (in
INR lakhs)
102
Expenses for Jan-June
2013
Opex per
amby per
%
month (in
INR lakhs)
328
(As detailed in Annexure
8.12)
(6 monthly average as shown in
Annexure 8.12)
0.227
23.20%
0.165
15.16%
0.158
18.19%
0.020
2.00%
0.019
1.78%
0.010
1.16%
0.028
2.90%
0.066
6.07%
0.031
3.57%
0.005
0.028
0.50%
2.90%
0.006
0.031
0.58%
2.88%
0.003
0.028
0.30%
3.17%
0.575
58.90%
0.615
56.39%
0.398
45.73%
0.016
1.60%
0.018
1.66%
0.009
1.00%
0.007
0.70%
0.016
1.42%
0.001
0.11%
0.039
3.90%
0.116
10.65%
0.074
8.50%
0.028
2.90%
0.034
3.14%
0.156
17.95%
0.004
0.40%
0.003
0.26%
0.003
0.32%
Marketing Expenses
11
IEC
Total (In Lakhs)
0.977
1.091
0.871
87
Key Observations
 Overall opex per ambulance per month – The overall opex per ambulance per month for the
period Apr-Dec 2012 (INR 1,09,100) was much higher than the target indicated in the MoU (INR
(97,700), however the same has improved in the period January to June 2013 (INR 87,081) with
454 ambulances launched in a phased manner. However, it is important to note that the new
ambulances launched are not yet fully operational and additional costs may be incurred during the
year once the operations of the expanded fleet stabilize and handle more emergencies.
Scope of Cost reduction
 Based on comparison of the individual cost heads against the MOU estimate27s, the following
expense heads are the potential areas of costs reduction :
 Ambulance repair, maintenance and Refurbishment,
 Medical consumables
 Administration Expenses and Travelling
While training also appears high this is due to the preparatory training programs for EMTs and
Pilots required to be conducted for all new 502 ambulances.
However, increase across these variables could be influenced by the flux in operations due to the
current expansion phase of the service. These ratios are expected to change once operations of all
604 ambulances stabilize.
 Based on analysis of 108 call data (as discussed in Section 2.1), ineffective calls constitute
approximately 95% of the total attended calls, which is very high. These calls could be due to
various reasons such as network, manpower and awareness related factors, etc. and have adverse
cost implications in terms of ineffective manpower and infrastructure utilisation. Hence, it
is important to address the high % of ineffective calls (especially awareness related, which
constitute around 35% - 40% of total calls) to reduce “Sense” related manpower & infrastructural
costs.
Conclusion
6.12 In conclusion, the key costing indicators related to 108 operations in MP have shown decreasing
trend and are largely comparable with the performance of the 108 service across other
operationally mature states of EMRI. An analysis of year wise trends of select expense heads
shows an overall decreasing trend especially across salaries, fuel, medical consumables,
communication and administration, indicating steps taken by the organization towards bringing
in cost efficiencies through improved operational and monitoring processes.
6.13 A quick analysis of the current operational costs for the period April-Dec 12 and Jan-Jun 2013
with respect to the cost estimates provided in the current MoU indicates that current costs are in
line with the targets, however, administration, medical consumables and repairs and maintenance
are the potential areas of cost reduction as the expansion phase stabilizes. Also, addressing the
high % of ineffective calls would help in reducing “Sense” related manpower costs28
significantly.
27
As a % share of the estimates of total operational expenses
Since the study was limited to Dec 2012, analysis of current sufficiency of manpower and thus exact scope of reduction is
not covered – NOT REQUIRED HERE
28
88
CHAPTER 7
SUMMARY OF OBSERVATIONS
AND
RECOMMENDATION
89
Assessment of ERS Performance in Madhya Pradesh
Final Report
SUMMARY OF KEY OBSERVATIONS
7.1 Provision of 108 services is an important step taken by GoMP towards addressing the
critical issue of timely accessibility to quality care in the state. As noted in the first
Common Review Mission of the NRHM, the EMRI partnership is one of the most
successful public private partnerships (PPP) of the country. In MP, this service has been
operational for over 3 years providing integrated emergency services.
7.2 Overall, the evaluation shows that the service meets its objectives of providing 24*7 quality and
timely pre-hospital care, evidenced by the high levels of satisfaction amongst users, field
functionaries and health care service providers.
Strengths and Weaknesses
7.3 The following section summarizes key strengths and areas of improvement of the current operations
of the 108 service.
Key Strengths
7.4 The exhibit below summarizes the critical success factors of the model
Exhibit 5.1: Strengths of EMRI

Efficiently functioning 108 Emergency Response Center, with clearly defined call
handling SOPs and adequate infrastructure

Well-equipped ambulances and good vehicle maintenance, owing to strong vendor tie-ups
and a comprehensive vehicle performance tracking mechanism.

Adequate population coverage, at 100,000 population per ambulance, on completion of
launch of 602 ambulances, which is in concurrence with WHO norms.29
29
Recent international norms suggest that there should be one ambulance for every 50,000 population
“ Ambulance Response Time in Developing Emergency Healthcare Systems” – Jochen Schmidt
90
Assessment of ERS Performance in Madhya Pradesh
Final Report

Provision of SOP based pre-hospital care, by trained medical technicians with online
medical support from ERCPs. As evaluated by MOs of government hospitals, relevant
enroute care provided by the EMTs.

Implementation of customer friendly processes, such as 48 hour patient follow-up and
vehicle busy desk.

Skilled and motivated staff at both the state and field levels

ISO 9001:2008 certified Quality Management System, consisting of detailed operational
and monitoring processes.

Decreasing trends of operating costs comparable with the performance of the 108 service
across other operationally mature states of EMRI, enabled by organization level strategies
aimed at improving operational and monitoring processes30.
Areas of improvement
7.5 The following are the identified areas of improvement:
Awareness related

Low awareness on service utilization for medical emergencies, other than pregnancies and
accidents due to inadequate IEC/BCC activities

Ambiguity on roles and responsibilities amongst GoMP and EMRI with respect to
IEC/BCC activities

Unclear strategy on the role of 108 service in handling police and fire emergencies leading
to inadequate awareness on the same
Operations related

High % of ineffective calls leading to ineffective utilisation of ERC resources

Gaps in technical knowledge of EMTs

Insufficient demand assessment practices in respect of drugs and consumables

Lack of clarity in respect of HR/ Administration processes among field staff

Weak Hospital Tie ups
Monitoring related

Inadequate monitoring of operations including key service parameters, adherence to MoU
clauses, financial parameters, and procurement processes etc. by GoMP.

Inadequate monitoring of support function processes and closure of non-compliances from
ambulance audits
Cost related

Potential cost reduction in the areas of administration, medical consumables and repairs
and maintenance as the expansion phase stabilizes.
30
Since the new 502 ambulances are not yet fully operational, the analysis covered in the study only shows the changing trend of
the expenses and does not reflect the true performance of the service with respect to the MoU estimates. It is therefore
recommended that a detailed costing analysis be done 6 months after stabilization of operations all 604 ambulances to clearly
identify areas of cost reduction
91
Assessment of ERS Performance in Madhya Pradesh
Final Report
RECOMMENDATIONS
7.6 This section outlines key recommendations to improve operational efficiency and service utilization.
These are based on our analysis of issues as presented in the previous chapters.
1
Comprehensive IEC/BCC to increase awareness of all elements of the service
Context:
Awareness levels for utilization of 108 services for medical emergencies other than accidents and
normal pregnancies are still low. The primary reason for this is lack of adequate on-field
IEC/BCC activities targeting certain gaps. Due to its limited budgets, the only planned activity
undertaken by EMRI is village demos, which is inadequate to bring about required behaviour
change.
Given that the responsibility to promote public awareness lies with GoMP, it is important for
both EMRI and GoMP to develop plans together to address awareness gaps.
Recommendation:
Clarity on the responsibility of IEC/BCC activities
 Till December 2012, EMRI was responsible for handling all IEC/BCC activities for the
ERS in the 10 districts where services were operational. However as per the renewed
MoU, the responsibility to promote public awareness in emergency response lies with
GoMP, in consultation with GVK EMRI, which has been given limited annual budgets.
 It is important for the Executive Committee to decide and agree upon the way forward for
required IEC activities. For example, in the case of ineffective calls while the targets for
achieving lower ineffective calls have been given to EMRI, since the responsibility to
spread awareness lies with GoMP, the way forward is not clear.
Development of Joint Communication Plans and regular monitoring:
 It is recommended that the current arrangement continues with extra budgets to be
allocated to EMRI based on the planned communication strategy.
 EMRI should develop long and short term communication plans for IEC/BCC activities
in the state, detailing geographical focus, focus areas, media tools, expected outputs,
planned timelines and required budgets based on in-depth periodic analyses done on
trends of ineffective calls. These plans should be reviewed by GoMP and budgets should
be approved accordingly.
 Regular review to ensure adherence and course correction (if required) should be
conducted through executive committee meetings.
 GoMP should also provide support in coordinating with other Govt departments or
bureaus such as Police department, IEC bureau etc., wherever required.
Information dissemination to Influencers:
 It has been observed that village influencers, including PRI members and field
functionaries, play an important role in spreading awareness and impacting service
utilization. It is thus important to improve awareness of this group. To initiate the
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Assessment of ERS Performance in Madhya Pradesh
Final Report
process, it is advisable that GoMP state officials instruct district administrations to issue
formal communications to all field functionaries, covering required focus areas for
including kinds of services available under 108, policy on choice of hospital, difference
between JEY and 108 etc.
2
Clarity on the objective of 108 service – Integrated or Medical?
Context:
As observed in the beneficiary feedback and ERC information, awareness levels of usage of 108
service for police and fire cases is very low. It is primarily perceived as a health initiative. This
problem is further compounded by the fact that forums such as the executive and district
committees, which are meant to be joint forums to develop joint strategies, are inactive, thus
continuing to emphasize the health focus of the service.
Recommendation:
 It is important for GoMP to decide the strategic purpose of the service – Integrated or
primarily medical with police support.
- Integrated: If the understanding is that it is an integrated service, then the
executive committee meetings should play an important role and should be
forums for deciding joint strategies between the health, police and fire
departments. Also the responsibility to spread awareness of using the number for
police and fire should be jointly owned by the respective departments.
- Primarily medical with police support: If the decision is that it would be
primarily a medical service with police support, then the current arrangement
would continue, however the executive committee meetings should be
regularized in order to periodically seek required support from police and fire
departments on particular issues faced by the service.
3
Addressing ineffective calls through increased data analysis and targeted BCC
activities
Context:
Ineffective calls constitute approximately 95% of total attended calls. An analysis of call handle
time for the period July-Dec 2012 indicates that approximately 40% of ERO time is spent in
handling these ineffective calls. This has cost implications in terms of ineffective manpower and
infrastructure utilisation. It is thus important to address ineffective calls, given its cost
implications through appropriate targeted field-level BCC activities.
Recommendation:
In addition to the above detailed IEC/BCC activities, the following are some specific activities
that could be implemented to address ineffective calls.
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Assessment of ERS Performance in Madhya Pradesh
Final Report
Re-categorization of Ineffective calls
 Deloitte’s study shows that almost 48% of ineffective calls are wrongly categorized,
leading to incorrect identification of underlying causes. EMRI should evaluate
consolidation of certain call categories (such as merging no-response and silent calls, and
general enquiry and wrong calls) and training EROs specifically for increasing their
understanding of the various categories to address this issue.
Analysis of trends and best practices of other states:
 In order to develop effective strategies, EMRI should study the trends of ineffective calls
in other matured states in terms of operations and set benchmarks/ targets for reduction of
ineffective calls in MP. Any successful and cost-effective practices implemented in other
states should also be identified that could be implemented in MP. It is suggested that the
analysis be conducted across all operational states of EMRI. The states could be
categorized on the number of operational years, to take into account the effect of
stabilized operations on ineffective calls into the following categories are: 0-2 yrs., 2-4
yrs. and > 4yrs.
Implementation of Targeted Demos:
 The marketing team should develop demos specifically targeted on ineffective calls
including relevant collaterals and role play story boards for the ambulance staff. These
would help the ambulance staff spread awareness to the target population clearly
focussed on the ineffective calls.
Increased role of GoMP officials and functionaries in prevention of ineffective calls:
 During launch conferences and other district level communications, senior officials from
GoMP, including the Chief Minster, Health Minister, officials from DoHFW and police
department (state and district) may also insist on the importance of the ‘108’ number and
the consequences of misusing the same.
 Exemplary actions should be taken by the state police, based on monthly reports
submitted by EMRI, on repeated nuisance callers, which may be followed by print
articles on the same.
4
Formal institutionalization of state and district level committees defined in the MoU
Context:
The state and district level institutional structures defined in the MoU to monitor EMRI’s
strategic and implementation plans have not yet been formed. These committees would be
important to strengthen service monitoring by GoMP and address key strategic and operational
issues such as:
Strategic
- Ambiguity on roles and responsibilities with respect to IEC/BCC activities
- Role of 108 in handling police and fire emergencies
Operational
- Lack of data transparency with respect to 108 operations
- Non-adherence to agreed service parameters
- Absence of required communication plans
- Facility handover problems faced by 108 ambulances at the district level
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Assessment of ERS Performance in Madhya Pradesh
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Recommendation:
Regularizing Executive Committee meetings:
 The first step towards strengthening institutional structures is to establish the executive
committee. Subsequently, the quarterly EC meetings should develop into active forums
for monitoring EMRI performance.
 It is recommended that the meeting should involve presentations by EMRI on the
quarter’s operational and financial performance, followed by detailed discussions
between GoMP and EMRI on issues, progress and way forward.
 The following matters could be covered in the EC meetings:
- Review of joint communication plans covering implementation strategies,
timelines, required budgets etc.
- Review of Performance (with updations, if any) w.r.t. service parameters and
plans to address gaps
- Financial performance with reference to the MoU
- Implementation status of additional MoU requirements such as,
 EMRI : population based feedback, dynamic website, AVLTs
 GoMP : Pre-Arrival Instructions
- EMRI’s internal audit findings as mandated by ISO 9001:2008, with a focus on
non-compliances and process changes, if any.
Regularizing District Committee Meetings:
 Awareness needs to be enhanced amongst district level functionaries on the clauses of the
MoU and their role in monitoring local operations 108 services. Following action need to
be taken at the state level in this regard:
- Developing and circulating guidelines on the role of district administration in
monitoring EMRI operations
- Collecting bi-annual updates from District committees on the status of 108
operations in the district
5
Amendments to existing service parameters
Based on a detailed analysis of the service parameters, both on-going-target and milestone based,
modifications to some of the parameters have been suggested in order to improve the objectivity
of the parameters. As discussed in table 4.3, the following are the parameters for which changes
are being suggest either in terms of redefining the measure or an explanation for the current
parameter or a new measure
S.No
Service
Parameter
Current
Threshold
Category
Reason for Change, if
any
Possible change
: EMRI has achieved this
milestone with the launch
of 352 new ambulances
For the next year this
parameter could be changed
to include district wise
population per ambulance.
Existing
1.
Geographic
coverage of the
district with
EMRI services
100%
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Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
Service
Parameter
District wise
vehicle busy
calls
2.
Current
Threshold
Not more
than 7.5%
Category
Reason for Change, if
any
: Target to continue.
However the denominator
for calculating the ratio is
unclear. Suggested to be
defined as No. of vehicle
busy cases / Total no. of
medical
dispatches
Possible change
: This target could start with
7.5% for the first year and
then reduced to 5% for the
next year.
(Value for Jan - Jul 2012
ranging from 14% to
18%).
Address
ineffective calls
3.
Introduce
Quality
Management
indicators for
skills and
equipment
4.
Reduce by
15%
: Target period not clear.
: Unclear parameter. Does
not give any activity based
target.
100%
:This would require the
Executive Committee to
define Quality
Management indicators
and approve their targets
:Target period should be
clearly specified
: As discussed in the Sense
section earlier, ineffective
calls should be reduced to
50% over next 2 years from
the current level i.e. 95%31 .
However, this target should
be finalized based on
analysis of trends of
ineffective calls across more
mature states such as AP
and Gujarat.
Could be changed to " Biannual sharing of internal
audit findings of all
processes and adherence of
performance to approved
skill and equipment quality
indicators"
New
5.
31
Monthly average
of % Unattended
Calls should not
be more than
1.5%
: This parameter evaluates
the effectiveness of the
call center in ensuring that
almost all EM Calls are
picked and attended to.
(As per data submitted by
EMRI for all months till
Dec 2012, this % has
never crossed 1.2%)
Target Value could be 1.5%
for the first year. Once
services in new districts
stabilize, target could be
revised to 1%
As of Jul-Dec 2012 data provided by EMRI
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Assessment of ERS Performance in Madhya Pradesh
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Note:

are milestone based parameters, which are dependent on achievement of a particular
milestone. These parameters would have to be constantly reviewed and updated based on the
dynamic operational plans of the service
are Ongoing target based parameters, which are based on operational targets of performance
indicators. While the parameters would be applicable for consecutive years, targets would need to
constantly update based on achievement levels of EMRI.

6
Strengthening monitoring of EMRI’s procurement processes
Context:
As discussed in section 3.3, the procurement processes at EMRI, both operational and
monitoring, were found to be reasonably satisfactory. However, the level of GoMP monitoring
appeared inadequate, given the high quantum of annual procurement. Also from discussions, no
clear documented approval of the current process was observed. Hence the following
recommendations are made to ensure that there is an inbuilt monitoring system in place for
GoMP.
Recommendation:
Formal approval of EMRI’s current procurement process – state and national:
 It is recommended that GoMP formally reviews, suggests modifications and approves
current procurement processes followed by EMRI currently for national tenders and state
procurement. This will ensure that for all future procurement done by EMRI, the
processes followed are in concurrence with GoMP’s requirements.
Analysis of GVK-EMRI’s national benchmarks by GoMP:

Since GVK EMRI is operational in over 12 states, almost similar items would be
procured in other states as well. As a practice for procurement of any high value or
quantity item, it could be a best practice for GVK EMRI to submit and discuss with
GoMP the current national benchmarks with respect to its price. Once the final price in
MP is fixed, variations from these national benchmarks should be documented as part of
the procurement process. This will assist GoMP in tracking national standards and prices
in a structured manner.
However, it may not be possible to consistently ensure that the final prices are below the
submitted national a number of parameters affect price such as number of bidders, level
of bidders – national vs. state, location of delivery, scale of operations etc. As discussed,
variations should be documented.
7
Strengthening on-going trainings for EMTs
Context:
While EMTs were conversant with emergency SOPs for cases previously handled by them on
ERCP advice, they were weak in other cases that were required to be known theoretically to
prepare them for all medical emergencies. Discussions with EMTs and the state-level care team
highlighted the fact that refresher training programs were not being conducted regularly.
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Assessment of ERS Performance in Madhya Pradesh
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Recommendation:
Regularize refresher programs for EMTs:
 The Care team needs to regularize the current refresher modules by developing an annual
training calendar detailing trainee names and dates of training. This would also help field
operations and HR teams plan for manpower rostering in advance.
As visualized by the Care team, the refresher could be conducted annually once for older
EMTs and bi-annually once for the EMTs trained in the shortened preparatory training
program.
Inputs to training programs:
 Key gaps operational / knowledge gaps should be identified based on findings from the
following sources and should be incorporated into the existing training program:
- Regularize current adhoc process of EMT evaluation based on patient
care records of critical cases, by defining a minimum number of PCR
evaluations to be done per EMT.
- Structured evaluation of new EMTs by Mentor EMTs
- Comprehensive evaluation of the new EMT program, to be conducted by
EMRI
Extended on-field training through network hospitals:
 The current preparatory program requires EMTs to undergo training in emergency
rooms(ER) of large hospitals. This could be replicated on an ongoing basis by developing
a quarterly or bi-annual schedule for each EMT to train in the ERs of EMRI’s network
hospitals of the district in consultation with the care team.
8
Strengthen hospital tie-ups:
Shift from hospital information management to Hospital Relationship management
Context:
EMRI has a process to capture details of services, specialties, resources and infrastructure
available across health facilities in each of the districts through surveys conducted by their
district EMEs. Currently this information is only used for assigning handled emergencies to
respective hospitals as part of their database. These established tie-ups and information are not
used by EMRI to address any of their field requirements such as case-based selection of
hospitals, on-field trainings etc.
Recommendation:
Regularize refresher programs for EMTs:
The Care team needs to regularize the current refresher modules by developing an annual
training calendar detailing trainee names and dates of training. This would also help
Provision of consolidated hospital information list should be made available to the ambulance
staff. In cases of a critical emergencies, this list would enable the ambulance staff take the patient
to the nearest appropriate health facility.
EMEs to report types of cases and no. of cases reported in the health facility.
 It is suggested that EMEs share the no, of emergencies accepted by each of the partner
hospitals with the district committee. This could also help in discussion hospital wise
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Assessment of ERS Performance in Madhya Pradesh
Final Report
feedback with the district administration in terms of ease of handover, availability of
infrastructure, attitude of MOs etc.
Conduct periodic meetings with Medical officers at the health facilities:

The field operations team should conduct periodic meetings with the MOs at the
health facilities to discuss service feedback and field level issues (if any). These
meetings also provide an opportunity to inform the doctors on correct usage of
PCR forms accompanying an emergency patient, which has been observed to be
an issue with most hospitals.
Hands-on training to new EMTs in hospital ERs:

9
Another initiative to train the newly inducted EMTs can be done by providing
hands-on training in the hospital ER. This also helps in building relation with the
doctors and paramedical staff.
Improving quality processes related to monitoring support functions and closure of
ambulance non-compliances
Context:
For the core functions of EMRI, while the audits are carried out diligently, minor gaps were
observed in monitoring of closure of ambulance audit non-compliances, especially related to
medical equipment. With respect to support functions (including HR, SCM, Marketing, IT-IS etc.),
while the teams are monitored closely by the national teams, state-level reviews of process
adherence needs strengthening.
Recommendation:
Systematic process to track ambulance non-compliances:
 The state-level quality team should work closely with field operations and SCM teams to
ensure that all ambulances meet compliance standards. A clearly developed tracking
sheet should be used to track observations made during audits, assigning clear
responsibilities for necessary action and regular follow to ensure timely closure.
Internal audits of support function processes
 The quality team must initiate internal audits for all support function processes. The
objectives of the internal audits should be to check relevance of existing processes,
adherence and status of performance indicators. Steps to be followed include
- training of at least 8-10 senior officials as internal auditors
- developing a well-defined bi-annual internal audit plan with a clear
documentation and non-compliance closure mechanism
10
Improving Inventory management practices
Context:
While no apparent cases of stock outs or excess stock were observed, currently the
reorder quantities are calculated only on monthly consumptions using excel sheets. The
process does not clearly define minimum stock, stock holding time or economic order
quantities. The current process is manual and time consuming.
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Assessment of ERS Performance in Madhya Pradesh
Final Report
Recommendation:
Training to SCM staff (Procurement and Store):
 As a first step, SCM staff should be provided training on concepts such as Adjusted
Consumption method and Economic Order Quantity (EOQ), safety stock norms etc.
Implementation of desired inventory management practices:
 A detailed demand assessment sheet should be developed for all store items to assess
exact demand levels, which could include norms for safety stock, monthly consumptions,
economic order quantities etc. to be decided by the state SCM team, in consultation with
the national team. The national team should handhold the state team for 2-3 months in
raising indent orders based on the demand assessment sheet. Once stabilized, the
organization could also decide to use an enterprise solution (probably an extension of the
current used Oracle) for inventory management and demand assessment. The tracker and
the use of SAP would automate the effort thus reducing the probability of errors. Also it
is suggested that this exercise be done once all the ambulances are stabilized. Since our
visits were conducted during the interval when the launches were still on, it was difficult
to separate drugs required for operational ambulances from those required for the launch
of the new ambulances.
11
Employee handbook for line staff
Context:
Discussions with field EMRI staff has highlighted there is lack of clarity on administrative/ HR
processes, especially on compensation break up.
Recommendation:
Designing an Employee Handbook:
 It is suggested that EMRI should develop an Employee Handbook providing clear
understanding of all processes related to ambulance staff. The handbook could include –
- Reporting structure
- Roles and responsibilities
- Grievance redressal system and escalation mechanisms
- Payroll and reimbursements
- Leave entitlements
- Rewards and recognition
100
CHAPTER 8
ANNEXURES
Assessment of ERS Performance in Madhya Pradesh
Final Report
Annexure 8.1 Selection of Sample Villages
Details the data sent by EMRI and the data comparison table used to finalize the sample
For block, 4 green “frequent” and 2 red “infrequent” villages were met
GWALIOR
GIRD
BHITARWAR
S.No
Village
Village Count
Average
EM Total
Null
Net EM Total
No. of Ems
177
4.5
2917
509
2408
S.No
Village
Village Count
Average
Total
Null
Net Total
No. of Ems
106
3.6
520
143
377
S.No
Village
No. of Ems
S.No
Village
No. of EMs
1
GWALIOR
1618
1
ADAMPUR
27
2
ADUPURA KHALSA
79
2
CHINOUR
27
3
RAIRU
31
3
4
GHATIGAON (BARAI)
30
5
BILHETI
6
26
4
BHITARWAR
AMROUL(AMROL
81)
20
5
DEORI KALAN
13
MOHANA
18
6
GOHINDA
13
7
BARAI
16
7
MEHGAON
9
8
UTILA
16
8
RARUA
8
9
GIRVAI
14
9
SILHA
8
10
JAKHARA
13
10
BANWAR
7
11
PURANICHAVNI
13
11
BHORI
6
12
BILARA
11
12
KHEDA TANKA
6
13
KULETH
11
13
MAINA
6
14
PANIHAR
10
14
BAGWAI
5
15
SONSA
10
15
DUBAHA TANKA
5
16
DUHIYA
9
16
GHARSONDI
5
17
MAHARAJPURA
9
17
KARHIYA
5
18
RENHAT
9
18
PURA BANWAR
5
19
SIRSAUD
9
19
RAHI
5
20
SOJNA
9
20
URWA
5
21
SUPAWALI
9
21
DEOGARH
4
22
DORAR
8
22
ERAYA
4
23
MOHNPUR (MURAR)
8
23
HARSI
4
24
NAYAGAON
8
24
KHADICHA
4
25
RAMPURA
8
25
KHAIRWAYA
4
26
SONI
8
26
MOHANGARH
4
15
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Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
Village
No. of Ems
S.No
Village
No. of EMs
27
BADAGAON
7
27
RAJAUA
4
28
BAHADURPUR
7
28
SAHARAN
4
29
BIJOLI
7
29
SAN KHINI
4
30
KHERIYA KESHAR
7
30
SEHBAI
4
31
PIPROLI
7
31
SINHARAN
4
32
SUSERA
7
32
SUKHNA KHIRYA
4
33
ANTRI
6
33
SYAU
4
34
BASTARI
6
34
BADKI SARAY
3
35
BERJA
6
35
BAJNA
3
36
GOWAI
6
36
CHARKHA
3
37
JIGANIYA
6
37
CHHIRATA
3
38
JIGSOLI
6
38
CHITOLI
3
39
KUWRPUR
6
39
DUBAHI
3
40
LAXMANGARH
6
40
ITMA
3
41
NAUGAON
6
41
JAURA
3
42
NIRAWALI
6
42
MASTURA
3
43
TIGHRA
6
43
MASUDPUR
3
44
ARON
5
44
RICHHARI KHURD
3
45
BADORI
5
45
BASAI
2
46
BANDHOLI
5
46
BELGADHA
2
47
GUTHINA
5
47
BERNI
2
48
IKEHARA
5
48
DAULATPUR
2
49
RAI
5
49
DHOBAT
2
50
SENTHRI
5
50
DONI
2
51
SIHOLI
5
51
GARHI SALAMPUR
2
52
SIRSA
5
52
GUJAR BANWARI
2
53
SURO
5
53
HIMMATGARH
2
54
BEHAT
4
54
JAKHWAR
2
55
DANGGUTHINA
4
55
KACHHAUA
2
56
GURRI
4
56
KAITHI
2
57
HASTANAPUR
4
57
KAITHOD
2
58
JAMAHAR
4
58
KHADAUA
2
59
JARGA
4
59
KHURDPAR
2
60
KAKRARI
4
60
LADHWAYA
2
61
MAHARAMPURA
4
61
MUSAHARI
2
62
MILAWALI
4
62
PACHORA
2
63
PAR
4
63
PIPRAUA
2
64
PARSEN
4
64
RITHONDAN
2
65
RATWAI
4
65
RUAR
2
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Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
Village
No. of Ems
S.No
66
RAWAR
4
66
67
ROODHPURA
4
68
RORA
69
Village
No. of EMs
2
67
SHYAMPUR
SIKROUDA(SIKROD
A)
4
68
SONTA KHIRIYA
2
AKBARPUR
3
69
AMARDHA
1
70
BHADROLI
3
70
BAJHERA
1
71
CHAK KESHOPUR
3
71
BANIYA TOR
1
72
CHARAIREHANTA
3
72
BASONDI
1
73
DABKA
3
73
BELA
1
74
GANESHPURA
3
74
BERKHEDA
1
75
GIRGAW
3
75
BIRGAWAN
1
76
JEBRA
3
76
CHIRROLI
1
77
JINAWALI
3
77
DHAKAD KHIRIYA
1
78
KAITHA
3
78
DONGARPUR
1
79
KHERIYA MODI
3
79
FATEHPUR
1
80
KHUDAWALI
3
80
GADAJAR
1
81
MALNPUR
3
81
GADHOTA
1
82
MEHADPUR
3
82
GIJORRA
1
83
MUGALPURA
3
83
JATRATHI
1
84
NAGOR
3
84
JHANKARI
1
85
NAINAGIRI
3
85
JUJHAR PUR
1
86
ODPURA
3
86
1
87
PATAI
3
87
KAKARDHA
KHEDA
BHITARWAR
88
RAMAUA
3
88
KHEDI DABARIYA
1
89
SIROL
3
89
MACHHARIYA
1
90
SIYAWARI
3
90
MAHUTHA
1
91
SURAJPURA
3
91
MANIKPUR
1
92
VIKRAMPUR
3
92
MARAGPUR
1
93
VIRPUR
3
93
MAUCHH
1
94
AJAYPUR
2
94
NAJARPUR
1
95
BARAUA NURABAD
2
95
NAYAGAON
1
96
BERKHEDA
2
96
NIHONA
1
97
BILPURA
2
97
NIKODI
1
98
DAYELI
2
98
PALAYACHHA
1
99
DONGARPUR TAL
2
99
PURI
1
100
GUNDHARA
2
100
RAWAT BANWARI
1
101
HARJANPURA
2
101
RICHHARI KALAN
1
102
HUKAMGARH
2
102
RICHHERA
1
103
JAGUPURA
2
103
SHEKHUPUR
1
2
1
104
Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
Village
No. of Ems
S.No
Village
No. of EMs
104
KAIMPURA
2
104
SIRSULA
1
105
KERIYA PDYAPUR
2
105
SURAJPUR
1
106
KHEDI
2
106
TEKPUR
1
107
KHERIYA BHAT
2
108
KHERIYA KULETH
2
109
KHERIYA MIRDHA
2
110
KHURERI
2
111
LAKHNOTIKALAN
2
112
LAKHNOTIKHURD
2
113
MAU
2
114
RAIPUR
2
115
RASHIDPUR
2
116
SHANKRPUR
2
117
TEHLRI
2
118
THAR
2
119
TURAKPURA
2
120
UDAIPUR
2
121
BADAGAONJAGIR
1
122
BADERAFUTKAR
1
123
BAHANGIKALAN
1
124
BAHANGIKHURD
1
125
BARAHANA
1
126
BARAUAPICHHORE
1
127
BARETHA
1
128
BASOTA
1
129
BEHATA
1
130
BENIPURA
1
131
BHATPURA SANI
BHATPURA(BRAHMAN
1
132
)
1
133
BHAVANPURA
1
134
BHELAKALAN
1
135
BIRAMPURA
1
136
CAKRAMPUR
1
137
CHAKMAHARAJPUR
1
138
CHANDPURA
1
139
CHANDUPURA
1
140
CHHONDA
1
141
DHANELI
1
142
DHUWAN
1
105
Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
Village
No. of Ems
143
GADROLI
1
144
GAJIPURA
1
145
GANGAPUR
1
146
GANPATPURA
1
147
GOSI PURA
1
148
HABIPURA
1
149
HIMAPURA
1
150
HIRI
1
151
JAKHODI
1
152
JLALPUR
1
153
KHERIYA KACHHAI
1
154
KHODUPURA
1
155
KRIPALPUR
1
156
MADHA
1
157
MAHESHWARA
1
158
MAITHANA
1
159
MUKHTYARPUR
1
160
SAHASARI
1
161
SANTALPUR
1
162
SARASPURA
1
163
SEKRA
1
164
SHEKHPURA
1
165
SHYAMPUR
1
166
SIHARA
1
167
SIKRAWALI
1
168
SIKRODA FUTKAR
1
169
SIMIRIYA TANKA
1
170
SINGHARPURA
1
171
SONAPURA
1
172
SUNARPURA KHALSA
1
173
SUNARPURA MAFI
1
174
SUPAT
1
175
TIHOLI
1
176
TILGHANA
1
177
UMMEDGARH
1
S.No
Village
No. of EMs
106
Assessment of ERS Performance in Madhya Pradesh
Final Report
SAGAR
BANDA
GARHAKOTA
S.No
Village
Village Count
Average
EM Total
Null
Net EM Total
No. of Ems
157
5.8
1205
292
913
S.No
Village
Village Count
Average
Total
Null
Net Total
No. of Ems
106
6.1
527
76
451
S.No
Village
No. of Ems
S.No
Village
No. of EMs
1
BANDA
122
1
GARHAKOTA
110
2
ABDAPUR
64
2
BACHHLON
31
3
DALPATPUR
33
3
UMARA
23
4
SAHAWAN
22
4
HARDI
15
5
SHAHGARH
21
5
CHHULLA
13
6
NIMON
19
6
PIPARIYA DIGARRA
13
7
HIRAPUR
18
7
RON
13
8
CHHAPRI
16
8
UDAIPURA
10
9
BINAIKA
13
9
DARARIYA
9
10
GANYARI
13
10
MADIYA AGRASEN
9
11
KHATORA KALAN
13
11
GHOGRA
8
12
RURAWAN
13
12
KUMRAI
8
13
PATAUWA
12
13
BASARI
7
14
TARPOH
12
14
CHANAUVA BUJURG
7
15
TIGODA
12
15
CHOURAI
7
16
KANTI
11
16
PHULAR
7
17
BARAJ
10
17
SANJARA
7
18
BHEDAKHAS
10
18
SHAHPUR
7
19
KETHORA
10
19
JARIYA KHIRIYA
6
20
PATAN
10
20
RATNARI
6
21
BAGROHI
9
21
BAMHORI GARAY
5
22
MAJHGUWAN
9
22
BARKHERA GAUTAM
5
23
PAPET
9
23
CHANDRAPURA
5
24
BUDHAKHERA
8
24
KEKARA
5
25
FATEHPUR
8
25
PIPARIYA BHATOLI
5
26
HANOTA PATKUI
8
26
VIJAYPURA
5
27
JASODA
8
27
BERKHERI KALAN
4
28
PIPARIYA CHOUDA
8
28
BICHHIYA
4
29
PIPARIYA IMLAI
8
29
BORAI
4
30
SIMARIYA KALAN
8
30
KHEJRA
4
31
SORAI
8
31
MADHO
4
107
Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
Village
No. of Ems
S.No
Village
No. of EMs
32
BAMANA
7
32
MAHUWA SEMARA
4
33
BILAGRAM
7
33
PIPARIYA AHIR
4
34
BILAUWA
7
34
PIPARIYA GUPAL
4
35
DHABOLI
7
35
RANGUWAN
4
36
NAHARMAU
7
36
BALEH
3
37
PATARI
7
37
CHARKHARI
3
38
RABARA
7
38
CHOKA
3
39
RAKHSI
7
39
JHUNDA
3
40
SADPUR
7
40
PACHARA
3
41
BAMHORIKHURD
6
41
RAGUWAN
3
42
BHADRANA
6
42
SINGPUR
3
43
GARROLI
6
43
SURAJPURA
3
44
GORAKHURD
6
44
TADA
3
45
KANIKHEDI
6
45
BAMNODA
2
46
MADAIYA
6
46
BELAI
2
47
MUDARI BUJURG
6
47
BHATOLI
2
48
NARWAN
6
48
CHANDOLA
2
49
TINSUWA
6
49
DATPURA
2
50
BEHROL
5
50
KADALA
2
51
BERKHERI
5
51
KUMERIYA
2
52
BESLI
5
52
MADIYA ASKARN
2
53
CHAKERI BINEKA
5
53
MAGARDHA
2
54
CHOUKA BHEDA
5
54
PADQUARI
2
55
GONDAI
5
55
PARASIYA
2
56
JHAGRI
5
56
SORKHI
2
57
MANJLA
5
57
CHANAUVA KHURD
1
58
NANAKPUR
5
58
DEOPURA
1
59
PADWAR
5
59
HINOTA
1
60
PANARI
5
60
JHAGRI
1
61
PIDARUWA
5
61
KAJRAWAN
1
62
RAJOULA
5
62
KHANPURA
1
63
SEMRA AHIR
5
63
KHAROTALA
1
64
BAMURA BINAIKA
4
64
KHERA
1
65
CHILPAHADI
4
65
KHIRIYA KHAWAS
1
66
DATYA
4
66
KUDAI
1
67
INDORA
4
67
KUNWARPUR
1
68
KHAHARMAU
4
68
MADIYA KHURD
1
69
KIRAULA
4
69
MAHESHA KHURD
1
70
KULLA
4
70
MAJHGUWAN
1
108
Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
Village
No. of Ems
S.No
Village
No. of EMs
71
NEGUWAN
4
71
MOTHAR NAYAK
1
72
RICHHAI SAGAR
4
72
MURGA
1
73
SASAN
4
73
SEVAS
1
74
SIMARIYA CHHAPRI
4
74
TAL SEMARA
1
75
AMARMAOH
3
76
BAMHORI JAGDISH
3
77
BASONA
3
78
CHITAUWA
3
79
GADAR
3
80
JAMUNIYA
3
81
KUWAYALA
3
82
MADANTALA
3
83
MATAYA
3
84
PIPARIYA CHAMARI
3
85
RAKH
3
86
RAMPUR
3
87
RANIPURA
3
88
SAGARI
3
89
SESAI MAFI
3
90
SHEKHPUR
3
91
SIMARIYA KHURD
3
92
TINSI
3
93
ULDAN
3
94
BAGRODHA
2
95
BARKHERA
2
96
BATWAHA
2
97
BILHANI
2
98
GANESHGANJ
2
99
JHADOLA
2
100
KANDWA
2
101
KHIRIYA
2
102
LIDHOURA
2
103
MAGRA
2
104
NOURAJ
2
105
PADRAI
2
106
PARASIYA
2
107
PARSUWAN
2
108
PRAHLAD PURA
2
109
SAJI
2
109
Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
Village
No. of Ems
110
AGARA
1
111
BAGODHA
1
112
BALYALPURA
1
113
BAMNORA
1
114
BARGUWAN
1
115
BIJRI
1
116
CHARODHA
1
117
CHITAULI
1
118
CHOUKI
1
119
DHAND
1
120
DHURMAR
1
121
DILAKHEDI
1
122
GOMATPUR
1
123
HANOTA SAHAWAN
1
124
HARDUWANI
1
125
HINOTI
1
126
JAWARA
1
127
KANDARI
1
128
KANERA
1
129
KARAI
1
130
KHAIRWAHA
1
131
KHAJRA BHEDA
1
132
KHATORA KHURD
1
133
LUDAYARA
1
134
MADIA
1
135
MALAKPUR
1
136
MUDARI KHURD
1
137
MUDIYA
1
138
NAYAKHEDA
1
139
NENDHRA
1
140
NIHANI
1
141
NIWAHI
1
142
PATHARIYA GOND
1
143
PATHARIYA VYAS
1
144
PITHOLI
1
145
RAMCHANDRAPURA
1
146
RAMPURA
1
147
RICHHAI BINEKA
1
148
RODA
1
S.No
Village
No. of EMs
110
Assessment of ERS Performance in Madhya Pradesh
Final Report
S.No
Village
No. of Ems
149
SAGORIYA
1
150
SALAIYA BINEKA
1
151
SASA
1
152
SEMRA DAULAT
1
153
SEMRA SANODHA
1
154
SIGDONI
1
155
SINGRAWAN
1
156
TAGIYA
1
157
TODA
1
S.No
Village
No. of EMs
SEHORE
ASHTA
BUDHNI
S.No
120
2.9
470
117
353
No.
of
EMs
Village
Village Count
Average
Total
Null
Net Total
NASRULLAGANJ
S.No
Village
Village Count
Average
Total
Null
Net Total
52
3.8
279
69
210
No.
of
EMs
66
3.8
290
80
210
No.
of
EMs
S.No
Village
Village Count
Average
EM Total
Null
Net EM Total
S.No
S.No
S.No
Village
1
ASHTA
50
1
BUDHNI
63
1
NASHRULAGANJ
60
2
ABDULLAPUR
28
2
AKOLA
17
2
AGRA
14
3
14
3
SHAHGANJ
13
3
11
11
4
BAYAN
10
4
GOPALPUR
CHHIDGAONMOU
JI (CHHITAGAON)
5
DODI
KOTHRI
KALAN
BADODIYA
GADRI
7
5
SALKANPUR
10
5
LADKUI
6
6
CHOPADIYA
7
6
JAHAJPURA
6
6
RITHWAR
6
7
HAKIMABAD
PAGARIYA
CHOR
7
7
JAJNA
6
7
NEELKANTH
5
7
8
BORI
4
8
PALASI KALAN
5
CHHAPAR
GURADIYA
RUPCHAND
6
9
TALPURA
4
9
5
6
10
KHANDA BAD
3
10
REHTI
SEMALPANI
KADEEM
6
11
KHOHA
3
11
GILHARI
4
12
JATA KHEDA
SHYAMPUR
TAPPA
6
12
MAKODIA
3
12
4
13
DUPADIYA
5
13
PANDADO
3
13
14
ROLAGAON
5
14
PILIKARAR
3
14
HALIYA KHEDI
BORKHEDA
KALAN
CHICHLAHA
KHURD
4
8
9
10
11
Village
Village
7
5
3
3
111
No.
of
EMs
S.No
No.
of
EMs
No.
of
EMs
S.No
S.No
Assessment of ERS Performance in Madhya Pradesh
Final Report
Village
15
AMARPURA
4
15
UNCHA KHEDA
3
15
DHOLPUR
3
16
4
16
BAGWADA
2
16
NANDGAON
3
17
ARNIYA GAJI
BAPCHA
BARAMAD
4
17
BORDHI
2
17
NIMOTA
3
18
BHATONI
4
18
DEHRI
2
18
PANDAGAON
3
19
BHAU KHEDA
4
19
DEVGAON
2
19
AMBA KADEEM
2
20
KURAWAR
4
20
GWARDIYA
2
20
BAGWARA
2
21
MUNDI KHEDI
4
21
2
21
BANKOT
2
22
NANAKPUR
RAMPURA
KALAN
4
22
JAHANPUR
JAWAHAR
KHEDA
2
22
BORKHEDI
2
4
23
JOSHIPUR
2
23
2
3
24
MARDANPUR
2
24
GILLAUR
MAHAGAON
KADEEM
3
25
MAUKALA
2
25
MARIYADO
2
3
26
NARAYANPUR
2
26
PADALIYA
2
3
27
NONBHET
2
27
PANCHOR
2
3
28
SAIDGANJ
2
28
SATRANA
2
3
29
BAKTRA
1
29
SEEGAON
2
23
24
25
26
27
28
29
Village
AMLA MAJJU
BHEEL KHEDI
SADAK
BOR KHEDA
CHACHA
KHEDI
DEEPLA
KHEDI
DEWAN KHEDI
Village
2
30
GAWA KHEDA
3
30
BANETA
1
30
SUKARWAS
2
31
HIRAPUR
3
31
BEHRAKHEDI
1
31
AMEERGANJ
1
32
KHACHAROD
3
32
BIBDA
1
32
ATRALIYA
1
33
3
33
BORNA
1
33
BADNAGAR
1
34
KHADI
MEMDA
KHEDI
3
34
CHARUA
1
34
1
35
METWARA
3
35
DIPAKHEDA
1
35
BAISAD
BASUDEO
(BANSDEO)
36
MUGLI
3
36
DOBI
1
36
BEEJLA
1
37
RICHHADIYA
3
37
DUNGARIA
1
37
BHADAKUI
1
38
SANGA KHEDI
3
38
HOLIPURA
1
38
1
39
SEODA
3
39
ITWAR
1
39
CHANDPURA
CHAUNDA
GRAHAN
40
3
40
JAIT
1
40
CHHAPARI
1
2
41
41
CHORSA KHEDI
1
2
42
1
42
DHANNAS
1
43
BHIL KHEDI
2
43
KHABADA
KHIDIYA
KURMI
KUSAM KHEDA
(KUSUM KHED)
1
42
TITORIYA
BADARIYA
HAT
BAMULIYA
BHATI
1
43
DIGWAD
1
44
CHANNOTHA
DHURADA
KHURD
2
44
MATTHAGAON
1
44
DIMAWAR
1
2
45
NEEM KHEDI
1
45
GORAKHPUR
1
41
45
1
1
112
No.
of
EMs
No.
of
EMs
S.No
No.
of
EMs
S.No
S.No
Assessment of ERS Performance in Madhya Pradesh
Final Report
Village
46
JASMAT
2
46
NEHLAI
1
46
HATHIGHAT
1
47
JHARKHEDI
2
47
PAHAR KHEDI
1
47
ITARSI
1
48
2
48
PANGRA
1
48
2
49
PATHODA
1
49
50
KHAJURIYA
KASAM
2
50
RAMNAGAR
1
50
ITAWA KALAN
JAMONIA
BAZYAFT
JAMONIA
KALAN(PANDAG
AON
1
49
KALYANPURA
KANNOD
MIRZI
51
KURLI KALAN
2
51
SATAR
1
51
JHAGAR
1
52
MAINA
2
52
SOMALWADA
1
52
JHALI
1
53
MAINAKHEDI
2
53
JHIRNIYA
1
54
MOLU KHEDI
2
54
KHANPURA
1
55
MORUKHEDI
2
55
KHARSANIA
1
56
PARDI KHEDI
PATARIYA
GOYAL
2
56
KOSMI
1
2
57
KOTRA PIPALYA
1
57
Village
Village
1
1
58
RASULPURA
2
58
KUMANTAL
1
59
RUPA KHEDA
2
59
1
60
RUPETA
2
60
MALAJPUR
MANDI
(MANDHI)
1
61
SIDDIQUEGANJ
2
61
MUHAI
1
62
AHMADPUR
1
62
NIMNAGAON
1
63
AMKHEDI
1
63
SATDEV
1
64
ARNIYA JOHRI
1
64
SHYAMPUR
1
65
ARNIYA RAM
1
65
SOHAN KHEDI
1
66
AROLIYA
1
66
TILADIA
1
67
BADKHOLA
1
68
BAGDAWADA
1
69
1
70
BAIJNATH
BAMULIYA
RAIMAL
71
BAPCHA
1
72
BARKHEDA
1
73
BEDA KHEDI
1
74
1
75
BHANA KHEDI
BHAVRI
KALAN
(BHAURI
KALAN)
76
BHERUPUR
1
77
CHANCHARSI
1
78
CHHAPRI
1
1
1
113
No.
of
EMs
79
DUKA
1
80
GAJNA
1
81
GOPALPUR
GURADIYA
KALAN
1
1
84
GWALA
HUSAINPUR
KHEDI
85
JAFRABAD
1
86
JHILELA
1
87
KABIR KHEDI
1
88
KAJI KHEDI
KAMALPURKH
EDI
1
KANDA KHEDI
KARMAN
KHEDI
1
1
94
KESHOPUR
KHAMKHEDA
ASHTA
KILERAMA
(FATEHPUR
KILERAMA)
95
LAKHIYA
1
96
LAKHMIPUR
1
97
1
98
LAKHU KHEDI
LASUDIYA
KHAS
82
83
89
90
91
92
93
Village
No.
of
EMs
S.No
Village
S.No
S.No
Assessment of ERS Performance in Madhya Pradesh
Final Report
Village
No.
of
EMs
1
1
1
1
1
1
1
99
LASUDIYA PAR
1
100
LORAS KALAN
1
101
LORAS KHURD
1
102
MAGAR KHEDI
1
103
MALI KHEDI
1
104
MALIPURA
1
105
1
106
MANA KHEDI
MOONDLA
MOHABA
107
MUNDLA
1
108
MURAWAR
1
109
NEELBAD
1
110
NIMAWARA
1
111
NOGAON
1
1
114
112
PAGARIYA HAT
1
113
SAMARDA
1
114
SANDO KHEDI
1
115
SHIV KHEDI
1
116
SINGARCHORI
1
117
SOBHA KHEDI
1
118
TANDA
1
119
TIGARIYA
1
120
UMARPUR
1
Village
No.
of
EMs
S.No
S.No
No.
of
EMs
Village
S.No
Assessment of ERS Performance in Madhya Pradesh
Final Report
Village
No.
of
EMs
115
Assessment of ERS Performance in Madhya Pradesh
Final Report
Annexure 8.2 List of interviews conducted (village-wise)
Gwalior District
Village
Category
Users/Attendants
Non-Users
ASHA/PRI
Gwalior Rural
Girwai
Purani Chavani
Gigsoli
Ajaypur
Kulat
Veerpur
Jalalpur
Frequent
Frequent
Frequent
Frequent
Frequent
4
8
8
2
6
11
8
8
Gwalior Urban
Infrequent
Infrequent
DH Murar
GRMC
GH Birla
16
5
11
Karhiya
Frequent
Rahi
Frequent
Chinour
Frequent
Mohangarh
Frequent
Bhagwai
Frequent
Shyampur
Frequent
Adampore
Infrequent
Maigaon
Infrequent
TOTAL
9
4
5
7
4
2
22
12
Gwalior Bitarwar
91
17
7
8
53
40
Sagar District
Village
Kumrai
Ron
Chanauva Bujurg
Chorai
Parasiya
Kajrawan
District Hospital Sagar
Chhapri
Sorai
Ganyari
Category
Users/Attendants Non-Users
Garhakota
Frequent
9
Frequent
9
Frequent
8
Frequent
9
Infrequent
8
Infrequent
8
Sagar Urban
31
16
Banda
Frequent
8
Frequent
9
Frequent
10
ASHA/PRI
12
12
12
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Assessment of ERS Performance in Madhya Pradesh
Final Report
Village
Fatehpur
Dilakhedi
Ricchai
TOTAL
Category Users/Attendants Non-Users
Frequent
11
Infrequent
9
8
Infrequent
104
49
ASHA/PRI
36
Sehore district
Village
Category
Users/Attendants
Hakimabad
Mundikhedi
Pagariya Ram
Jatakheda
Kilerama
Sonda
Frequent
Frequent
Frequent
Frequent
Infrequent
8
9
8
8
Chidgaon
Ladkui
Gopalpur
Agra
Baisad
Chapri
Frequent
Frequent
Frequent
Frequent
Infrequent
Infrequent
Non-Users
Ashta
ASHA/PRI
12
8
8
Nasrullahganj
Infrequent
9
9
9
6
12
6
8
Budhni
Bayan
TaalPura
Bori
Salkanpur
Jahajpur
Pandado
Pilikarar
Frequent
Frequent
Frequent
Frequent
Frequent
Infrequent
Infrequent
TOTAL
8
10
5
4
11
104
12
8
8
46
36
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Assessment of ERS Performance in Madhya Pradesh
Final Report
Annexure 8.3 – Comparison of 108 ambulances as per international norms
1.
As depicted in the table below equipment (marked in green) are currently available in the BLS
ambulances. Names of equipment not available in the BLS ambulances are marked in red and
further categorised as; For B.L.S., For A.L.S. and Not Relevant.
S. No.
International Checklist for BLS
1
2
3
4
5
6
Stethoscope – adult and paediatric
Thermometer with low temperature capability
Blood pressure device – automatic / manual, with paediatric and adult cuffs
Pulse oxymeter with paediatric and adult probes
Portable and fixed suction apparatus with a regulator
Glucometer
Portable and fixed oxygen supply equipment, capable of metered flow with
adequate tubing
Nebulizer
Atomizers for administration of intranasal medications
Laryngoscope handle – paediatric and adult
Laryngoscope blades, sizes ( sizes 1–4, curved – Macintosh)
Bag-valve mask (manual resuscitator) – adult and infant
Portable, battery-operated monitor/defibrillator (with paediatric capabilities –
child- sized pads and cables or dose attenuator with adult pads).
Transcutaneous cardiac pacemaker, including paediatric pads and cables
Blood glucose test strips
Intravenous catheters 14G –24G
Intraosseous needles or devices appropriate for children and adults
Venous tourniquet, rubber bands
Syringes of various sizes
Needles, various sizes (one at least 1 ½” for IM injections)
Intravenous administration sets (microdrip and macrodrip)
Intravenous arm boards, adult and paediatric
Large bore needle (should be at least 3.25” in length for needle chest
decompression in large adults)
Blood sample tubes, adult and paediatric
Endotracheal tubes (if ALS service scope of practice includes tracheal
intubation) sizes 2.5 –5.5 mm cuffed and/or un cuffed and 6 – 8 mm cuffed (1
each), other sizes optional
Infant oxygen mask
Alternative airway devices (for example, a rescue airway device such as the
ETDLA [esophageal-tracheal double lumen airway], laryngeal tube, or laryngeal
mask airway)
Nasogastric tubes, paediatric feeding tube sizes 5F and 8F, sump tube sizes 8F–
16F
3.5 –5.5 mm cuffed endotracheal tubes, with stylettes
Topical haemostatic agent/bandage
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Availability
Status
Not Relevant
For ALS
For ALS
For ALS
Not Relevant
Not Relevant
Not Relevant
For ALS
For ALS
For ALS
For ALS
For ALS
For ALS
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Assessment of ERS Performance in Madhya Pradesh
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S. No.
International Checklist for BLS
31
32
33
Emesis bags or basins
Elastic bandages
Needle cricothyrotomy capability and/or cricothyrotomy capability
Burn kit (sterile burn sheets, bandages, dressings, gauze rolls, occlusive dressing
or equivalent, adhesive tape, arterial tourniquet, heavy bandage or paramedic
scissors for cutting clothing, belts, and boots).
Obstetric Kit
IV pole or roof hook
A length based paediatric dosing tape or appropriate reference material that
converts length to estimated ideal body weight in kilograms for paediatric drug
dosing and equipment sizing
Wheeled cot / Folding stretcher
Stair chair or carry chair
Long Spinal Board complete with head immobilizer and Security Straps
Impervious backboards (long, short; radiolucent preferred) and extrication
device
Paediatric backboard and extremity splints
Femur traction device (adult and child sizes)
Cervical collars
Head immobilization device (not sandbags)
Pelvic immobilization device
Upper and lower extremity immobilization devices
Vacuum Mattress
Bedpan
Urinal
Blankets
Flashlights (2) with extra batteries and bulbs
Sheets, linen or paper, and pillows
Towels
Triage tags
Protective helmet/ jackets or coats/ pants/ boots
Fire extinguisher
Cellular phone
Appropriate CBRNE PPE (chemical, biological, radiological, nuclear, explosive
personal protective equipment), including respiratory and body protection
Applicable chemical antidote auto injectors (at a minimum for crew members’
protection; additional for victim treatment; appropriate for adults and children)
Cold packs
Hazardous material reference guide
Patient care protocols
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
Availability
Status
Not Relevant
Not Relevant
Not Relevant
For ALS
Not Relevant
Not Relevant
Not Relevant
Not Relevant
Not Relevant
Not Relevant
For BLS
For BLS
For BLS
Source: http://www.nasemso.org/Councils/PEDS/documents/AmbulanceEquipmentGuidelinesJune2012.pdf
Item available in EMRI – BLS Ambulances
Item not-available in EMRI – BLS Ambulances
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Assessment of ERS Performance in Madhya Pradesh
Final Report
2.
The equipment which are not currently available but could be part of a Basic Life Support
Ambulance are categorised as ‘For BLS’, those which could be part of the planned 50 Advanced
Life Support ambulances are marked as ‘For ALS’ and those which are not relevant in the Indian
setting or are not required at the level of care provided in the ambulances are marked as ‘Not
relevant’.
EQUIPMENT
For BLS
For ALS
Cold packs
Laryngoscope handle – paediatric
and adult
Hazardous material reference Laryngoscope blades, sizes ( sizes
guide
1–4, curved – Macintosh)
Patient care protocols
Not Relevant
Atomizers for administration of
intranasal medications
Transcutaneous
cardiac
pacemaker, including pediatric
pads and cables
Portable, battery-operated
Intra osseous needles or devices
monitor/defibrillator (with pediatric appropriate for children and
capabilities – child- sized pads and adults
cables or dose attenuator with adult
pads).
Large bore needle (should be at
Intravenous arm boards, adult
least 3.25” in length for needle
and pediatric
chest decompression in large
adults)
Blood sample tubes, adult and
Needle
cricothyrotomy
pediatric
capability
and/or
cricothyrotomy capability
Infant oxygen mask
A length based pediatric dosing
tape or appropriate reference
material that converts length to
estimated ideal body weight in
kilograms for pediatric drug
dosing and equipment sizing
Nasogastric tubes, pediatric feeding Impervious backboards (long,
tube sizes 5F and 8F, sump tube
short; radiolucent preferred) and
sizes 8F–16F
extrication device
3.5 –5.5 mm cuffed endotracheal
tubes, with stylettes
Topical hemostatic agent/bandage
Pediatric backboard and extremity
splints
Femur traction device (adult
and child sizes)
Pelvic immobilization device
Upper and lower extremity
immobilization devices
Vacuum Mattress
Triage tags
Protective helmet/ jackets or
coats/ pants/ boots
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Assessment of ERS Performance in Madhya Pradesh
Final Report
Annexure 8.4 – Roles and Responsibilities of key stakeholders involved in carrying out field
operations
Key Stakeholder
Program
Managers
(PM)
Emergency
Management
Executive
`(EME)
Emergency
Management
Technician
(EMT)
Pilot
Responsibility
Responsible for adherence of regional performance to decide service level
parameters of the state
 Monitoring and supervising EMEs for each district
 Managing the field operations at the state level
 Liasoning with other support teams such as quality team for Ambulance go live
audits
Managing Operations
 Monitoring and supervising EMTs and Pilots in the district
 Rostering and scheduling of field staff
 Planning and conducting district events such as EMT day, Pilot day etc.
 Adding and updating data on health facilities in H.I.S. and syncing it same with
the Sense team
 Liaising with other support function teams such as quality team, sense team etc.
 Responsible for ambulance fund management
 Conducting periodic ambulance audits on regular intervals
Marketing
 Create awareness of EMRI services in the district such as conducting demos
Liaising
 Liaising with the district committees for quarterly meetings
 Vendor management at district level
 Liaising with media
 Collecting information on health facilities and maintaining hospital relations
within the district
Care
 Receiving calls from the Emergency Response Centre (ERC) and the caller to
reach the emergency site and providing case closure reports to the ERC
 Providing emergency pre-hospitalization care to the patient. The EMT is required
to speak with the ERCP before administering any medicine to the patient
 Recording vitals of patients and filling out Patient Care Records and getting
forms signed by the MO on duty at the health facility
 Filling of PCR form and hand over one copy of PCR to the hospital with the
attending doctor signature
Administration
 Submission of PCRs to state office
 Periodic medicines indenting and equipment repair
 Conduct demos as planned with the EME
 Maintain medicine, care and demo related registers
 Providing transport services to the patients
 Assisting Emergency Medical Technicians (EMTs) in victim shifting and scene
management.
 Assisting EMTs during demos
 Maintaining log books and recording number of kilometers covered in each trip.
 Ensure complete documentation in cases of accidents
 Coordinate with fleet department for scheduled service maintenance

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Assessment of ERS Performance in Madhya Pradesh
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Annexure 8.5 – Launch Details of Ambulances and Population Coverage per district
Coverage
(Population per
ambulance)
1
Bhopal
1,843,510
15
2
Jabalpur
2,151,203
14
3
Gwalior
1,632,109
12
4
Indore
2,465,827
5
Rewa
1,973,306
6
Sagar
7
Datia
8
As on
May'13
May ‘13
Apr ‘13
Mar ‘13
Feb ‘13
Population
(Census
2011)
Jan ‘13
District
As on
Dec'12
S.No.
No. of Ambulance
Dec '12
May'13
15
122,901
122,901
15
153,657
143,414
13
136,009
125,547
15
15
164,388
164,388
15
15
131,554
131,554
2,021,987
17
17
118,940
118,940
628,240
3
8
209,413
78,530
Damoh
1,083,949
3
7
361,316
154,850
12
215,782
89,909
8
361,422
135,533
1
1
5
4
9
Sehore
1,078,912
5
10
Hosanagabad
1,084,265
3
11
Raisen
1,125,154
9
9
125,017
12
Dhar
1,740,329
13
13
133,871
13
Katni
1,064,167
8
8
133,021
14
Shajapur
1,290,685
9
9
143,409
15
Morena
1,592,714
9
9
176,968
16
Rajgarh
1,254,085
8
8
156,761
17
Sidhi
1,831,152
6
6
305,192
18
Sheopur
559,495
5
5
111,899
19
Shivpuri
1,441,950
10
10
144,195
20
Shahdol
1,575,303
7
7
225,043
21
Umariya
515,963
6
6
85,994
22
Dindori
580,730
6
6
96,788
23
Singroli
1,178,132
6
6
196,355
24
Anuppur
749,521
6
6
124,920
25
Harda
474,416
5
5
94,883
26
Satna
1,870,104
6
7
13
143,854
27
Betul
1,395,175
5
5
10
139,518
28
Vidisha
1,214,857
8
8
151,857
29
Bhind
1,428,559
9
9
158,729
30
Ashok nagar
844,979
6
6
140,830
31
Guna
1,666,767
8
8
208,346
32
Chinddwara
1,849,283
12
12
154,107
33
Mandla
34
Khargone
7
5
894,236
9
9
99,360
1,872,413
10
10
187,241
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Assessment of ERS Performance in Madhya Pradesh
Final Report
Coverage
(Population per
ambulance)
As on
May'13
May ‘13
Apr ‘13
Mar ‘13
Feb ‘13
Population
(Census
2011)
Jan ‘13
District
As on
Dec'12
S.No.
No. of Ambulance
Dec '12
May'13
35
Panna
856,558
8
8
107,070
36
Narsinghpur
957,646
6
6
159,608
37
Seoni
1,166,608
9
9
129,623
38
Tikamgarh
1,202,998
9
9
133,666
39
Chhatarpur
1,474,723
11
11
134,066
40
Balaghat
1,497,968
10
10
149,797
41
Jhabua
1,394,561
7
7
199,223
42
Alirajpur
728,677
6
6
121,446
43
Dewas
1,308,223
8
8
163,528
44
Ratlam
1,215,393
8
8
151,924
45
Mandsaur
1,183,724
8
8
147,966
46
Badwani
1,081,441
9
9
120,160
47
Khandwa
1,309,443
8
8
163,680
48
Neemuch
726,070
6
6
121,012
49
Burhanpur
756,993
6
6
126,166
50
Ujjain
1,710,982
12
12
142,582
TOTAL
64,545,485
102
454
632,799
142,171
*Population per ambulance is expected to reduce to 1, 07,218 with the launch of 150 ambulances
123
Assessment of ERS Performance in Madhya Pradesh
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Annexure 8.6 – Facility Feedback
District
Ambulance
Facility

JAH medical
College - Gwalior

Gwalior City
Centre
Maheshwari Private
Hospital*


Gwalior
Bhittarwar Block
Ambulance
CHC Bhittarwar
JAH medical
College - Gwalior
DH Morar
Birla Nagar
Maternity Home



Comments/Feed back
Sometimes EMTs leave patients without attendants at
casualty without informing the receiving doctors on
history and location of pick up.
Level of care could be better for example in wound
care and inserting intra cath line in patients.
PCR copy not handed over directly to attending
doctors as a practice. Attending doctor never seen
PCR copy.
Overall service is good and response time is fast.
Care provided on ERCP advice (I/v and O2) was not
required in a specific case.
Overall satisfactory care provided by EMT.
Response time is fast.





Timely response provided by 108.
Sufficient care provided at the level of EMT.
Good advice provided by ERCP
Good response time maintained by 108 service
DH Sagar
Sagar Police
Good management of cases and quality of care
Daffrin Hospital
Control Room
satisfactory.
(DH Sagar)
 Adequate documentation done by EMT.
 Good response time maintained by 108 service.
Garhakota
 Good management of cases and quality of care
Sagar
CHC Garhakota
Ambulance
satisfactory.
 Adequate documentation done by EMT.
 Good quality of care at the EMT level.
Banda
CHC Banda
 Advice from ERCP useful.
Ambulance
 Documentation is adequate.
 Timely response provided
CHC Budni
 Correct care provided by EMT.
Budni Police
 Services found useful especially since large number of
Chowki
trauma cases transported to facility by 108.
DH Hoshangabad
 Sometimes serious cases not transferred to Bhopal.
 Care provided is adequate as per level of EMTs
Sehore Traffic
DH Sehore
however services could be better.
Thana
 ERCP advice is useful and correct.
Sehore
 Good response time maintained.
 Adequate pre-hospital care not provided.
 PCR forms sometimes not properly filled.
Ashta Police
CHC Ashta
 ERCP advice inadequate at times.
Chowki
 Good care of pregnancy related cases.
 Useful and sufficient documentation.
 Service quality better than JEY.
* Maheshwari hospital is a private health facility and no doctors were available for interview.
Purani Chavni
Ambulance
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Assessment of ERS Performance in Madhya Pradesh
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Annexure 8.7 – Minimum qualifications and recruitment process for EMTs, Pilots and ERO
1. The minimum qualifications and recruitment process for EMTs, Pilots and EROs is presented
below:
Employee
EMT
Pilot
ERO










Minimum Qualifications
Science Graduate (preferably with Biology)
Max age at entry- 32 years
Also accepts 2 year Science diplomas like
BEMS, BHMS etc.
Class 10 appearance (pass/fail)
HTV/LTV/Commercial
vehicle
driving
license
5 years driving experience
Max age at entry- 38 years
Graduate in any discipline
Typing speed of 30 words per minute (after
undergoing training)
Max age at entry- 35 years








Recruitment Process
Written test
Technical interview
Training
Examination after training
Written test
Interview
Medical test
Driving test
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Assessment of ERS Performance in Madhya Pradesh
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Annexure 8.8 – Assessment parameters and tool used for EMT assessment
Technical Knowledge
1. The EMT was assessed on the knowledge level and soundness of understanding of clinical conditions,
their associated signs and symptoms and their management protocols. The common emergencies
handled were segregated into four sub categories for a detailed understanding of each category. The
sub categories were general orders, medical, trauma and pregnancy.
 General Orders- This section focussed on basic protocols on initial patient assessment, areas
to investigate for the same and overall history taking and physical examination procedures for
all types of cases and standard protocols on BLS, AVPU, CPR etc.
 Medical Emergencies- This section focussed on specific medical conditions other than trauma
and pregnancy related cases like anaphylaxis, altered mental status, cardiac arrest, stroke and
seizures etc.
 Trauma-Vehicular and Non Vehicular emergencies- This section focussed on cases like
injuries due to RTA, suicidal cases, severe pain and amputations
 Pregnancy related emergencies- This section focusses on emergency cases related to
pregnancy and child birth complications.
Questions from the section on General Orders and questions from two of the other three sections were
administered to all EMTs.
Practical knowledge (Skill and Direct Handling of cases)
2.
The EMT was assessed on the ability to practically put to use his/her technical knowledge in direct
handling of an emergency case. This was done by the expert by way of qualitative discussions
(captured at relevant areas in the tool) when administering the tool and on direct observation. The
expert travelled with the EMT in the ambulance where ever possible to observe the level of skill
and direct patient handling among EMTs in real time.
Systems knowledge
3.
As part of their responsibilities the EMTs are mandated to follow certain standard processes once
the central call centre directs a caller to the nearest ambulance to the time they are transferred to the
nearest health facility. These include details on processes involved in receiving the call by the EMT
to recording the case ID, connecting with the patient, confirming the choice of the health facility,
recording the details to handing over the patient at the facility and closing the case. The EMTs were
assessed in their knowledge of these mandated processes.
Documentation
4.
EMTs are expected to maintain several formats/ registers, based on the services provided and for
program management purposes. The following registers are mandated to be maintained by the EMT
in the ambulance:
 Patient Data Register
 Prehospital Care Record forms
 Against Medical Advice Form
 Inter Facility Transfer Form
 Handing Over Register
 Storage of medicines
 Bio Medical Waste Handover Register
 Daily checklist
 Complaint Register
 Attendance Record
5.
These documents were checked for availability and completeness, and EMTs’ understanding of
what information is required to be maintained in these documents.
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Assessment of ERS Performance in Madhya Pradesh
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Assessment tool for EMT
1.
2.
3.
4.
5.
6.
7.
EMT Details
Name of the EMT
Educational qualification
Total years of experience
Years of service with EMRI
Trainings received from EMRI till date
Duty timings
Process Related
8. What is the process followed once you receive a call from the ERO at the call centre?
9. What are the SOPs you follow while handling various types of emergencies? Please share*
10. During an EM call, who decides the health facility? You or the patient? Where is the patient taken
to - with EMRI tie-ups only or any facility?
11. What are the records you are required to maintain? Observe 1-2filled PCR Forms
12. In case of off duty hour emergencies, who is responsible for attending that emergency?
13. Has it ever happened that the patient/caller has refused the service once you reached the site of
emergency? What is procedure followed in such a situation?
14. What is the case closing procedure followed after the patient has been handed over at the health
facility?
Monitoring and Supervision
15. Did you receive any further training / refresher from EMRI (on updated equipment, medication,
protocols etc.)? Please detail if any? Do these trainings happen at regular intervals?
16. Is there any monitoring activity undertaken by GVK EMRI?
17. What are the major issues that you face in ensuring smooth functioning of operations in relation
to your roles and responsibilities? Is there a grievance redressal system for employees at GVK
EMRI?
18. Do you have any suggestions for improvement of services?
EMT Assessment
(To be carried out by the technical expert) On pre hospital care given to the patient on reaching the site
of emergency
19. What interventions constitute the Initial Patient Assessment?
20. What are the components of history taking and physical examination in medical and trauma
cases?
21. Under what conditions will you call for medical directions in emergency cases?
22. What constitutes the BLS protocol? In what condition will you start BLS protocol? Please specify
for adult and pediatric age group.
23. What are the components of the TRIAGE protocol?
24. What is the AVPU protocol?
25. What is GCS? When is it used? When did you use it last?
26. What is the CPR Protocol? Please enumerate steps
Medical Emergencies
27. What is the management protocol for a patient with altered mental status? What is GRBS and
what is the normal value for it? What is the BP check which is crucial?
28. What is an anaphylactic reaction? What is the treatment protocol to be followed in cases of
anaphylaxis? What are crucial observations which are required in such cases?
29. What are crucial signs and the treatment protocol for cases of breathing difficulty?
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Assessment of ERS Performance in Madhya Pradesh
Final Report
30. What are the crucial standing orders for a case of chest pain? What is the treatment protocol for
the same?
31. What are treatment protocols for a case of cardiac arrest? (Check if mentions BLS protocol)
32. What are the management protocols in a case of stroke?
33. Please enumerate key seizure management protocols. Check for position knowledge in seizure
management.
34. Will you take history in a case of cardiac arrest?
Trauma (Vehicular/Non Vehicular) and Suicidal Cases
35. What are the general standing orders in cases of trauma?
36. What are the key areas of physical examination in cases of abdominal injury? Please enumerate 5
key steps of management for the same.
37. What is the management and treatment protocol for cases with Burn injuries? What actions are
contraindicated in the same?
38. What are the key management protocols in cases of external bleeding/injury and amputations?
What is to be done with amputated parts if any? What are the other protocols to be kept in mind
in such cases? What is contraindicated in amputations?
39. Please enumerate key examination areas and shock management protocols.
40. What are the key areas for physical examination in cases of head injury? Also point out 4 key
management protocols.
41. What are the treatment protocols for a case of hanging? What is a crucial contraindication in such
cases?
42. What is the kind of information to be sought from the patient and the management protocols in
cases of poisoning?
43. What is a major contraindication in cases of hypothermia/drowning?
Pregnancy Related
44. What is the first action as per SOP which you will undertake in an emergency child birth case?
What all will constitute in the initial history taking of such cases?
45. What are the signs and symptoms which you will observe initially in such a case?
46. What are the key management protocols for such a case?
47. Once the baby is delivered (in the ambulance) safely what steps are to be taken as per the SOP?
48. What is the Apgar score? What is considered as a normal score and what is a critical score?
49. What are the important steps in placenta management once the woman has delivered?
50. What are the key management protocols in spontaneous abortion cases? Enumerate key steps.
51. What are the presenting signs and symptoms in the condition ‘Prolapsed Cord’
52. What are the key management protocols for the same?(Don’ts important here)
53. What are the presenting signs and symptoms in a breech presentation and what are the key
management protocols for this condition?
54. What are the presenting signs and symptoms of mild pre eclampsia, moderate and eclamptic
condition in a pregnant woman?
55. What are the key management protocols in a case of pre eclampsia/eclampsia?
56. What is PPH and what are its key management protocols?
EMT Assessment form
The interviewer is expected to document observations based on his/her interview with the EMT on
following parameters –
128
Assessment of ERS Performance in Madhya Pradesh
Final Report
1. Process Understanding
2. PCR Documentation (Completeness and Correctness)
3. Theoretical Knowledge on management protocols and standing orders(understanding of terminology
and technical language used)
4. Direct Handling of Cases (correct identification of signs and symptoms) Direct Observation where
applicable
5. Overall Impression
129
Assessment of ERS Performance in Madhya Pradesh
Final Report
Annexure 8.9– List of consumables and equipment present in sample ambulances assessed
1:Urban block
2: Rural block
3: Rural block
1: Rural block
2: Rural block
3: Rural block
1.
Pulse Oxymeter
0
0
1
1
1
1
1
1
1
2.
Manual BP Apparatus
0
1
1
1
1
1
1
1
1
3.
Glucometer
1
1
1
1
1
1
1
1
1
4.
Thermometer- Digital
1
0
1
1
1
1
1
1
1
5.
Suction Device (Automatic and Manual)
1
0
1
1
1
1
1
1
1
6.
Needle and Syringe Destroyer
0
1
0
1
1
1
1
1
1
7.
Nebulizer Machine
1
1
1
1
1
1
1
1
1
8.
Humidifier
1
1
1
1
1
1
1
1
1
9.
Stethoscope
1
1
1
1
1
1
1
1
1
10.
Oxygen Cylinder (+ Flow Meter, Pressure
gauge, Volume gauge)
1
1
1
1
1
1
1
1
1
11.
Disposable Gloves
1
1
1
1
1
1
1
1
1
12.
Disposable Masks
1
1
1
1
1
1
1
1
1
13.
Disposable Delivery Kit
1
0
1
1
1
1
1
1
1
14.
Pediatric Kit
0
0
0
0
0
0
1
1
1
15.
Oropharyngeal Airway Size 0,1,2,3,4
1
1
1
1
1
1
1
1
1
Nasopharyngeal Airway Size 6.5,7,7.5,8,8.5
1
1
1
1
1
1
1
1
1
17.
Oxygen Masks- Adult and Child
1
1
1
1
1
1
1
1
1
18.
Nebulizer Mask- Adult
1
1
1
1
1
1
1
1
1
19.
Mucus sucker
1
1
1
0
1
0
0
1
1
20.
Macintosh Rubber Sheet
1
1
1
1
1
1
1
1
1
21.
Non Breather masks- Adult and Child
0
1
0
0
0
0
1
1
1
22.
Nasal Cannula- Adult and Child
1
1
1
1
1
1
1
1
1
23.
Suction Catheter
0
1
1
1
1
0
1
0
1
24.
Drip Sets
1
1
1
1
1
1
1
1
1
25.
Cervical collar- Hard (all sizes)
0
1
1
0
1
1
1
1
1
26.
Ambu Bag (silicon)- Adult and Child
1
1
1
1
1
1
1
1
1
27.
Sputum cup
1
1
1
1
1
1
1
1
1
28.
Bed pan
1
1
1
1
1
1
1
1
1
29.
Urine pan
1
1
1
1
1
1
1
0
1
30.
Kidney tray
1
1
1
1
1
1
1
1
1
31.
Liquid Hand wash
1
1
1
1
1
1
1
1
1
S.no
3: Rural block
Sehore
2:Urban block
Sagar
1:Urban block
Gwalior
Consumables & Equipment
16.
130
Assessment of ERS Performance in Madhya Pradesh
Final Report
1:Urban block
2: Rural block
3: Rural block
1: Rural block
2: Rural block
3: Rural block
32.
Adjustable wrench
1
1
1
1
1
1
1
1
1
33.
Screw Driver- Flat and Star
1
1
1
1
1
1
1
1
1
34.
Hacksaw with blades
1
1
1
1
1
1
1
1
1
35.
Vise grip pliers
1
1
1
1
1
1
1
1
1
36.
Large Hammer
1
1
1
1
1
1
1
1
1
37.
Fire Axe
1
1
1
1
1
1
1
1
1
38.
Wrecking Bar
1
1
1
1
1
1
1
1
1
39.
Crowbar
1
1
1
1
1
1
1
1
1
40.
Shovel
1
1
1
1
1
1
1
1
1
41.
Tin Snips
1
1
1
1
1
1
1
1
1
42.
43.
44.
Leather Gloves
Reserve Blanket (2)
Ropes
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
1
1
1
1
1
45.
Mastic Knife
1
1
1
1
1
1
0
1
1
46.
Centre punch
1
1
1
1
1
1
1
1
1
47.
Pruning Saw
1
1
1
1
1
1
1
1
1
48.
Luminous warning torch
1
1
1
1
1
1
1
1
1
49.
Fire extinguisher
1
1
1
1
1
0
1
1
1
50.
Ambulance Tool Kit
1
1
1
1
1
1
1
1
1
51.
Rain Coats
1
1
1
1
1
1
1
1
1
S.no
3: Rural block
Sehore
2:Urban block
Sagar
1:Urban block
Gwalior
Consumables & Equipment
1 – Available; 0 – Not Available
131
Assessment of ERS Performance in Madhya Pradesh
Final Report
Annexure 8.10 – Comparison of cases handled by 108 and Janani Express Yojana (JEY) in Sagar
District
1. As suggested by GoMP during the state level evaluation of ERS in MP, Deloitte conducted a brief
comparison of pregnancy cases handled by JEY in comparison to 108 in the high focus district of
Sagar.
Introduction
JEY in Sagar
2.
The JEY service was launched in Sagar District in Jan 2011 and currently operates 14 vehicles.
This helpline number serves to the entire district providing home to facility and facility to home
drop service to pregnant women. Under this scheme, the Sagar DH has a dedicated phone line with
a 24 X 7 attendant answering calls made on the helpline.
108 in Sagar
3.
The 108 service was launched in Sagar District in November, 2010 with a fleet size of 17 BLS
ambulances. The service provides integrated emergency care for medical, police and fire
emergencies.
Objective
4.
The objective of this comparison was to get an understanding of the share of pregnancy cases
handled by JEY and 108. The comparison was done based on the no. of home to facility cases
handled by 108 and JEY for the month of May 2013, as 108 covers only home to facility and does
not handle drop back.
Data Limitations
5.
Irregular functioning of JEY in 2012: While the services were launched in the district in Jan, 2011
the services were not functional in 2012 due to contractual and systemic delays. Since the service
resumed in January 2013, data from February 2013 was being captured and submitted to the district
administration.
6.
Unavailability of home to facility data: An analysis of JEY reports for the period Feb – May 2013
indicated that, for the months of Feb, Mar and Apr, only consolidated number of pregnant cases
handled was available. Classification of data into home to facility and facility to home drop was
available only for the month of May. Therefore the comparison between 108 and JEY was done
only for the month of May 2013.
Observation
7.
In the month of May 2013, the total no. of institutional
deliveries in Sagar district was 254932, pregnancy cases
carried by JEY were 54933 and by 108 were 117334. The key
finding is that due to irregular functioning of JEY 108,
continues to carry pregnancy related cases to hospitals.
8.
However, drop back is done only by JEY. For the month of
May, JEY dropped back 414 cases from facility to home,
constituting about 43% of total trips done by the JEY
vehicles
32
Monthly District report provided by CMHO, Sagar District
Monthly District Report of JEY
34
Information provided by EMRI’s district EME of Sagar District
33
132
Assessment of ERS Performance in Madhya Pradesh
Final Report
Annexure 8.11 – Financial data submitted by EMRI
Financial Year
09-10
(YTD)
10-11
(YTD)
1112(YTD)
Apr-12 to
Dec-12
(YTD)
Jan-13 to
March-13
(YTD)
Apr-13 to
Jun-13
(YTD)
Capital Expenditure
Ambulance
44,981,280
84,758,367
84,758,367
84,758,367
8,434,000
Equipments
9,973,518
14,630,497
14,671,591
14,685,941
3,133,999
102,839,61
1
23,559,599
12,978,541
13,962,863
14,185,975
14,389,659
315,985
14,916,718
Hardware
12,722,691
12,976,346
13,017,961
13,037,061
64,260
13,131,321
Software
262,401
283,596
283,596
287,853
-
287,853
Telecom
8,837,781
8,956,482
8,956,482
8,956,482
-
8,956,482
89,756,212
135,568,151
135,873,972
136,115,363
11,948,244
163,691,58
4
880,510
3,527,578
4,886,225
5,697,555
1,985,013
3,779,622
Fuel
5,962,079
17,270,747
21,229,723
15,184,944
Tyre
187,814
1,302,103
2,568,797
1,787,301
16,743,919
1,151,200
Insurance
154,047
145,198
79,313
581,034
95,490
418,204
Others
10,259
208,595
66,720
17,097
81,500
-
Infrastructure
IT Infrastructure
Total (Capex)
Operational
Expenditure
Fleet
Repairs
840,200
-
Equipment
Repairs
14,434,384
4,483
14,411
118,963
Calibration
-
-
Maintenance
-
Insurance
19,683
-
-
-
-
-
-
-
-
-
-
-
-
-
106,192
283,035
260,820
234,202
73,339
175,322
2,201,048
4,443,428
3,718,297
2,887,343
2,358,768
3,080,206
Telephone-Land line
1,290,619
1,743,830
1,175,688
798,540
159,931
350,104
Telephone-Mobiles
692,397
1,031,175
836,889
595,533
219,072
748,396
Internets
320,186
457,525
355,957
272,961
86,334
153,670
1,975,657
483,596
2,040,636
1,422,911
158,408
31,404
Marketing
2,210,098
354,554
230,949
257,074
274,358
268,000
Administrative
6,531,974
11,395,486
7,966,238
6,148,895
4,520,272
4,322,851
Oxyzen
Drugs & Consumables
129,924
Communication
AMCs
License Renewal
133
Assessment of ERS Performance in Madhya Pradesh
Final Report
-
-
-
-
Jan-13 to
March-13
(YTD)
-
1,118,458
1,885,303
1,885,640
1,650,295
460,113
1,002,823
351,249
197,404
204,011
449,906
369,494
133,014
2,461,774
2,463,078
3,993,947
3,143,267
Security
242,844
405,655
533,116
432,412
19,383,517
471,196
Houskeeping
211,851
484,980
533,248
479,996
199,877
291,906
Courier
256,237
556,343
560,384
569,574
199,834
738,943
Stationery
490,642
592,605
1,032,590
899,004
585,184
1,021,839
Others
3,961
28,254
19,815
76,369
(44,640)
-
Salary
29,565,936
57,080,117
71,817,566
56,468,057
106,354,999
126,115,529
100,184,194
Financial Year
Office Maintenance
Electricity and Water
Repairs and
maintenance of office,
building and computer
Trainings
Total (Opex)
09-10
(YTD)
10-11
(YTD)
57,230,313
Apr-12 to
Dec-12
(YTD)
1112(YTD)
24,329,379
73,881,239
Apr-13 to
Jun-13
(YTD)
11,373,332
243,934
54,042,067
97,450,222
134
Assessment of ERS Performance in Madhya Pradesh
Final Report
Annexure 8.12 – Details of year wise parameters for costing ratios – no. of ambulances, emergencies handled and Kms travelled
Jul 09 - Mar 10
Apr 10 - Mar 11
Apr 11 - Mar 12
Apr 12 - Mar 13
Months
No. of
ambys
April
May
June
July
August
September
October
November
December
January
February
March
40
40
40
52
52
52
52
52
52
48
Kms/
trip
17.26
17.3
Total
Ems
50,599
50,599
No. of
ambys
52
52
52
52
67
67
67
84
84
84
84
84
69
Kms/
trip
35.51
35.5
Total
Ems
116,048
116,048
No. of
ambys
88
94
94
94
99
99
99
99
99
99
99
102
97
Kms/
trip
37.8
37.80
Total
Ems
148,467
148,467
135
No. of
ambys
102
102
102
102
102
102
102
102
102
102
217
286
127
Kms/
trip
Total
Ems
Apr 13
- June
13
No. of
ambys
454
454
454
40
163,556
32.58
37.03
163,556
114
Assessment of ERS Performance in Madhya Pradesh
Final Report
Annexure 8.13 – Year wise costing details
(Amount in Rs)
Financial Year
Ambulance Running and
Maintenance
Fuel Cost of ambulance
Jul 09 to
Mar 10
10-11
11-12
Apr to Dec
2012
5,962,079
17,270,747
21,229,723
15,184,944
Tyre Expenses
187,814
1,302,103
2,568,797
1,787,301
Ambulance repair, maintenance and
refurbishment
890,769
3,736,173
4,952,945
5,714,652
Equipment repair & maintenance
110,675
297,446
379,783
364,126
Vehicle insurance
154,047
145,198
79,313
581,034
2,201,048
4,443,428
3,718,297
2,887,343
29,565,936
57,080,117
71,817,566
56,468,057
2,461,774
2,463,078
3,993,947
3,143,267
Communication expenses
2,303,201
3,232,531
2,368,533
1,667,034
IT/Equipment maintenance and Tech
support
1,975,657
483,596
2,040,636
1,422,911
Administration and Travelling
9,207,215
15,546,029
12,735,041
10,661,811
Marketing
IEC and Marketing
2,210,098
354,554
230,949
257,074
57,230,313
106,354,999
126,115,529
100,139,554
Medical consumables
HR
Salary
Training
Communication and Tech Support
Administration
TOTAL
136