Performance in Madhya Pradesh FINAL REPORT September 2013
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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 IMPLEMENTATION MODEL 2 11 SENSE – REACH – CARE 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 SUMMARY OF KEY OBSERVATIONS & 7 89 RECOMMENDATIONS 8 ANNEXURES 101 ANNEXURE LIST 8.1 Selection of Sample Villages 102 8.2 List of interviews conducted (village-wise) 116 8.3 Comparison of ambulances as per international norms 118 Roles and Responsibilities of key stakeholders involved in carrying out field 8.4 121 operations 8.5 Launch Details of Ambulances & Population coverage per district 122 8.6 Facility Feedback 124 8.7 Minimum qualifications and recruitment process for EMTs, Pilots and ERO 125 8.8 Assessment parameters and tool used for EMT assessment 126 8.9 List of consumables and equipment present in sample ambulances assessed 130 Comparison of cases handled by 108 and Janani Express Yojana (JEY) in 8.10 132 Sagar District 8.11 Financial data submitted by EMRI 133 Details of year wise parameters for costing ratios – no. of ambulances, 8.12 135 emergencies handled and KMs travelled 8.13 Year wise Costing Detail 136 List of Abbreviations ALS Advanced Life Support ANM Auxiliary Nurse Midwife AMC Annual Maintenance Contract ASHA Accredited Social Heath Activist AVLT Automatic Vehicle Location Tracking Systems BLS Basic Life Support CAPEX Capital Expenditure CFMS Customer Feedback Management System CME Continuing Medical Education CMHO Chief Medical Health Officer COO Chief Operating Officer DHS Directorate of Health Services EC Executive Committee EM Emergency EME Emergency Medical Executive EMLC Emergency Medical Learning Centre EMT Emergency Medical Technician ERC Emergency Response Centre ERCP Emergency Response Centre Physicians ERO Emergency Response Officer ERS Emergency Response Service FEFO First Expiry First Out FMS Feedback Management System FT Fleet Technicians GoMP Government of Madhya Pradesh GPS Global Positing System HIS Hospital Information System HR Human Resource IEC Information, Education and Communication IFT Ineffective Calls IT-IS Information Technology and Information System JSSK Janani- Shishu Suraksha Karyakram KAP Knowledge Attitude Practice MO Medical Officer MoU Memorandum of Understanding OLMD On-Line Medical Directions OPEX Operating Expenditure PCR Pre-Hospital Care Record PM Program Managers PPP Public-Private Partnership PRI Panchayat Raj Initiative QMS Quality Management System RM Regional Manager SCM Supply Chain Management TL Team Leader UA Unavailed Cases UAC Unattended Calls VB 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-for- profit 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. 6 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 Urban Blocks Rural Blocks District No. Name of block No. Name of block Gwalior 2 Gwalior-Urban 1 Bhitarwar Gwalior-Rural Sagar 1 Sagar-Urban 2 Banda, Garhakota Ashta, Budhni, Sehore 0 None 3 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 No. Covered Total Sample GoMP . 108 Nodal Officer 1 1 . COO . Sense, Reach and Care teams State . Quality team . SCM team EMRI 28 28 . Marketing team . Hospital relations team . Technology teams . Finance and HR teams . Chief Medical Officer of Health 1-2 5 GoMP . District Programme Manager per district For 3 districts District . District Magistrate (optional) . Operations in-charges (Emergency 3 EMRI 1 per district Management Executives) For 3 districts 14* . Doctors at Govt Health care facilities (CHC s) ~2 per block For 9 blocks Block . Ambulance staff and 18 o EMTs (paramedical staff) 2 per block Below For 9 blocks o Pilots (ambulance drivers) . Users, non-users, Field Level Workers, Influencers ~60 per block 559 etc. 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. Implementation model of the 108 service: Sense-Reach-Care and assesses Section – 2 processes followed, key performance indicators and monitoring aspects. Section – 3 Findings and analysis of all support functions within GVK EMRI. Contractual and institutional framework of the public private partnership between Section – 4 GVK EMRI and GoMP Section – 5 Feedback on the service from users, non-users and field functionaries.