BBMP has spent over 100 crores on fixing, remodelling, and maintaining drains in just one ward – HSR Layout. Their Stormwater Drain Department does not maintain records like work registers or the progress reports of works. BBMP has been indicted for ineffective and inefficient collection of waste, non-compliance with waste management rules, and lack of scientific processing facilities at landfill sites.
These are just three instances of impropriety and poor performance in local government bodies.
All these are issues that citizens should demand accountability from their elected reps and officials. One easy way to be aware of such issues is to track the audit reports from agencies like the Comptroller and Auditor General of India (CAG). Speaking at the first Audit Diwas, Prime Minister Narendra Modi pointed out, “We will find the solutions only when we recognise the problems.”
This article is the second of a series by experts from Indian Accounts and Audit Service, with focus on Karnataka’s Arogya Kavacha/108 ambulance service.
The German Philosopher, Frederich Hegel said “State is the march of God on Earth”. The words inscribed on the magnificent legislature of Karnataka, Vidhana Soudha – Government work is God’s work – echoes a similar sentiment. Indeed, the duties and responsibilities that the state is endowed with are such that they need to be performed with God like dedication. Saving a life is one such duty. Emergency medical care is the most important function of the state to save precious lives of citizens. While citizens cannot demand accountability from God, they most certainly can from their state.
A report published by the Union Ministry of Road Transport and Highways, “Road Accidents in India (2018)” states that India, with only 1% of the world’s vehicles, accounted for 11% of all accident related deaths. Further, 29.5% of these road accidents were fatal, claiming 1.5 lakh lives.
It is likely that some of these deaths could have been avoided if the victim had got prompt emergency medical care. In fact, in the Pt Parmanand Katara vs. Union of India and Ors case (1989), the Supreme Court had held that Article 21 of the Constitution includes the right to emergency medical care. The SC had also emphasised the importance of the “Golden hour” i.e ‘the time period lasting one hour following a traumatic injury during which there is the highest likelihood of preventing death by providing prompt medical care’.
A NITI Aayog report on emergency care in India states that 62% of deaths in India are due to non-communicable diseases like cardiovascular and respiratory diseases. It estimates that 50% of these deaths could be averted with pre-hospital and emergency care.
Thus the need for an efficient and effective Emergency Medical Services (EMS) system cannot be overemphasised.
Given this context, the Office of Principal Accountant General (Audit1), Karnataka conducted a comprehensive audit of the functioning of the Aarogya Kavacha/108 Ambulance Service in Karnataka during the period 2014-15 to 2018-19.
The audit had two objectives:
- Examining the adequacy and responsiveness in delivery of quality emergency medical services by Arogya Kavacha–108 project
- Examining whether the IT system deployed in the project was adequate in delivering quality care.
The main components of the IT system include Emergency Management Centre Application , Automated Vehicle Location Tracking System, Fleet Management System and Hospital Information System
The audit evaluated the performance in eight out of the erstwhile 30 districts using methodologies which inter-alia included joint inspection of 25% ambulances in each district, structured interviews with emergency medical technicians, pilots and emergency department staff in district hospitals, beneficiary survey of those admitted in the district hospitals etc.
The purpose of the audit went beyond mere identification of inadequacies. The objective was to try and understand the underlying causes and suggest possible solutions.
Between April 2014 and March 2019, the 108 call centres attended 253.30 lakh calls out of 256.45 lakh calls, i.e. 98.8%. However, of this only
- 36% (91.62 lakh) were effective calls.
- The balance i.e 64% (161.68 lakh) were ineffective calls i.e. no response calls, missed calls, nuisance calls, wrong calls, prank calls etc.
- Of the total number of effective calls, 44% were non-emergency calls i.e. enquiry calls, follow-up calls, caller concerns and appreciations, calls from field staff seeking clarifications etc.
Since such a humongous volume of ineffective/non–emergency calls were certain to affect service quality adversely, measures such as providing an alternate number for enquiries, educating the public about the use of 108 for emergencies only, penalising those who indulge in prank calls, sharing the contact details of the ambulance crew with the caller etc should have been implemented.
The audit noticed one case wherein the ambulance crew stopped for dinner during which the caller made four follow up calls to enquire about the arrival of the ambulance. Since the ambulance did not arrive even after 80 minutes, the patient was transported to a hospital in a private vehicle and died. The audit also observed that there was no call-back mechanism in place in case of inability to attend inbound calls, disconnected calls etc.
A case was noticed wherein an emergency call was disconnected but not returned. Subsequently, the patient died. Accurate pre-arrival instructions to emergency callers before help arrives at the scene is a well-recognised practice in emergency situations. These instructions are potentially life-saving in many cases. However, the audit observed that Emergency Response Officers (ERO) and Despatch Officers (DO) were not trained to provide pre-arrival instructions to callers.
Time is of the essence in emergency care services
An indicative list of observations is given below:
- The mandated response time for cardiac, respiratory, stroke and accident cases is 10 minutes. However, actual response time for all these types of emergencies was above 10 minutes in more than 60% of cases. Further, in 50% of trauma cases, the patients were admitted to the hospital after the “golden hour”.
- An ambulance can be deployed afresh only after the case on hand is closed. The prevailing practice was that the ambulance crew closed the case only on reaching the base location. Analysis of timelines revealed that in 89% of cases the ambulance crew did not report closure of cases immediately after reaching the base location. Audit noticed a case wherein the two nearest ambulances at base station were not allotted to the patient because the ambulance crew had not closed the previous case. The call centre allotted the fourth nearest ambulance which was far away. The patient did not survive.
What cannot be measured, cannot be managed
Today we have a surfeit of IT tools which can enable precise measurement and analysis of voluminous data. However, we observed that the project suffered from various data integrity issues such as manual data capture, incorrect reporting by ambulance crew, null values for the type of emergency, manual insertion of cases, back-end updating of data, unrealistic data points like transportation of more than 20 patients at a time in multiple cases etc.
Such weaknesses render data unusable for corrective action. One serious inconsistency noticed was in the recording of Chute Time i.e the time taken between the assignment of an ambulance and the moment it starts moving towards the scene. The software recorded chute time uniformly as one minute without capturing actual time taken.
Based on GIS data, the audit analysed the chute time of 38,737 cases for the period January 2019 to June 2019 and found that in 60% cases it was more than 10 minutes. This is a painful loss of time which can be a matter of life and death for patients.
The private service provider was appointed by the government without any competitive bidding, by obtaining exemption under Karnataka Transparency in Public Procurement (KTPP) Act for this Public Private Partnership (PPP) arrangement. Further, the nature of the contract with the service provider and its implementation has a massive impact on the latter’s performance.
Audit observed that the Memorandum of Understanding (MoU) entered into by the state government with the private partner had several shortcoming –absence of penalty for deficient delivery of services, failure to specify qualifications for various personnel, lack of any protocol for handling grievances, non-existence of separate service level agreements for IT systems, absence of exit strategy plan post contract period etc. Zero tolerance for non-performance as per prescribed service levels and fool proof mechanisms for establishing accountability and transparency should have been factored into the contract and its enforcement.
The MoU states that each ambulance was to be provided with pilots and Emergency Medical Technicians in the ratio of 2.75 per ambulance each by service provider, which was not followed. A 20% vacancy was observed affecting the functioning of ambulance service and also resulted in additional burden of existing staff to work for longer durations.
In addition to the above, the audit report highlights other serious issues. Like the huge shortage of pilots and Emergency Medical Technicians leading to stress on available resources, use of ambulances for non-emergency purposes, double despatch of ambulances, disruptions in communication, non-availability of automated location identification based on calls, allocation of Basic Life Support (BLS) ambulances to cases that require Advanced Life Support (ALS) ambulance etc.
Thus, a noteworthy government initiative to provide emergency medical services was marred by various deficiencies as mentioned above. The audit report which includes specific recommendations to the government for consideration and early adoption was presented to the state legislature on September 12th, 2020. It can be accessed at https://cag.gov.in/en/audit-report/details/112920 (English and Kannada versions).
The authors are from the Indian Audit & Accounts Service. Views expressed are personal.