Moving the wheels of healthcare
Ambulance services and MMUs, a specialised healthcare delivery system, are playing a major role to meet medical needs. Besides, these can also help the Government achieve universal health for all
A van parked on the outskirts of Delhi, in Uttar Pradesh’s Noida Sector 16, is packed with essential medicines, basic medical equipments, a bed enough for a patient to lie down for basic medical checkup — these are the supplies that make up for a Mobile Medical Unit (MMU) for the residents of nearby slum clusters. Unmindful of the foul smell emanating from the heap of garbage nearby, its occupant, 72-year-old Doctor DD Arora, with his team comprising of an auxiliary nurse midwife, Saiba Bharti, and two community outreach workers, Rupam and Baby, are busy tending to the medical needs of the locals, mostly from the slums.
As the day progresses, patients queue up. Living in unhygienic conditions, they desperately need basic healthcare services. While some wanted to get their eyes treated, others were in pain due to rotten teeth, fungal infection and open wounds. Mothers wanted to get help for their babies who were suffering from mild to high fever or diarrhea.
Arora attributed most of the health problems to poor sanitation, impure drinking water and lack of awareness. “Many are suffering from non-communicable diseases like diabetes. Besides attending to their medical needs, we also need to educate them about cleanliness and basic precautionary measures to prevent health ailments”, said Arora.
MMU service is available across the length and breath of the country. A part of the Hindustan Latex Family Planning Promotion Trust (HLFPPT) project, ‘Merrymobile’, in collaboration with the DLF estate’s major corporate social responsibility activity, the MMU, with its team and coordinator, Narendra Kumar, travel across various locations in Noida and nearby villages to provide first aid, minor surgical procedures and suturing to those in need.
“The MMU services also provide linkage to Primary Health Centres and district hospitals in the area for referral and immunisation services. These can go a long way to help the Government in its non-communicable disease control programme by regular followups,” said Sharad Agarwal, CEO of HLPPT.
In a country where a large number of villagers in remote areas still do not have access to medical care, the National Rural Health Mission, under the Union Ministry of Health and Family Welfare, has identified MMUs and emergency ambulance services as an important component to help achieve its goal of Universal Health Coverage.
According to Additional Health Secretary in the Health Ministry, Manoj Jhalani, over 21,000 ambulances under the National Ambulance Service, ferrying pregnant women and patients of critical care to hospitals, and around 1,600 MMUs are operational across various States in the country.
He further said that while ambulances have helped in increasing institutional deliveries and saving lives in emergency, MMUs are like mobile PHCs; and seek to serve the underserved. “We are working to bring down the response time of the ambulances”, he said, noting that a lot needs to be done to improve these services.
Recognising the need of emergency transportation services in view of the huge gap in health resources, the Planning Commission, now Niti Aayog, a decade ago had suggested that every district should have at least one fully equipped, fully staffed MMU and an adequate number of ambulances in place by 2020. However, there is a tremendous shortfall in emergency medical services in urban and rural areas where critical patients as well as pregnant women risk their lives due to lack of affordable ambulance services. There have been several media reports from across the country to prove this point.
The World Health Organisation has stipulated one ambulance for every 100,000 people in the plains and one ambulance per 70,000 people for more sparsely populated areas. Clearly, the present strength is not impressive. Performance wise too, while some States have performed well in providing these services, many have failed due to short supply, poorly trained staff, shortage of staff and fund, among others.
A recent Comptroller and Auditor-General report revealed it all. It said that MMUs were non-functional in Chhattisgarh, Himachal Pradesh, Mizoram and Uttar Pradesh, while in States of Bihar, Gujarat, Haryana, J&K, Jharkhand, Kerala, Madhya Pradesh, Maharashtra, Odisha and Tripura, MMUs were partially operational. The audit observed that services provided by MMUs were largely deficient in States of Assam, Gujarat, Haryana, J&K, Jharkhand, Meghalaya, Rajasthan, Tamil Nadu and Uttarakhand.
Fund utilisation for NAS too has remained poor. In eight States, out of Rs 175.26 crore allotted for procurement of ambulances, Rs 155.93 crore were unutilised. Some of the irregularities observed by the audit in this regard were administrative delays, tendering process for procurement not being initiated, diversion of funds for other purposes etc, resulting in non-fulfilment of the intended objectives.
The Central Review Mission (CRM) of the Health Ministry in its latest report too noted that the degree of utilisation varied across States because of poor planning, lack of human resources and weak awareness activities. Andhra Pradesh, Gujarat, Jharkhand, Maharashtra, Kerala and Tamil Nadu have reported better utilisation of MMUs to provide healthcare services to tribal and marginalised population, as per the CRM. Now, many States are opting for Public Private Partnership (PPP) arrangements for various services, including better management of ambulance services.
In Bihar, 744 ambulances are run by Dedicated Healthcare Services, 10 by Ziqitza Health Care Ltd and 94 by Sammaan Foundation. In fact, Andhra Pradesh was the first State to start the 108 emergency ambulance service on PPP mode with Emergency Management and Research Institute, now known as GVK EMRI. It has its network across the country. Currently, the HLPPT is operating MMU in 16 districts of nine States; in alliance with Government agencies in two States and corporate sector as CSR partner in seven.
Like for ambulance services, more and more States are looking towards PPP model to operationalise MMUs. Himachal Pradesh is planning MMU on PPP basis for 10 districts while in Maharashtra and Tamil Nadu, civil society partners are major players.
“Their role (MMUs and ambulance services) cannot be negated”, said Anand Bang from Gadchiroli-based Society for education, Action, and Research in Community Health project in Maharashtra. MMUs are reaching out to the people in far and remote areas, filling the gaps in the health system. Of course, challenges are there, like roads are poor, trained and adequate staff is not available”. He also pointed out that there was a huge gap between the salary given to a doctor sitting in a PHC and the one who is attached with the MMU and travel far distances daily to reach out to patients. “These double standards must be done away with if the Government wants good doctors.”
However, Yogesh Jain of Jan Swasthya Sahyog, a non-governmental organisation working in the interiors of Chhattisgarh and other States, is against the idea of MMUs. He feels that their presence means that the Government is accepting its failure to provide adequate health services. According to him, such short-term measures are not enough to meet the needs unless India ramps up health services, particularly in rural areas.
Health experts may have divergent views on efficacy, MMUs and ambulance services are likely to remain a vital link in the health system to help the Government achieve its goal of UHC. This especially for a country that spends less than one per cent of its gross domestic product on health. The need is to increase their efficiency, reduce time response and make them more affordable.
(The writer is Special Correspondent, The Pioneer)
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