Emergency Medical Services in India: Challenges and Opportunities
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This literature review discusses the challenges and opportunities of emergency medical services in India, including fragmented EMS, lack of standardization, and poor infrastructure. It also suggests solutions such as public-private partnerships and a centralized medical emergency authority.
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1 NAME OF THE STUDENT-SHARU JACOB STUDENT ID-n10031561 SUBJECT NAME-RESEARCH METHODS IN HEALTH
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2 Literature Review Several studies suggested that mortality and morbidity rate is increasing due to injuries and non- communicable disease in low and middle income countries including India which suggests that emergency services needs to be improved urgently to prevent needless death and disability (Hirshon, et al., 2013) (Kotagal, et al., 2014). Rajdou, Mahajan and Balinga further supported this notion by stating that the trauma structure in India still needs massive improvements. They also presented the data that seriously injured people in India have six times more chances to expire as compared to other nations with improved and efficient trauma structure. These countries offer early referral to absolute care leads to better outcome and reduction in poor outcomes (Radjou, Mahajan, & Baliga, 2013). On overlooking, the specific flaws in the EMS of India, two of the studies conducted by Garg and Subhan; Jain called the emergency medical services in India as fragmented (Subhan & Jain, 2010) (Garg, 2012). Further another study conducted by Sriram et. al. called the EMS in India as fragmented, uncoordinated, and of poor quality. In Sriram et.al, study, it was concluded that the stakeholders informed about an absence of regulation and standardization of EMS facilities at the national and regional level in the given hospital. They observed that most of the organizations independently planned and executed their EMT training programs as per their requirements without any accreditation from a national institution or authority. Further, the trainees were also not needed to get a certification from external institutions (Sriram, Gururaj, Razzak, Naseer, & Hyder, 2016).Another study outlined that the pre-hospital services in India are provided by several providers from public, for-profit and non-profit sectors, with are varying from extremely basic patient transport to highly specialized, mobile coronary care units. The study also found out that majority of the people
3 have no awareness of the number to call in case of an emergency such as Dial 108/102/1298 Ambulances, Centralized Accident and Trauma Service (CATS), private ambulance models are available with a wide range of dispatch and transport facilities. (Sharma & Brandler, 2014). Another significant aspect of emergency medical service is the emergency referral services. Government of India has taken initiative to reinforce emergency referral services to enhance the reachfor facility-based intrapartumservice delivery. Government has designed and planned several models for executing the service based on the health infrastructure and several other aspects of different states (Shankar Prinja, et al., 2014). ERS, which is implemented in all the states, is publicly financed however, the mechanism of delivery differs. For example, in states of Jharkhand, Gujarat, Madhya Pradesh and Haryana, delivery of ERS is publicly managed while in states like Bihar, Kerala, Rajasthan and Punjab ERS provision is based on public-private partnership (PPP) mode with public funding and private delivery(Sundararaman, Chakraborty, Nair, Mokashi, & Ved, 2012). However, another study contradicts the findings and identifies the ERS of India as poor. The study found that often the emergency patients are referred government hospitals which leads to wasting of the crucial time which could save patient’s life or improve health outcomes. Further, for the government hospitals, the study reported that there are no well- defined distinction of roles and responsibilities in emergency department(Garg, 2012). In public as well as private sector, a failure of integration and standardization with regards to human resources and regulation within leadership and governance is observed. Due to lack of standardization, the organizations were free to set their own objectives which resulted indiverse range of strategies and approaches. It further led to the conclusion that the EMS scenario in India persists to be fragmented, with least control over the quantity or quality of services. As there is a lackof sufficientgoverning systemsatthe nationalor sub-nationallevels,theduty for
4 emergency care systems is dispersed across a range of public and private actors, without a compulsory force linking these factors and eventually directing the system. Public sector support for services seems to be central to the long-term financial sustainability of EMS organizations. However, the laws and public policy regarding EMS is either lacking or poorly imposed in India. In addition, for improvement in the current EMS scenario in India, more regular and increased funding will be required. Further, there is need for integration and coordination among existing services,andbetterorganizationandleadership.ItcanbeachievedbymakingEMS administration and leadership a more desired career choice. (Nielsen, et al., 2012). It is essential that the guidelines by the Supreme Court of India must be compulsorily presented publicly at emergency in order to remind doctors of their responsibilities and rights and the patients could get the required care easily. When they fails to provide the needed fund and assistance then it must come in the notice of people by auditing through authorized audit companies. Another study identified the barriers to implementing efficient EMS which were classified into six divisions and those were culture differences, poor infrastructure, inefficient communication resulting in ill-coordination, lack of transport, equipment and human resource (Kironji, et al., 2018). Another study supported the argument by revealing that seriously injured patients miss useful prehospital time in the emergency as there is lack of guidance about destination and inter facility transfer, absence of efficient transportation, and no concept of initial trauma care (Radjou, Mahajan, & Baliga, 2013). The extension of EMS especially in rural areas or under reach areas can be done by making use of the already present systems of first responders which are mostly the commercial drivers and lay persons. Initiatives can be taken to improve their efficiency by providing them more comprehensive first aid training, and better including their
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5 endeavors within formal EMS, are necessary. Another study also supports this idea that strengthening the existing network of unofficial sources of drivers and police and with training, funding fast transport with taxes on roads and vehicle fuels and standardizing the private ambulance providers. It could be more cost-effective in a society in which assisting and helping others is not just wanted, but is essential for general financial survival (Roy, et al., 2010). The Government of Delhi in an attempt to address the issue of uncoordinated EMS set up the CentralizedAccidentsandTraumaServices(CATS)intheearly1990s.CATSwere subsequently set up across the whole country. However, it fail to provide any reasonable gains and failed in spite of having a toll free number -102 which is the emergency telephone number for ambulance in several parts of India. But, there are different emergency numbers in different states and Union Territories. Therefore, there is a critical requirement of a centralized Medical Emergency authority that will be responsible for providing guidelines for introducing emergency services with a single telephone number throughout the country. The centralized body can serve several essential purpose such as planning protocols, granting technical support, training, capacity creation, and certification of emergency services. Several studies have identified the need of standardization of procedures, guidelines, and personal competencies along with creation of law in parliament to offer legal safeguard for the workers in emergency services. For example, Government of Gujarat state took the initiative by introducing the Gujarat Emergency Medical Services Authority. It is a required measure in the correct direction. Gujarat was the first state to truly pass emergency services regulation in India. Although in Gujarat, a statewide system of emergency care by integrating government, non-government organizations (NGOs), and other private firms, has been established (Subhan & Jain, 2010).In India if different working bodies such as Securities and Exchange Board of India, Telecom Regulatory Authority of India, and
6 Insurance Regulatory and Development Authority to standardize share market, telecom, and insurance services, respectively, then establishing a governing authority for standardizing the health services, especially the emergencies, can also be taken seriously. One study suggested that public and private partnerships can be significant in executing a structured prehospital care system in India which can be a justifiable solution for improving EMS (Sharma & Brandler, 2014). Another study revealed that Public-Private Partnership mode can be an option to move forward to improve the quality and expand the reach of EMS in India (Gupta & Basu, 2014). But the organizers of private firms have showed apprehension that if the collaboration with the government will achieve the desired goal of expanding the scope of EMS throughout India at a reasonable price. One of the case study revealed that the hospitals adheres to the regulated model across the states and union territories where they have contractual arrangements. Procedures for fleet handling, information systems and training, and placement were efficiently organized at the organizational stage. The public-private partnership seems poor in direction.Thisstudy supportsthe implementationof Public-PrivatePartnership mode. However another study also raised a debatable issue that whether the state-funded EMS scheme will be sufficiently strong a poorly resourced facility in which public hospitals are ill-funded (Gupta & Basu, 2014). Further, one of the studies concluded that due to lack of an EMS system currently, the prehospital care is the responsibility of the citizen which he/she fulfills by using societal associations. It is essential to stop this system and move this responsibility to the state. The arguable point is whether the state-funded EMS system will be strong enough in a setting, which is poor in resources where public hospitals are ill-funded. (Roy, et al., 2010). Even though trauma is a commonly recognized public health issue, its primary prevention has lingered in the field of town organizers and railroad constructers and developers. A combined research on
7 primary prevention of road traffic accidents, domestic injuries, industrial trauma and civil mass fatality has not been conducted in India to this point. Therefore, further research is needed in future to understand the different aspects of EMS in India and their connections with each other as it will enhance the overall understanding of the functioning and governance of EMS organizations. REFERENCES 1.Garg, R. H. (2012). Who killed Rambhor?: The state of emergency medical services in India.J Emerg Trauma Shock, 5(1), 49–54. 2.Gupta, R., & Basu, S. (2014). Ziqitza Healthcare Limited: Challenge of Scaling up Emergency Medical Services (EMS) in India using Public-Private Partnership (PPP) Mode.Asian Journal of Management Cases, 11(1), 5-21. 3.Hirshon, Risko, Calvello, Stewart, Ramirez, Narayan, . . . O'Neill. (2013). Acute Care Research Collaborative at the University of Maryland Global Health I.Health systems and services: the role of acute care, 91, 386–388. 4.Kironji, A. G., Anest, T., Wallis, L., Razzak, J., Jenson, A., Hansoti, B., . . . Ramirez, S. S. (2018). Identifying barriers for out of hospital emergency care in low and low-middle income countries: a systematic review.BMC Health Serv Res, 18. 5.Kotagal, Agarwal-Harding, Mock, Quansah, Arreola-Risa, & Meara. (2014). Health and economic benefits of improved injury prevention and trauma care worldwide.PloS one, 9. 6.Nielsen, Mock, Joshipura, Rubiano, Zakariah, & Rivara. (2012). Assessment of the status of prehospital care in 13 low- and middle-income countries.Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 16, 381–389. 7.Radjou, A. N., Mahajan, P., & Baliga, D. K. (2013). Where do I go? A trauma victim's plea in an informal trauma system.J Emerg Trauma Shock, 6(3), 164-170.
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8 8.Roy, Murlidhar, Chowdhury, Patil, Supe, Vaishnav, & Vatkar. (2010). Where there are no emergency medical services-prehospital care for the injured in Mumbai, India. Prehosp Disaster Med, 25(2), 145-51. 9.Shankar Prinja, 1. ,., Mokashi, T., Aggarwal, A. K., Kaur, M., Reddy, K. R., & Kumar, R. (2014). Evaluation ofPublicly Financed and Privately Delivered Model of Emergency Referral Services for Maternal and Child Health Care in India.PLoS One, 9(10). 10.Sharma, & Brandler. (2014). Emergency Medical Services in India: The Present and Future.Prehospital and disaster medicine, 1-4. 11.Sriram, Gururaj, Razzak, Naseer, & Hyder. (2016). Comparative analysis of three pre- hospital emergency medical services organizations in India and Pakistan.Public Health, 169–175. 12.Subhan, & Jain. (2010). Emergency care in India: The building blocks.Int J Emerg Med, 3, 2017-11. 13.Sundararaman, Chakraborty, Nair, Mokashi, & Ved. (2012).Publicly Financed Emergency Response and Patient Transport Systems Under NRHM.New Delhi: National Health Systems Resource Centre. APPENDICES PART 1-KEY WORDS AND SEARCH TERMS 1.Governance- 12396 articles were identified. 7903 met the inclusion criteria. None of them were found relevant to the topic. 2.Governance and emergency medical services- 210 articles were identified. 152 met the inclusion criteria. 3 were found relevant to the topic. 3.Emergency medical services- 134450 articles were identified. 53281met the inclusion criteria. 2 of them were relevant. 4.EmergencymedicalservicesandIndia- 917 articleswere identified.551 metthe inclusion criteria. 4 were found relevant
9 5.Prehospital care and India 119 articles were identified. 89 met the inclusion criteria. 3 were found relevant. Inclusion criteria 1.English language 2.Published within 10 years 3.Full-text available PART 2-FLOW DIAGRAM OF ARTICLE INCLUSION School of Public Health and cial Work 12 full articles articles were included 667 titles were read 39 abstracts were retrieved 27 articles were excluded ï‚·Key terms used- 1. Governance 2. Governance and emergency medical services 3. Emergency medical services 4. Emergency medical services and India 5. Prehospital care and India. ï‚·Databases included- PubMed, ScienceDirect, Government websites Exclusion criteria 1.Unsuitable target population 2.Irrelevant information 3.outdated Exclusion criteria Irrelevant information as the information was related to other aspects of Emergency Medical Services and not Governance 12 articles met all the inclusion criteria and were found relevant to the research topic
10 Queensland University of Technology HLN707 Research Methods in Health Assessment Item 1, Part A. Expression of Intent. Student name:SHARU JACOB Student number:n10031561 What course (code) and major are you enrolled in?PU84(Master of health management) Depending on your course and major, this unit will serve different purposes. For some students, it is an elective unit and there is no requirement to undertake the research. Are you taking this as an elective?yesno For other students, HLN707 will help you develop a research proposal and undertake either a research project or research thesis. Which one are you intending to complete? HLN703 (24cp project)HLN700 or HLN750 (48cp thesis) Internship (PU84 only) If this is you, are you taking HLN707 the semester before you do your project or thesis? yesSemester enrolled:__________no
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11 If No please explain why? ______________________________________ You may be able to explore an idea of your own, or there are a number of potential research projects available on Blackboard. If you are interested in one of these projects, in the first instance, you must discuss this with Kaeleen or Erika. Which type of research are you considering at this stage?Please circle or highlight Literature review:scoping reviewsystematic (narrative) review systematic review (meta-ethnography) Methodology:qualitativemixed methodsquantitative Secondary data analysis using:qualitativeorquantitative data Tentative research question: GOVERNANCE OFEMERGENCYMEDICALSERVICESININDIA, ASCOPING REVIEW Background:(What is the context to your research proposal?). The mortality rate in emergency medical services and prehospital care is high in spite of several initiatives taken by the Government. Due to the poor condition of the emergency services, the health outcome for the patient drops down. Medical Emergency has not been defined by the Indian Judicial system and it is still largely left to the discretion of medical professionals to define it. At present, the peripheral level health centers, i.e., S/C, PHC, and CHC, are nothing more than the referring centers. Doctors also show unwillingness to attend to emergency cases as they deem it medico legal cases. EMS in India has been identified as unfragmented and coordinated therefore, it is essential to understand the
12 governance of these servicesin order to hold the system accountable andlook for improvement. Broadly, what is research topic or area?(up to 5 keywords) 1.Governance 2.Governance and emergency medical services 3.Emergency medical services 4.Emergency medical services and India 5.Prehospital care and India. Now, describe your research topic in a little more detail. The research topic will identify the challenges faced in the emergency medical services in India. It will also identify the reasons for these challenges especially in terms of structures, processesandsystemsinvolvedinEMS.Further,theresearchwillprovidethe recommendations to improve the governance of EMS in India so that mortality rate can be lowered and health outcomes for patient can be improved. What is the aim (1) of your proposal? To understand the structures and processes involved in Emergency medical services in India and look for scope in improvement of EMS in India What are objectives (3) of your proposal? 1.To identify the current status of emergency medical services in India 2.To understand the structures and processes involved in Emergency medical services in India
13 3.To identify theneed of effectivepublic and private partnership systemthat could provide quality emergency care with equity of access in India Is there a need for this project, and how will your project address this need?Please only complete if your project is related to your current workplace ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _________ What are the expected outcomes?(What you want to achieve with this project) 1. Develop understanding of the emergency medical services scenario in India 2.Gain understanding of the structures and processes involved in Emergency medical services in India 3.Use the findings to contribute to future developments of emergency medical services policies and improve the emergency services in India. Who will benefit?(Who this project is targeted towards?) Policy-makers involved in decision-making regarding the EMS will benefit. Further, researchers looking for further investigation on the topic of EMS can also benefit. Who are potential supervisors?(Search staff on the QUT website) 1.Dr. Kaeleen Dingle 2.Dr. Erika Borkoles
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14 What is the timeline for your project? Please attach a table/Gantt chart Aug week 1 Aug Week 2 Aug Week 3 Aug Week 4 Sept Week 1 Sept Week 2 Sept Week 3 Sept Week 4 Oct Week 1 Oct Week 2 Oct Week 3 Oct Week 4 Identify EOI Meeting with the supervisor Searching articles for EOI Submissio n of EOI Aug 19/8 Searching Review of literature Gather points related to article Submissio n of literature review Sept 23/9 Preparing for research proposal Pitch presentati on and brief research protocol Oct 29/10 big rethinkbit more thoughtfew tweaksgood to go
15 Comments: Coordinator:______________________________________PASS / FAIL (10%) You must submit this EoI in Week 4 during class (INTERNAL students) or on EXTERNAL students Blog and resubmit your corrected version EOI via BB by the end of week 4
16 PART 3-Search strategy DateURLAuthorStudy synopsis 1.14/09/20 18 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4983503/ VeenaM. Sriram; Gopalkris hna Gururaj; JunaidA. Razzak; Rizwan Nasser; AdnanA. Hyder Qualitative studyto conducta cross-case comparative analysisof threeEMS organizations inIndiaand Pakistanin order to draw out similarities and differencesin their models 2.14/09/20 18 https://www.cambridge.org/core/journals/ prehospital-and-disaster-medicine/article/ emergency-medical-services-in-india-the-present- and-future/ Mohit Sharma; EthanS. Brandler Reportto highlight recommendati ons that have
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17 E91F6B69AB28EEA6E4D92865C81434FEbeen put forth tohelp optimizethe Indian prehospital emergency caresystem, including regionalizatio nofEMS, better training opportunities, budgetary provisions, and improving awareness amongthe general community 314/09/20 18 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4964166/ Matthew C Strehlow; Jennifer A Prospective observational studyto Characterise
18 Newberry; CoreyB Bills; Hyeyoun (Elise) Min;Ann E Evensen; Lawrence Leeman; Elizabeth A Pirrotta; GV Ramana Rao; S V Mahadeva n the demographics, management and outcomes ofobstetric patients transported by emergency medical services (EMS) 414/09/20 18 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3299154/ RajeshH Garg Toidentify thestateof emergency medical servicesin India
19 514/09/20 18 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4215978/ Shankar Prinja; Pankaj Bahuguna ; P. V. M. Lakshmi; Tushar Mokashi; Arun Kumar Aggarwal; Manmeet Kaur;K. Rahul Reddy; Rajesh Kumar Evaluationof publicly financedand privately delivered model of ERS inPunjab state, India, to assessits extentand patternof utilization, impacton institutional delivery, qualityand unit cost 614/09/20 18 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3452474/ Sandeep Kumar; Sushant Chaudhar y; Akshay Kumar; Observer studyto study the infrastructure, human resource
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20 Arpit Kumar Agarwal; M.C. Misra allocation, working, futureplans and vision of the established trauma centers at the 3 capital cities of India —Delhi(2 centres), Lucknowand Mumbai. 714/09/20 18 http://journals.sagepub.com/doi/abs/ 10.1177/0972820113520207 Rakesh Gupta; Sriparna Basu To understand the Challenge of Scaling up Emergency Medical Services (EMS)in Indiausing Public-Private Partnership
21 (PPP) Mode 814/09/20 18 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4972360/ Samiksha Singh; Pat Doyle; OonaM. Campbell; Manu Mathew; G.V.S. Murthy Systematic review to find outthe proportionof referrals between publichealth institutions for womenwith obstetrichigh risk, complications, or emergencies in India 914/09/20 18 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3746436/ Angeline N Radjou; Preetam Mahajan; DillipK Baliga Surveyto studythe prehospital profileof patientswho dieddueto trauma,
22 computethe time taken to reachour facility,find thecauseof delay,and make feasible recommendati ons. 1 0 14/09/20 18 https://www.ncbi.nlm.nih.gov/pubmed/20467994Roy; Murlidhar ; Chowdhur y;Patil; Supe; Vaishnav; Vatkar A. Todescribe the prehospital careand transportation thatcurrently is available in Mumbai. 1 1 14/09/20 18 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5907770/#CR17 Antony Gatebe Kironji; Peter Hodkinso n;Sarah Systematic reviewto identify barriers to and key interventions
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23 Stewart de Ramirez; Trisha Anest; Lee Wallis; Junaid Razzak; Alexander Jenson; Bhakti Hansoti forOHEC deliveryfor owandlow- middle income countries 1 2 14/09/20 18 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3360803/ Katie Nielsen; Charles Mock; Manjul Joshipura; Andres M. Rubiano; Ahmed Zakariah; Frederick To better plan for development of prehospital careglobally, thisstudy soughtto better understand the currentstatus of prehospital
24 Rivaracare in a wide rangeof LMICs. PART-4 Data extraction table Study titleYearAuthorCountryStudyResults
25 of stud y setting 1.Comparative analysisof threepre- hospital emergency medical services organizations inIndiaand Pakistan 2016VeenaM. Sriram; Gopalkrishn aGururaj; JunaidA. Razzak; Rizwan Nasser; AdnanA. Hyder India and Pakistan GVK EMRI (Karnataka ,India), Aman Foundatio n (Karachi, Pakistan), and Rescue 1122 (Punjab, Pakistan) Emergentthemesunder eachhealthsystem ‘building block’ of service delivery, health workforce, medicalproductsand technology,health informationsystems, leadership and governance, andfinancingwere described.Cross-cutting issues not applicable to any single building block were further identified. 2.Referrals between PublicSector Health Institutions forWomen 2016Samiksha Singh;Pat Doyle; Oona M. Campbell; Manu IndiaTheproportionof institution-referralswas high.
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26 with Obstetric HighRisk, Complications ,or Emergencies in India – A Systematic Review Mathew;G. V.S. Murthy 3.Evaluationof Publicly Financedand Privately Delivered Modelof Emergency Referral Servicesfor Maternaland ChildHealth Care in India 2014Shankar Prinja; Pankaj Bahuguna; P.V.M. Lakshmi; Tushar Mokashi; Arun Kumar Aggarwal; Manmeet Kaur;K. Rahul Reddy; Rajesh India20 districts ofPunjab withERS services Onanaverage,an ambulance transported 3–4 patients per day. Poor and those farther away from the health facility had a higher likelihoodofusingthe ambulance.Althoughthe ERS had an abrupt positive effectonincreasingthe institutionaldeliveriesin the unadjusted model, there wasnoeffecton institutionaldeliveryafter adjustmentfor autocorrelation.Costof
27 Kumaroperatingtheambulance servicewasINR1361 (USD22.7)perpatient transportedorINR21 (USD0.35)perkm travelled. 4.Emergency Medical Servicesin India:The Presentand Future 2014Mohit Sharma; EthanS. Brandler IndiaTheimportanceofpublic and private partnerships in implementing an organized prehospital care system in India discussed in the report maybeareasonable solution for improved EMS inotherdeveloping countries. 5.Wherethere areno emergency medical services- prehospital careforthe injuredin 2010Roy; Murlidhar; Chowdhury; Patil;Supe; Vaishnav; Vatkar A. IndiaLevel-I, urban, trauma center Currently, as a result of not havinganEMSsystem, prehospital care is a citizen responsibility using societal networks.
28 Mumbai, India 6.Identifying barriersfor out of hospital emergency careinlow andlow- middle income countries:a systematic review 2018Antony Gatebe Kironji; Peter Hodkinson; Sarah Stewartde Ramirez; Trisha Anest;Lee Wallis; Junaid Razzak; Alexander Jenson; Bhakti Hansoti Low and low- middle income countrie s systematic reviewof thepeer reviewed literature from January 2005to March 2015in PubMed, Embase, Cochrane, andWeb of Science BarrierstoOHECwere divided into six categories thatincluded: culture/community, infrastructure, communication/coordinatio n, transport, equipment and personnel. 7.WheredoI go? A trauma victim'splea in an informal 2013AngelineN Radjou; Preetam Mahajan; Indiatrauma centerin Puducherr y Seriouslyinjuredpatients losevaluableprehospital timebecausethereisno directionregarding
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29 trauma systemDillipK Baliga destination and interfacility transfer, a lack of seamless transport, and no concept of initial trauma care. 8.Traumacare —a participant observer studyof trauma centersat Delhi, Lucknowand Mumbai 2009Sandeep Kumar; Sushant Chaudhary; Akshay Kumar; Arpit Kumar Agarwal; M. C. Misra Indiatrauma centers Unionandstate governmentsofDelhi, MaharashtraandUttar Pradesh have spent heavily tocreatetraumaand emergency infrastructure in their capital cities. 9.Assessment of theStatusof Prehospital Carein13 Low-and Middle- Income Countries 2012Katie Nielsen; Charles Mock; Manjul Joshipura; AndresM. Rubiano; Ahmed low- and middle- income countrie s emergency medical services (EMS) leaders andother key informants Prehospital care capabilities varied significantly, but in general,wereless developedinlow-income countries and in rural areas, where utilization of formal emergency medical services was often very low.
30 Zakariah; Frederick Rivara 10 . Characteristic sand outcomesof womenusing emergency medical servicesfor third-trimester pregnancy- related problemsin India:a prospective observational study 2016MatthewC Strehlow; JenniferA Newberry; CoreyB Bills; Hyeyoun (Elise) Min; AnnE Evensen; Lawrence Leeman; ElizabethA Pirrotta;G VRamana Rao;SV Mahadevan IndiaFive Indian states usinga centralised EMS agency that transporte d3.1 million pregnant womenin 2014. Pregnantwomenfrom vulnerableIndian populationsusefree-of- charge EMS for impending delivery, making it integral to the healthcare system. 11Whokilled Rambhor?: Thestateof 2012RajeshH Garg IndiaCase studyIt has to be understood that routine doctors could not be relieduponproviding
31 emergency medical servicesin India emergencyservicesin routineatemergency departments. 12 . Ziqitza Healthcare Limited: Challengeof Scalingup Emergency Medical Services (EMS)in Indiausing Public-Private Partnership (PPP) Mode 2014Rakesh Gupta; Sriparna Basu IndiaThefounderswere apprehensiveofworking withthegovernmentand unsure whether this should be the next step to expand thereachofEMSacross India at an affordable price