Philippine Emergency Medical Services : A Medical Student ’ s Perspective

The Philippine Emergency Medical Services (EMS) has evolved greatly from the time of its establishment. One of the recent changes in the EMS is the establishment of a nationwide emergency hotline. However, the Philippine EMS continue to face different problems such as overcrowded hospital, lack of sufficient facilities, referral system and regulated ambulance system and paramedic profession. Strategies that can help resolve these issues include updating local EMS data through research, unifying national and local EMS program through standardization and patient education.

The emergency medical services (EMS) in the Philippines is not fully centralized and standardized.Despite the governmentʼs effort to unify the emergency medical services, different sectors such as hospitals and ambulance services continue to work independently.Changes in this system are needed to provide a better quality of service and to avoid overcrowding in the emergency rooms of different hospitals.However, in order to come up with a proposal for the improvement of the EMS, it is essential to review the current system in the Philippines.

Emergency medicine (EM)
Emergency medicine in the Philippines was recognized as a specialty in 1988, resulting to the establishment of post graduate exams in 1991 and establishment of a national EM society (Philippine College of Emergency Medicine or PCEM) in 2011.Emergency departments (ED) in the Philippines operate 24 hours a day.These departments are not allowed to refuse any patients as legislated by law since 1997.As of 2015, only 11% of the hospitals in the Philippines have emergency departments with more than adequate equipment and system to care for emergency cases 1) .In terms of emergency doctors, the population to doctor ratio is 37, 167 while the population per certified emergency physician is 157,886.Beyond this, data show that 15% of nurses in the Philippines are emergency department nurses.Patients who go to the emergency department will be admitted within 6-24 hours 1) .However, it will take more than 24 hours for some patient in the emergency department to get admitted in some hospitals, particularly public hospitals.
For example, in the Philippine General Hospital (PGH), a tertiary referral center in Manila providing inexpensive medical services for the poor, patients are admitted if medically justified.Given the hospitalʼs medical expertise, some Filipinos prefer to go straight to PGH than go to the regional hospitals.Moreover, governmentʼs subsidy to PGH as a national university hospital helps to provide specialized services such as neurosurgery, diseases that require multidisciplinary care and intensive care.The huge volume of patients who seek treatment in the ED results in a longer turnaround time (> 72 hours) from ED entry to admission.

Centralization
Previously, only a few cities and provinces had a hotline available for emergency medical purposes.In 2016, the government established a nationwide hotline 911 for emergency medical services.This 911 hotline will transfer the call to a regional call center depending on the location of the emergency caller.This hotline is not solely for medical emergency but it also caters to security and disaster reports.A call to the hotline costs around P5 per call to discourage prank calls.In 2016, out of 4.5 million calls received via the hotline, 50% were legitimate calls while the remaining were incomplete or illegitimate calls.Communication between responders and hospitals is not well established due to lack of information (e.g.bed availability, critical specialists, surgeons, operating room availability) provided 2) .Additionally, the differences in record keeping by institution/service decrease the efficiency of the communication system.

Pre-hospital care
The well known responders in the Philippines are those with the Philippine Red Cross (PRC), which has an operation center that operates 24/7 with 97 chapters across the Philippines.At the community level, trained volunteers are capable of providing assistance in emergency situations.
In the Philippines, paramedic is not yet a licensed profession recognized by the Philippine Regulatory Commission (PRC).Emergency medical technicians and emergency medical doctors provide medical service on-board the ambulance.EMTs are either affiliated with hospitals, local government or private sectors.The EMTs are trained by their department/affiliated accredited sectors using a curriculum that varies by institution.Currently there is a proposed bill in the Philippine congress to regulate the EMT profession to ensure quality service.
Ambulance services in the Philippines are one of the following: a service offered by the city or provincial government, an extension of the hospitalʼs department of emergency medicine or a service offered by private companies or community-based ambulance services like Red Cross Philippines.As of 2015, the population to ambulance ratio was 2,106 1) .Regulation of ambulances was first ordered in 2016 by the Department of Health to ensure quality service.Some ambulance services render free service while others require payment depending on the distance they have to cover.Due to this factor, Filipino patients who do not utilize ambulance services usually bring the patient via public or private transportation.Since the number or patients expected to go to the ER per day varies, the emergency rooms of trauma centers and government hospital are usually overwhelmed by patients.

Strategies to improve Philippine Emergency Medical Services (EMS)
The lack of funding, infrastructure and government are issues that greatly hinder the development of EMS in different countries 3) .Specifically, the identified major issues with current EMS system of the Philippines are the following: standardization of EMS, overcrowding of hospitals and underdeveloped pre-hospital care.There are many things that can and should be done to improve the Philippine EMS.As a medical student, it is important to understand that the EMS is a part of a countryʼs health system.Therefore, it would be ideal to involve all sectors that are part of the health care delivery system in improving the countryʼs EMS (Figure -1).

Data and research
First, the lack of nationwide EMS should encourage the health sectors (hospitals, Red Cross, NGOs and health centers of each local government unit) particularly the PCEM to do studies on the performance of their respective EMS.These studies should evaluate all the capacities and limitation of each institution (ex.beds, ORS, staffs, ambulance) and relate it to the demand of the patients that are accepted in the ER and the quality of service they render.The analysis of the data should not only be used to improve the institution but should be pooled together by the Department of Health (DOH) to identify the problems in each EMS.These data can be presented to the congress for the statesmen to push for bills/laws relating to EMS.For example, in 2009 and 2013, two bills were proposed in the senate both emphasizing the importance of pre-hospital emergency care and regulation of the EMT profession.However, no news on these bills was heard after the proposal.More credible studies and data from the health sectors of the country can help lawmaker see the relevance of these bills and gain their support.

Standardized EMS programs
The health system in the Philippines is devolved -meaning that the implementation of primary health care programs is the responsibility of the local government units.Funding for health care services -such as equipment, supplies, manpower, infrastructure and transport ambulances are dependent on the prioritization of health by local chief executives.The DOH generally functions as the regulator of health policies and programs in order to assure basic health access and quality health care services.DOH deploys physicians to doctorless municipalities through its Doctors-to-the-Barrios Program.The DOH also monitors the implementation of national programs like TB-DOTS, vaccination and dental programs, antenatal care and child immunization.Implementation and allocation of resources, especially the national budget is however, still centralized with national agencies despite the devolution of health services.The system has good and bad aspects.First, the services are identified at a national level but quality of service rendered in each region or province varies.Second, the implementation of this type of health system is dependent on the political leaders.Health projects will only be prioritized if health is advocated a leader.It is not uncommon for BLS ambulances in some municipalities to carry the faces of the public officials who bought the transport vehicles.Additionally, since local government officials are elected every 3 years, health project monitoring can be erratic, and the projects themselves are sometimes discontinued.
Given this situation, DOH should work with the Department of Interior and Local Government (DILG) -the department that oversees local government performance, to create policies that ensure quality and unbiased health services.Current performance indicators for local government in terms of health programs are reported annually.Using these data, the DOH can allocate appropriate resources such as health workers and medicines in each locality.For EMS, DOH should regulate the ambulance services (identification of optimal location of services; provision of appropriate number and type of ambulances, EMTs and ambulance drivers;) provided by each local government to assure that these services are unbiased and will not be abused by the leaders for their own political ambitions.The successful implementation of the 911 hotline in the Philippines should encourage the government to go beyond the hotline.DOH and DILG should work together to establish communication and dispatch centers by locality.
The DILG should mandate prioritization for communication among hospitals, police and fire departments.DOH with the help of the PCEM should also push for a standard protocol for accepting patients to the ER particularly with the sharing of information on incoming patients between responders and the hospital.Finally, regulation of emergency technicians and the establishment of paramedic licensing should be pushed both by the DOH and PCEM in the congress in order to triage the patients more efficiently at the site of emergency so that they can contact and go to the appropriate hospital.Establishment of paramedic licensing and communication lines can drastically reduce going to hospitals blindly without any prior communication.

Education
Aside from the government and health sectors, ordinary citizen as prospective patients should also be part of the change.This change can be made through education.The reason behind this is that Filipino families usually are not aware of the proper institution to which to bring their sick relatives.Usually, Filipinos want what is the best for their family, and thus go to tertiary hospitals immediately instead of going to district hospital or rural health units for primary health care.The lack of improvement in health facilities and trained manpower at this level maybe a factor for their choice of institution.Likewise, health care providers have difficulty in transporting and referring patients in need of tertiary care have resulted in poor health outcomes.Social innovations like having interisland boat ambulances in Zumaraga, Samar to connect remote birthing stations to main birthing station in the district is an example of how people can change access to health care.At the community level, information on health facilities and services should always be available.Vulnerable groups may be organized to access health resources at all levels of the health care system.
In school, health education pertaining to access to health information may be given to parents during parent-teacher consultations.Brochures informing people of ways to prevent diseases may be given by community health workers.Information about common signs and symptoms and first-aid may be disseminated to families and parents.Public health lectures can be initiated by local government with the help of medical students or NGOs.These training and education activities may hopefully decrease the number of patient in tertiary hospitals, enabling higher quality services.

Conclusion
Among these proposals, emphasis must be on the importance of data and research since this can help us identify problems and improve the existing system.It can also help in bringing awareness of the current situation to the public and to the government.I believe that this aspect is where the medical students can contribute.Secondly, public education should also be emphasized as a crucial part of pre-hospital care.Students can initiate this project but the support of NGOs and government are greatly needed.
Indeed, improving the EMS in the Philippines requires the various stakeholders to work together to organize and standardize EMS services.As future healthcare providers, medical students need to learn how to care for patients both in the primary and tertiary health care settings and to properly transfer and transport patients.Indeed, it will require a quality healthcare system to improve the health outcomes in our country.

Figure- 1
Figure-1 Proposed Conceptual Framework for EMS 4) Good governance and legal framework should manage the service providers, support facilities and other stakeholders in order to improving the EMS delivery particularly emergency dispatch, emergency response and care, inter-facility referral and transport, and emergency transport.(Lorenzo FME, et al: Development of Guidelines for the Establishment of Emergency Medical Services (EMS) prior to Hospital Care Book 1 -Final Technical Report, Department of Health-Disease Prevention and Control Bureau, 2013 4) )