Death and disability from severe injuries can be avoided if the right care is provided quickly.
By TABITHA AREBA
World War II gave birth to the concept of emergency air evacuation, a mission that lowers morbidity and mortality rates due to the speedy movement of patients to hospitals coupled with timely management and proper handling of patients.Since then, air ambulance service has become an essential component of the health care system which when utilised appropriately saves lives and reduces the cost of health care.
Dr Bettina Vadera, AMREF Flying Doctors Chief Executive Officer and Medical Director notes that very few countries in Africa have this service offered despite the huge number of medical emergency occurrences occasioned by terrorist attacks, wars as well as tribal and cross-border clashes.Anne Baran in an article published in the Journal of Nursing argues that emergency air evacuation minimises the time-lapse before a critically injured or the ill will spend before they can get to a hospital. The saying “time is human tissue” is a saying that best describes air evacuation, as it means death and disability from severe injuries can be avoided if the right care is provided quickly.
The picture of an air ambulance responding, following a car crash or a terrorism incident evokes visions not only of the life-saving power of air medical services, but also of the inherent risks in the environment in which they are required to operate. Yet, Dr Vadera argues, air medical patient care and transportation promises less risk to the patient’s life than does a patient’s stay at an ill-equipped medical facility.
Air ambulance service is a valuable medical resource which involves transportation of patients and medical staff, as well medical equipment and supplies to the affected area(s). AMREF Flying Doctors has been offering air ambulance services in East Africa for close to 60 years under its parent company Amref Health Africa. In 2011, AMREF Flying Doctors was incorporated as a company limited by guarantee and not for profit because all its proceeds go to Amref Health Africa to meet funding gaps.
Air evacuation services
Through its Maisha product, the organisation provides medical air evacuation cover targeting individuals, families, groups, corporate and tourists. Subscribers of Maisha, the annual ambulance scheme, can be evacuated from anywhere in the Eastern Africa region including Ethiopia and South Sudan.
With the decline in tourist numbers over the last one year, the company has recorded a slowdown in the uptake of Maisha Tourist product resulting in 11 per cent drop on the subscription numbers compared to the year before. “In the overall context of the economic climate in Kenya, certain sectors of the industry that affect us directly such as tourism, investment and travel, recorded a slump,” says Dr Vadera.
Overall the company has recorded steady and clear growth for three consecutive years from the time it was incorporated.
Terrorist attacks in Kenya over the last two years have led to a 25 per cent fall in visitor numbers. Whenever there is an attack, western countries issue travel advisories on non-essential travel to Kenya. According to Kenya Tourism Board, the country lost a quarter of its visitors in the first five months of 2015, from 381,278 to 284,313. Additionally, Ebola in West Africa affected tourism and movement to Africa.
Although this only directly affected West Africa, Guinea, Liberia and Sierra Leone – once word is out that thousands of people are dying, the perception by people living outside Africa is that the whole continent has been affected. “However hard you try advising them that there are tens of thousands of miles between West Africa and East Africa, it doesn’t help,” she adds.
Despite the drop in tourist subscription numbers, the organisation has adopted cost saving measures and aggressive marketing to boost profits. “We managed to grow our Maisha Annual product by about 14 per cent over the last year. Additionally, we expanded our agreement with National Hospital Insurance Fund (NHIF) to cover more civil servants.”
The organisation entered into the partnership with NHIF in 2014, but initially covered disciplined forces. Other than NHIF, other key industry players that purchase Maisha for some of their customers include CIC Insurance, Infarma insurance, Paradigm Insurance, Resolution Health insurance, AAR Health, J W Seagon, Britam Kenya and South Sudan, UAP South Sudan and Uganda, Jubilee Insurance Kenya and Uganda as well as Pacis Insurance.
MaishaAir Ambulance Scheme, which is AMREF Flying Doctors flagship product, targets the East African Market. Eighty per cent of the annual subscription comes from Kenya, followed by Tanzania, Uganda and the other East African countries.
“We really want to concentrate on the Kenyan market first because of low risks,” says Dr Vadera.
The organisation’s aircraft are based in Nairobi, which is also touted as the centre of medical excellence in East Africa. It is believed that doctors in Nairobi have open and free exchange in education and training with the Northern countries, and the West, and have embraced international medical standards and work according to internationally recognised protocols.
The organisation also targets tourists who visit Uganda, Rwanda and Tanzania. Ugandan Authorities allow AMREF Flying Doctors aircraft to fly in and out the country but with regulatory barriers. “But there is a stark difference between Tanzania and Uganda –Tanzanians rate Kenya’s medical care highly and this seems not necessarily to be the attitude in Uganda,” says Dr Vadera.
With Tanzania, the organisation has a blanket flat clearance agreement and can fly direct to the location without passing through a port of entry.
The Maisha cover reaches as far as Ethiopia where a big number of the country’s population also view Kenya as a centre of medical excellence.
“The problem that we have with Ethiopia is that authorities do not make it easy for us to cross the border. We recently had a request to evacuate a patient from Addis Ababa to Nairobi for further medical treatment. While the insurance company gave us approvals, we were not able to get clearance by Ethiopian authorities from late afternoon throughout the night till late morning the following day. We experienced a delay of more than 12 hours,” she laments.
While Ethiopia may have air evacuation demands, logistics are so difficult and the organisation has excluded the country from its marketing strategies. “We cannot go out there and take people’s money when it takes us 12 to 14 hours to deliver our job,” she says.
Where clients require further medical treatment outside Kenya, and the patient is stable enough to use commercial airlines, AMREF Flying Doctors offers medical escort, especially to countries that are popular in medical tourism such as South Africa, India and Thailand.
“What impresses me with these countries – which I think Kenya is missing – is the attention to detail and customer care,” notes Vadera. Patients’ frustration in Kenya’s private hospitals due to complex systems, notwithstanding their critical state, is a factor that has driven Kenyans out of the country for better medical care.
“People detest the long bureaucratic procedure. As a customer, you never feel appreciated, you get little assistance, you are sent from one place to the other, and nobody realises that you came to the hospital because you were sick.
A study titled Service quality and its impact on customer satisfaction in Indian Hospitals established that patients and attendants treat the interpersonal aspect of care as the most important as they cannot fully evaluate the technical quality of healthcare services.
In countries where medical tourism is strong, most patients report generally high satisfaction with quality of care received.
Partnership with counties
Historically, AMREF Flying Doctors has carried out air ambulance evacuation from remote areas in Kenya such as Northern Kenya, where medical facilities are poorly equipped and medical expertise and specialisation is unavailable. “We have always provided charity evacuations but we want to pass on this responsibility to the County Governments,” she says. It is the responsibility of the County Governments to ensure that its people have access to medical care and if the medical specialisation is unavailable in the county, Dr Vadera believes that the leaders should look for ways to ensure patients are transferred to better facilities rather than relying on private operators to absorb the entire burden.
During the Garissa Terrorist attack in early 2015, AMREF Flying Doctors sent six aircraft which evacuated 26 patients. Since there was no proper plan as to who would finance the mission, the company had to cater for the expenses which amounted to USD45,000 (KSh4,500,000).
“With the County Government in place, we want to partner and distribute that responsibility. We are in dialogue with them through Amref Health Africa,” she says.
One of Amref Health Africa missions is to take specialised medical outreach support to rural areas. The organisation is looking at how a medical outreach programme can be intertwined into the partnership with county governments.
Investing in infrastructure
Every year, AMREF Flying Doctors puts money into well-equipped ground and air ambulances as well as new staff and staff training programmes. Baran notes that having adequate and properly trained medical attendants such as surgeons, nurses and medical technicians aboard the transport planes while evacuating patients is an important consideration.
Over the last three years, the organisation has added three ground ambulances into its fleet. “We now have a total of four advanced life support ground ambulances.
In 2014, we added a new aircraft into our fleet. In our exclusive partnership with Phoenix Aviation, we have just brought in the first long haul ambulance aircraft into the country,” says Dr Vadera. The new aircraft, an exclusive air ambulance with high level ICU, can evacuate a patient from Nairobi to London with just one stop.
The organisation recently invested close to USD30,000 in a whole range of ventilation equipment that can that can handle premature babies to adults, as well as a quality incubator that can safely transport a premature new born.
The capital-intensive business has seen AMREF Flying Doctors gain autonomy of the market in East Africa, with the closest competitor being in South Africa and Europe for the tourism market. While AMREF Flying Doctors is the only organisation that operates in the local market, Dr Vadera ensures that best practices and industry standards are maintained to remain at the top of the market.
Last year, the company did close to 1,000 evacuations, that averages to two to three missions a day. The cost per evacuation depends with distance and the aircraft deployed An evacuation from Mombasa to Nairobi during the day costs about USD9,000 (KSh900,000).
Towards the end of 2014, AMREF Flying Doctors won the air ambulance provider of the year Award for the second time. The international award, given out by the International Travel Insurance Industry within the industry of medical providers and travel insurance, is the most prestigious. “What makes us stand out and what is really appreciated by international stakeholders is that we have very high standards of professional excellence, despite our challenging operating environment” she says.
AMREF Flying Doctors was the first company to be accredited internationally for the high standards of air ambulance medical provision and has maintained this annual accreditation since 2007.
Additionally, she notes, everybody acknowledges that working in Africa, a continent that lacks meteorological aviation support, is more difficult than Europe or United States.