The concerns highlighted by the general public appear to be echoed in the physician survey. Although it is reassuring that the physicians intend to treat patients regardless of their ability to pay, it stands stark in contrast to belief of the general public that they will be asked to pay up front (50%). In addition, thirty three percent of ambulance staff physicians believe that patients are better off to drive themselves to the hospital. There appear to be significant barriers to trust in the system by both doctors and patients. Forty seven percent of physicians expressed serious concerns regarding the emergency services that they and their colleagues are providing. In addition, serious deficits in equipment and medications further deepen their concern. These barriers can delay or hamper treatment and offer an opportunity for improvement in both public education and continuing medical education for physicians in the ambulance system.
Discussion of themes
EMS organization and structure
In-depth interviews and focus group discussions conducted in 2005 as part of a needs-assessment yielded interesting themes. The comments were transcribed and analyzed manually for thematic saturation. Physicians working in emergency medical services who participated in the study also relayed the history and organization of the ambulance system and the training center in Yerevan. Some relayed the advantage of the current system, namely emphasizing that the presence of a medical doctor in an ambulance team is a rare practice for other countries and is an advantage for the Armenian population. The quotes that follow are taken from focus group discussions (FGDs) and in-depth interviews (IDIs).
After independence, in 1993 on the basis of the Department of Emergency Services, we established the Educational-Methodological Center. From 1993 to 1995 we trained 36 specialists and formed 12 brigades. Each of these brigades involved a doctor, a nurse, and a driver. They learned how to work in team and effectively divide responsibilities. At that time, in the Educational-Methodological Center we also organized training of people without medical background – policemen, firemen, etc. Overall 7000 people were trained in CPR techniques. (General practitioner, FGD)
The idea and organization of our ambulance service system is very good. Having a general practitioner in regular brigade and a cardiologist in cardio brigade is a big advantage for the quality of services provided to our population. Other countries also understand these advantages but cannot practice the same thing because ambulatory visits of doctors are very expensive there, while our professionals work for a little salary. (Cardiologist, IDI)
Barriers to the work of emergency medical services
Among different technical barriers for the effective work of the ambulance services in Armenia as one the most crucial, the study participants indicated the delays in ambulance arrivals to patients. They associated this problem mostly with the state ambulance services, proving its ineffectiveness by the lack of incentives for the doctors as it was until recently a free of charge service for the population of Armenia. They believed that though the private ambulance services are more expensive, in emergency situations it is safer to call a private ambulance, because they respond quickly.
It happened to our neighbors… it was a heart attack. When they called ambulance, doctors arrived after a long time and even being late they moved up to the stairs very slowly, like nothing happened. (High-school student, FGD)
Our neighbors once called the ambulance for some heart problem and they arrived very fast. They told that delay in couple minutes might be fatal for that man… The cars of private [paid] ambulance services are usually on time, because they receive money for that. You cannot say the same thing about the state ambulance or regional services. (Medical student, FGD)
Other rationales given by the study participants for the lateness of the ambulance arrivals were the bad technical conditions of state ambulance cars and bad physical conditions of roads leading to slow driving and the lack of rules for other drivers to give way to ambulances.
Ambulances are in a very bad condition and they move very slowly, so in the most of times they are too late to help patient. (High-school student, FGD)
Other drivers do not understand that on the streets they should give advantage to the ambulance cars keeping left-driving-side free. It had happened many times when drivers of the ambulance get into accidents on the streets. (Medical student, FGD)
The study participants also specified inadequate organization of emergency services as another reason for the late ambulance arrivals. However, participants from the emergency medical services explained the same problem by the insufficiency of specialized cardio brigades available in the state services. Though professionals believed that population caused by emotional and stressful conditions tend to exaggerate the problem of delays, they tried to understand also the feelings of patients’ relatives.
Usually, the first ambulance brigades that come to the patient are not cardiologists. After confirming that the patient needs a specialized care, they call for the special cardio brigade. And we start waiting for the second brigade... we were waiting 45 min, while the ambulance center is located pretty close to our home, you can get there for about 15 min walk. (High-school student, FGD)
The delays are happening when we have difficulties in finding a free ambulance brigade. I mean sometimes all cardio brigades (they not many) are busy in the moment of call and it takes certain time to forward the brigade from one address to another. (General practitioner, FGD)
You know, it is difficult for patient’s relatives wait even for a few minutes. They count every minute as an hour. Thus sometimes they think it took too long for emergency brigade to arrive…. But we should understand people too, because if it concerns cases of cardiac arrests then during those official 30 minutes patient could die 5 times. (General practitioner, FGD)
Medication and equipment
All study participants agreed that the quality and the quantity of medication and equipment in the state emergency medical services are insufficient in Armenia and incomparable to other countries with the developed emergency services. Many participants, despite indicated problems, were optimistic about current and further gradual improvements, while others were more critical about existing problems and preferred radical changes.
Medication and equipment are insufficient in [emergency medical] services in Armenia. In the Europe they [ambulance team] have adequate drugs in necessary amount and the ambulance car is equipped up to date, thus doctors are able to resuscitate the patient immediately, on the way to the hospital. (High-school student, FGD)
Without doubt, looking back on previous years we have had improvement not only in the quantity of medication, but also in its quality and variation. However, the quality of equipment is a problem not only for our [Yerevan] services, but also for the whole Republic. The main obstacle is financing. (General practitioner, FGD)
This is the area [emergency medical services] where we cannot be excused because we live in not developed enough country. The life of people in the first place and condition that assure safe life should be adequate for anybody. Thus we need to have better drugs and equipment. (General practitioner, FGD)
Professional qualifications and service reimbursement
Some study participants highlighted deficient qualifications of the medical staff as a barrier for the effective work of the state emergency medical services. They reported that the knowledge of the medical personnel is out of date, especially those in regions. There were concerns that this shortage of knowledge might be crucial for the lives of patients. However, other participants, comparing public and private services, believed that it is more matter of financial incentives, low level of technical support and insufficient medications rather than inadequate qualifications of specialists.
In the state emergency services, the qualification of doctors is poor. I am not saying for everyone, 10% might be very qualified professionals, but in general, we should aspire to have a better state of emergency service. It is very sad, but the qualification of the doctors who work in the regions is even worse. They simply do not know what to prescribe for the patient, who has anaphylactic shock. (Medical student, FGD)
If the medical doctor would be paid accordingly to his qualifications and time as well as supported by adequate medication and equipment the result would not be disappointing. We can see that by comparing Erebuni Medical Center [private] ambulance system with the state ambulance. (Cardiologist, FGD)
Recommendations and Conclusions
The post-Soviet transition has largely been a crisis of prioritization especially in the healthcare sector. In the process, emergency care has remained underdeveloped. Emergency care systems development is important on many levels; to boost other health programs in place such as cardiac, stroke and trauma care, to mitigate risks to the Armenian population and for disaster planning including mass casualty events and even war. The understanding of current challenges to emergency medical services developed by examining qualitative in-depth and focus group discussions combined with the quantitative surveys administered to the public and the ambulance physicians has revealed several areas in need of improvement. Themes that have emerged highlight a distrust from the public about financial motivations, speed of care, as well as insufficient training. On the physician side there are grave concerns about equipment, medications and most importantly their own training, preparedness, and on-going education. It is vital that data driven strategies combined with a comprehensive plan to retrain the workforce take the forefront in the next stage of development.