Ambulance Service Report
Abstract
The Author, who is a State Registered Paramedic and Ambulance Control Officer, first visited St. Luke’s Hospital in October 2006
and following discussions with staff determined that upon a return visit, he would attempt to assist his Ambulance colleagues in
both their delivery of service and personal well being. A second visit took place in the period of late October/ Early November
2007 with the aim of constructing this document which would include a series of proposals to enhance the service.
At this juncture the Author would like to thank all those with whom he talked for their open and honest approach, the
management of the hospital, who provided all the information requested in an open and forthright manner and the staff who
engaged in discussions, provided information and ultimately opened up to provide an insight into the work they do.
The information was collected as detailed in the report and judged against three primary criteria.
• Efficacy
• Affordability
• Delivery
These three areas were not exhaustive but failure to meet any of these criteria led to ideas being not being considered for further
investigation at this time.
It rapidly became clear during discussions that provision of even the most basic upgrades of training or equipment would be
problematic due to the lack of a basic infrastructure and fundamentally the low priority placed on the provision of an emergency
service at National, Regional and Local levels.
Given the short-comings of the system at present, there appeared to be a serious paradox in terms of provision i.e. the staff are
not trained to deal with medical emergencies and the general public have no expectation that they can (indeed there is no
uniform system for obtaining an emergency Ambulance). This then poses the question do we up skill staff and provide better
facilities and equipment whilst they still serve the current constituency or do we increase public awareness of the service and up
skill as we proceed.
It was at this stage that it became apparent that the development of services can not be a linear process and resultantly the
proposals outlined in the summary section are categorised as dependant and non dependant i.e. those that can be
implemented on their own with availability of funds and those that will require either State involvement or input from another
agency. Given this dynamic it is essential that the areas of development that can be addressed are done so immediately whilst
work must commence/ carry on in the other areas. To this end an implementation strategy and business plan must be prepared,
developed and delivered.
Chapter 1
Information Collection
Information in this report was collected from three Primary sources:
Mr. Anthony Chilembwe- Principal Hospital Administrator
Mr. Samson Kajawai- Senior Maintenance Officer
Ambulance Drivers St. Luke’s Hospital, Chilema, Malawi
The author also spent considerable time within the hospital environment and was involved in numerous discussions with other
health professionals in an attempt to gauge the general feeling with regard to Ambulance provision. In all cases the participants
give their time freely and engaged fully for which I am grateful.
Mr. Chilembwe 1
The first meeting was an informal session with Mr Chilembwe who outlined the current status of services and demands thereon.
This was an attempt to obtain an insight into the way the system worked in a relaxed manner. (There were no minutes for this
meeting.) It was then agreed that a series of meetings would take place with the relevant people and Mr. Chilembwe organised
these.
During the meeting it became apparent that the service provided is not simply an Ambulance Service but also, what we in Ireland
would regard as, a hospital transport department as well. It became clear that this in itself was a problem as these
administrative duties often caused excessive demand on the fleet available but it also was evident that staff worked with the
resources available and deployed them to cover the maximum work load possible. (Most vehicles work most of the time).
It was also apparent that Mr. Chilembwe, as Principal Hospital Administrator, has an extremely heavy work-load and that there
are other demands on his time. The resultant effect being he is forced to manage the resources without having the chance to
prioritise their use. Due to the requirements of cost controls and accountancy practice he is often required to devote time to
minor details (such as approving transport requests), which is a distraction from his natural role as a senior manager.
At the conclusion of this informal session, the Author was left with the impression that Mr. Chilembwe is an able administrator
with excessive demands on his time but has still managed to introduce a number of cost control initiatives aimed at removing
any abuse or slack in the system.
Mr. Chilembwe 2
The second meeting with Mr Chilembwe was more formal and structured. The Author prepared a number of areas for debate
and made extensive notes throughout the meeting. The areas discussed were:
• Basic structure and management
• Accountability
• Wages
• Drivers (Knowledge and skills)
• Government/professional registration
• Estate
• Communications
• Staffing levels
Basic Structure and Management
The administrative unit that is St. Luke’s covers the hospital itself, St. Martin’s (a subsidiary hospital) and eight rural clinics
spread over a wide rural area. 5 drivers are based at St. Luke’s and 2 at St. Martin’s. The current fleet (as supplied by the
maintenance supervisor) is 2 minibuses (used for the school of nursing), 2“Toyota Land Cruiser Ambulances”, 2 Toyota
Pickups, 1 Toyota Hilux and one Toyota Carina saloon (which is used for admin purposes).
The drivers have a senior driver who along with administration and maintenance assess the workload and decide priorities.
Work is then passed to the individual drivers. The work load includes
• Transport of patients to hospital from the rural clinics
• Transport of staff to and from areas of work (clinics, meetings etc.)
• Disbursal of communications and wages, collection and delivery of supplies
• General ‘messages’.
The group approach to assigning the different tasks does not work. Whilst every effort is made to keep one vehicle at the hospital
as an “Emergency Car” the demands on the system do not always allow for this. The Author witnessed a number of occasions
over the period of several days where due to the lack of proper coordination, the amount of work assigned to a vehicle could not
physically have been achieved. This is an inherent system weakness that must be addressed. In addition once the vehicles
leave the hospital, even on routine work, there is no way of diverting them to emergencies due to lack of communications.
It is clear that there needs to be an ambulance coordinator (Controller), responsible for taking all ambulance requests,
prioritising them and assigning the duties. This person must be a competent administrator, who has an awareness of vehicle
capabilities and the authority to reassign vehicles on a priority bases at short notice. They must also possess local knowledge
and a sound understanding of journey times, essential in ensuring the most appropriate resource can be tasked in an
emergency.
Accountability
In essence staff members are accountable to the Hospital Administrator. As previously stated he has a large remit and it is
unrealistic to believe that he can effectively micro manage the system. Day to day responsibility should be in the responsibility of
the Controller with the Administrator in an overseeing role. This in turn would have a positive effect on the ability of the
Administrator to work on other areas of his remit.
Wages
The basic salary (40 hour week) for a driver is 8285 Malawi Kwacha (Mka.) This basic component is paid by the Government. In
addition drivers receive a ‘Duty Allowances’ totalling Mka.1300 in recognition of their role as Ambulance drivers and a ‘Shift
allowance’ of Mka. 1000, which equates to less than £37 per month (rate Mka. 289.81 to £1). The leading Ambulance driver also
receives a premium of Mka. 2030 (£7). The government component will be paid by agreement but the enhancements are the
responsibility of the institution. Staff numbers are also set by the government and any attempt to enhance response (e.g. two
staff per vehicle) must be approved by them.
Drivers (Knowledge and skills)
Drivers are exactly what it says on the tin. They have a basic driving licence and nothing more. They have no medical training of
any kind, though they have built up a wealth of knowledge through experience. Both of these are critical areas of development. In
the last year there have been three serious accidents involving Ambulances. Apart from the human cost the practical cost to
provision of services was that one vehicle was out of service for three months and the resultant knock-on effect. The medical
training requirement is self evident.
Each driver should receive extended driver training i.e. ‘Defensive Driving’ This training is available locally by certified instructors
and the costs of implementation and time scale must be addressed as a priority. There is however a possible down side to this
training in that skilled drivers are a premium resource in Malawi and could be tempted to leave once skilled.
Given the current remit of the staff it is imperative that they be given basic general first aid training and a more in depth course in
obstetrics. (Much of their current work is transporting maternity cases). The nursing school should be approached in the first
instance to see the availability of tutors for specific areas of health care and this knowledge can be underpinned by Experienced
Ambulance tutors on short courses.
Government/professional Registration
Ambulance services the world over are increasingly been seen as a fundamental part of the medical estate in response to
emergencies. It is increasingly recognised that a fast appropriate response leads to better patient outcomes and in this respect
services are developing rapidly. Many countries now expect Ambulance staff to be educated to college degree level such is the
importance given to their work and at the same time many countries have professional certification/ registration in place to
ensure best practice. There is no such system in Malawi and at the moment it is not perceived as an imperative. Little effective
action can be taken at this time to address this problem but it should remain on the list of priorities.
Estate
There are no proper facilities within the hospital for the ambulances or staff. This is a totally unworkable standard. Ambulance
staff are forced to use the maintenance office and workspace where they lack even the most basic facilities to either prepare
themselves or vehicles.
The provision of dedicated accommodation is a further priority. Staff require a station that is equipped with a garage,
maintenance area, rest room, Shower/locker facilities, Sluice and administrative area. These facilities could be shared with the
maintenance staff to avoid on site duplication but they are a necessity.
It should be remembered that these staff are in the front line and often visiting places where their risk of exposure to infectious
agents is much higher than the norm in Malawi and barely conceivable in Ireland.
Consideration should be given to building this resource as part of an aid event such as those undertaken by various charities.
Communications
Communications are non existent between the hospital and Ambulance staff once they go through the gates. There are no
radios or mobile phones available to staff and the staff on call have no phone. Security staff have to go and call at their homes if
they are required during their on call period which lasts a week at a time.
A dedicated radio is required and each vehicle should be equipped with a mobile phone. In addition there should be an ‘on call’
mobile which is passed around as required.
Staffing levels
There has in the past been a difficulty in recruiting and retaining staff for the Ambulance however that appears to have mitigated
in the recent past and as a result no problems are envisaged in the medium to long term. However given the proposal to up skill
staff this is an area that will require constant monitoring.
Mr Kajawai Maintenance Supervisor
Mr Kajawai was extremely forthright when we spoke. It is clear that he is running a maintenance department with little resources
or tools to carry out his job. Whilst he shared all of Mr. Chilembwe’s concerns he emphasised the need for both tools and
spares to keep the fleet running. In addition he raised the possibility of some basic car maintenance tuition for drivers so that
they might identify minor problems before they become serious and also in the need for an emergency kit for breakdowns in
remote areas so that the driver can where possible get the vehicle back to the hospital or at least a place of safety. He also
raised the replacement of Vehicles as a concern. Given that they have all been donated to the hospital, there is no planned
replacement schedule. Again this is a priority issue. The newest vehicle is 2006 and the oldest 1997 and he again pointed out
that the ageing fleet required more maintenance and therefore incurred more cost. He also expressed a desire to carry out more
in house maintenance.
Mr Kajawai’s proposals and needs whilst evident are also cash intensive. Some tools and basic spare parts can be obtained at
a reasonable cost but the long term answer is more difficult. The provision of an Ambulance facility with a maintenance area
would certainly alleviate a large part of the problem and should also be seen in this context.
St. Luke’s Ambulance Drivers
The meeting with the drivers started off rather formally when they read a list of their needs. In the most part this reflected the
information received in my previous meetings. However once the staff opened up it became clear that they had other concerns
also. They paid great emphasises to further training both medical and driving. They felt undervalued and sidelined to a degree
and wished to improve not only their knowledge base but also their standing. Lack of training often left them in a difficult position
whilst dealing with patients.
They expressed an interest in a uniform which is already being addressed as they felt they constantly were being exposed to
infection with no barrier between them and their families.
However the provision of basic accommodation was their primary goal. As previously stated they have no facilities and are
sharing the maintenance area and again the provision of a dedicated facility would solve this problem.
It was clear that the staff were willing to learn and participate in developing their role and this must be regarded as a very positive
benefit. The delivery of small improvements will maintain this good will and enable a positive out come to this project.
Conclusion and recommendations
Ambulance Services at St. Luke’s are virtually non existent in terms of emergency provision given the competing demands for
resources. It is clear that huge investment is required if anything is to be achieved and that considerable effort will be required to
obtain this. This report has identified a number of areas for action as follows.
• Provision of training in First Aid and advanced driving.
• Provision of dedicated facilities.
• Provision of First Aid equipment including restocking
• Uniform provision (underway)
• Maintenance and spares
• Employment of an Ambulance Controller
Each of these areas will require a significant amount of work and a structured business plan to both raise the required funds
and to ensure their best use. The list is not exhaustive but is a starting point. It must however be emphasised that additions to
the requirements but be carefully considered so as not to allow costs to spiral.
Lughaidh Mac Giolla Bhrighde
_________________________
Zomba
7-11-2007
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