Problem: Decentralized management of prehospital emergency medical services resulting in fragmentation, lack of coordination and service inefficiencies; regional disparities in access to ambulance services and inequitable distribution of resources; lack of standardized care guidelines for prehospital emergency medical services.
Solution highlights: Latvia’s 39 separate emergency service organizations were merged to form the single, centralized State Emergency Medical Service; implementing a unified structure for the provision of prehospital emergency medical services reduced fragmentation, standardized care and improved the coordination of services; formalizing provider training and education embedded new practices as the professional norm and helped ensure high-quality care delivery according to the guidelines in place; strong national leadership, along with a clear narrative and communication plan, helped gain stakeholder support for the initiative; widespread population support was secured by making services available free of charge.
Description of practice
In the early 2000s, Latvia’s 39 municipalities were each responsible for separately contracting emergency medical services within their own jurisdiction. Over time, this organizational structure was found to contribute to increasing regional disparities in care access and inequitable distribution of resources. Furthermore, decentralization restricted effective coordination and planning for emergency medical services and posed geographical limitations to patient transfers.
The Government of Latvia established the State Emergency Medical Service in 2009 with the aim of streamlining prehospital emergency medical care. Over the next year and a half, the State Emergency Medical Service oversaw efforts to merge the existing 39 organizations and two public institutions delivering emergency medical services across the country to develop one unified service. Challenges during the merging process included resistance to change among local governments, as well as providers’ concerns over new stricter quality standards. However, with strong government support behind them, the State Emergency Medical Service was able to direct necessary changes through a top-down approach and set clear rules and regulations. By July 2010, the new arrangement of emergency medical services, along with the necessary institutional adjustments, was complete. Key changes focused on establishing a unified system for managing resources, developing equipment and medicine standards, increasing training for providers and improving services in rural and underserved areas. The State Emergency Medical Service now employs all necessary medical personnel to deliver prehospital emergency medical care. A network of five call centres coordinates approximately 186 ambulance teams stationed at 98 locations across the country. The State Emergency Medical Service is responsible for transporting all patients, free of charge, to the nearest hospital in accordance with guidelines and within specified time limits. Ongoing monitoring holds providers accountable to following care guidelines and helps ensure performance targets continue to be met. Today, the State Emergency Medical Service continues to direct and manage the delivery of prehospital emergency medical services, using monitoring and evaluation as a means to inform quality and process improvements. An electronic information system is currently being developed to support enhanced communication between providers and facilitate monitoring and evaluation.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
The State Emergency Medical Service was established by the government in 2009 to lead the necessary changes in the configuration and delivery of emergency medical services. This organization became the central actor for the initiative and worked with the various municipal governments and institutions previously charged with delivering emergency medical services to merge them under centralized state control. The Ministry of Health provided support throughout the transition process, lending authority to proposed changes and ensuring resources to support activities were available. The State Emergency Medical Service is now well-established as the sole organization responsible for the management and delivery of emergency medical services in Latvia.
Informal reports indicate that unification has led to improvements in quality, efficiency and cost-effectiveness, with centralized management resulting in patients receiving services quicker and in the most appropriate location. Widespread satisfaction with services has been reported, with over 80% of patients indicating they are pleased with the care provided.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Renata Pupele
- State Emergency Medical Service