The Asia-Pacific (APAC) region is the most populous in the world, accounting for over half (about 56 per cent) of the world’s population, which is no surprise considering it is home to the most crowded country in the world – China – and some of the world’s most densely populated destinations. And while a lot has obviously changed since Covid-19 lockdowns were established, the region has long been a popular destination for international travellers, thanks to a rich cultural heritage and breathtaking natural landscapes.
But with the towering mountain systems of the Himalayas, deciduous islands scattered across the Pacific Ocean, the vast steppe and desert landscapes, and numerous bodies of saltwater and freshwater, topography is just one of the factors contributing to challenges for air medical assistance operations in the area – as does a vast disparity in the provision of high-quality medical facilities.
A report from P&S Intelligence, which analysed global air ambulance market expansion, cited that APAC is expected to register the highest growth rate in the air ambulance services market during the forecast period (2020-2030). P&S Intelligence attributed this growth to the expanding presence of helicopter ambulance services and the increasing number of patients diagnosed with life-threatening diseases in the region. The governments of various countries in this region, P&S Intelligence reported, are making considerable efforts towards increasing the deployment of air ambulance services in order to improve patient survival rates.
For example, back in August 2019, in India, the government of Tamil Nadu announced plans to establish air ambulance facilities for transporting patients, or those injured in road accidents at faraway places, to healthcare centres situated within a 200- to 300-kilometre radius. And in China, in April 2019, the Civil Aviation Administration and National Health Commission launched a pilot project aimed at providing air transport services to critical patients, and those that are severely wounded, who are in need transportation from places lacking medical resources.
India, with a population of over 1,366 million, is a vast country, with almost 500 airports, 125 of which welcome scheduled commercial flights, and just 35 of which allow international flights to land, so the successful arrangement of an international air ambulance can be difficult. Added to which is the fact that not all these airports are open at night, and as an assistance company, your transfer can quickly become very complex, explained Dr Nitin Yende of local firm HI Flying Air Ambulance. He continued: “Many patients who need tertiary care facilities for trauma need to travel to major cities like Mumbai and New Delhi for treatment. They are required to be stabilised before they are transported to the appropriate facilities by air ambulance services, so the restriction in airport timing and the difficulty of obtaining aviation permits can be a daunting task.”
Many patients who need tertiary care facilities for trauma need to travel to major cities like Mumbai and New Delhi for treatment
Considering that back in 2018, an Airbus release identified that countries in the APAC region had insufficient numbers of helicopters (based on the standards in Europe and the US, which consider an average of two helicopters per million people to be adequate), P&S Intelligence’s projected market growth, along with these recent initiatives, makes sense. China, with a population of 1.4 billion, needed to obtain about 700 helicopters, and India was looking at around the same, the Airbus report deduced.
Milan Floribus, Owner/Founder and Vice-President at AC Global Air Ambulance, told ITIJ that over the last few years and up until the beginning of 2020, the provider’s business in the APAC region was flourishing: “Because of the surge in missions, new air ambulance providers were emerging every month and there was a lot of market competition.” However, Covid-19 has caused a huge dent in operations – business executives were sent home, leisure travellers disappeared, and airlines cancelled many destinations and flights, he explained.
domestic transportation of Covid-positive patients is not allowed in spite of us receiving at least three to five transfer requests every day
Floribus detailed that the new logistical challenges that have come about since Covid-19 restrictions were imposed include: being unable to position crew and aircraft; there being no commercial airline availability; difficulty in getting permits; crew quarantines; crew rest logistics (often being re-routed to other countries to spend the night); medical staff not able to leave an airport; Covid-19 tests required for patients, family members, and crew. “In many cases, it can take a week or longer to overcome these,” he said.
Dr Yende told ITIJ: “In these times of coronavirus pandemic, there is a huge population of Covid-19-positive cases who would want to come to tertiary care centres in major cities. However, Covid-19-positive cases till the present moment of time are not allowed to travel on domestic sectors. For non-Covid patients, there are a number of regulatory documents needed before transport is finalised. This includes a Covid-negative report of patient and relatives, hospital diagnosis ruling out Covid, district magistrate letter, and NOC from the State Health Department. Some of this regulation has eased, but domestic transportation of Covid-positive patients is not allowed in spite of us receiving at least three to five transfer requests every day.”
Still, Amy Villalobos, Head of Case Management and Assistance Services at nib Assist in Australia, told ITIJ that even before Covid-19, the APAC region’s concentration of air ambulance providers was not as high as is seen in other parts of the world. “And this can, at times, provide some challenges in access to more remote locations,” she said, adding the APAC region in particular has some unique challenges in distance and terrain, and ‘relatively small fleets can often impact availability’. “Despite the challenges, air ambulance providers in the region are very often operated and staffed by some of the most highly regarded and experienced clinicians we have had the opportunity to work with,” she said.
Villalobos explained that illness and injury patterns, as well as health service availability, can provide some unique challenges, and, in some circumstances, a wing-to-wing transfer may be the best option where co-ordination between air ambulance providers comes into consideration. “When we activate a provider, we look at safety, both in terms of aeronautical safety and comfort, as well as clinical safety and care. Medical care requirements, aircraft choice and range, potential flight path and layovers are a regular consideration in selecting the most suitable provider for each mission.”
Air ambulance providers in the region are very often operated and staffed by some of the most highly regarded and experienced clinicians we have had the opportunity to work with
And Claudia Schmiedhuber, Managing Director of the European Aero-Medical Institute (EURAMI), like Villalobos, agreed that there are providers offering an excellent service on both a national and international level in the region. “As there are many small local operators, it is quite difficult to capture the overall market size,” she said, adding that she still believes that there is room for more quality providers in the market.
Eileen Frazer, Executive Director of the Commission on Accreditation of Medical Transport Systems (CAMTS), believes that the APAC region is well served. She also said that the region continues to see mergers and reorganisations within the major aviation operators. “There are a few fixed-wing services in the US who respond worldwide, but not many. It is a bit more complicated in countries where the government must approve or actually conduct air ambulance missions.”
As Frazer references, there are a number of air ambulance operators serving the APAC region that are based elsewhere – take Latitude Air Ambulance as a prime example, the Canadian air medical and repatriation operator, which has ample experience assisting patients in Asia. Peter Byl, President and CEO of the company, told ITIJ that the logistical challenges in the APAC region are ‘enormous’: “Most of them deal with government rules, regulations and the constant changing of expectations, especially now with the Covid-19 situation. Visa rules are also a real issue, as timelines and expectations at local embassies and consular offices are sometimes different than [what is] posted on government websites. Each mission to the region is challenging to say the least.”
Schmiedhuber added: “As of today, there are still many countries in need of reliable providers who can service the regional market and support international programmes with national resources. This is especially true for evacuation flights and wing-to-wing transfers. Evidently, the Covid-19 pandemic will also have a massive impact on the development of the APAC market, thus it remains to be seen on how the rapid market development in the region can continue.”
While Villalobos observed that there is a ‘notable absence’ of industry accreditation in the APAC region, Schmiedhuber reasoned that the region has been developing at a rapid pace as far as accreditation goes. It is generally recognised that EURAMI accreditation is a necessity for those wishing to work at an international level, she tells ITIJ, detailing that EURAMI currently has four accredited programmes in the region, with around five providers who are interested in applying to become accredited. “While their historical focus is mainly on a national level, it is obvious that these programmes want to be seen as a reliable local aeromedical provider and as a safe resource for international clientele,” she said. “This is not only a promising development for the region itself, but also for the global market, as insurers and fellow providers will be able to use local providers with the same standards when it comes to quality, safety and operational excellence.”
In addition, Frazer revealed that her organisation has two services in Thailand that have been accredited since 2015. And she told ITIJ that there is interest in CAMTS Global in the region. “In fact,” she said, “Dr Dhun Damrongsak from Bangkok Hospital and Medical Director for BDMS Emergency Services serves on our CAMTS Global Board of Directors. We have also had inquiries from other parts of Asia, and we have an international team of site surveyors who conduct surveys.”
Quality and pricing
Schmiedhuber explained that EURAMI’s accredited providers in the APAC region are ‘held to the same standards as everyone else’. This also pertains to quality and pricing, she said. However, she noted that there are many remote and underdeveloped areas that are being serviced by non-accredited providers. “These providers are – in many cases – the only choice due to the location,” she told ITIJ.
Byl said that while there may be several local or regional operators, not many seem to have the crewing capabilities or licensing for long-haul repatriations. “Just our observations, as we specialise in long-range [repatriations] into and out of the region to the Americas and Europe, as well as other long-range repatriations worldwide,” he said. “We also find that local handlers are expensive and charge you for every possible item, so our costs running into the region are substantially higher. Ultimately, these costs are borne by the end client.”
A lack of pricing transparency and industry data is an issue that both Frazer and Villalobos also commented on. Frazer explained that with different privacy rules in each country, transparency could be a problem when it comes to quality and pricing, and Villalobos said that there is a general absence in industry data on the cost of services, service capabilities and clinical outcomes. “This often makes differentiation of new providers difficult,” she added. “Accreditation programmes can be very valuable in regulating service levels and scrutiny, and we hold these standards in high regard as these make credentialing processes easier for both parties. Wherever possible, we encourage a standardised industry approach for improved transparency of data, promotion of differentiation and increased competition.”
Generally, providers agree that while there may not be the same spread of air ambulance operators in the APAC region as there are in Europe and the US, those that provide a quality service, do so outstandingly. And, as AC Global Air Ambulance’s Floribus reasoned, providers that operate outside of the region often have access to fleets that enable them to travel long distances to assist patients in the region. On the other hand, conditions brought about by Covid-19 have made these operations more difficult than normal – and as Floribus noted: “Operating in the APAC region is still challenging, and I anticipate that these challenges will continue into the next year.”
Perhaps, with government initiatives cropping up to improve air ambulance operations in the area, there will also be a renewed appeal for accreditation of new and existing air ambulance fleets. As Schmiedhuber said: “I do believe that the increasing interest and recognition of EURAMI (and accreditation in general) in these regions will help the global aeromedical market greatly, having demonstrated quality, safety and operational excellence from providers in these regions.”
In all, a standardised industry approach will be beneficial, both in terms of quality and pricing – wouldn’t it be nice. ■