HEMS, how helicopter rescue works in Russia: an analysis five years after the creation of the All-Russian Medical Aviation Squadron
HEMS operations are necessary and vital in every corner of the world, including Russia, where the centralisation of medical aviation services was decided five years ago
In 2021, the aircraft of the National Air Ambulance Service (NSSA), created by the efforts of the Rostec State Corporation, after completing over 5,000 missions, helped save the lives and health of over 6,000 patients.
Over the past three years, the helicopter market has multiplied its value fivefold, from 3,886 billion roubles in 2018 to a record 16,672 billion in 2021.
One euro is worth as we write this article about 60 roubles.
But it is a process that is not going smoothly, and the project to centralise the air ambulance service is encountering quite a bit of local resistance.
HEMS in Russia, the creation of the All-Russian Medical Aviation Squadron
The beginning of the project to create the All-Russian Medical Aviation Squadron can be roughly dated to 2011-2012, when a specialised working group was organised under the Ministry of Health of the Russian Federation.
The stated aim was to implement and professionalise the helicopter service.
In October 2013, Veronika Skvortsova, then head of the Ministry of Health, presented a thematic pilot project with a budget investment of 2.2 billion roubles.
It was assumed that in two years the mechanism for the operation of the medical aviation service would be worked out and the legislative basis formalised, and if the pogetto got off the ground, the centralisation of medical air transport up and down the country would begin in 2016.
Given the size of the nation, a project that coordinated HEMS and MEDEVAC: Russia has oblasts of enormous size
For local flights, the project was to use helicopters and small aircraft, and for interregional and international flights – medium- and long-haul aircraft.
It must be considered that in terms of size, Italy is 57 times the size of Russia.
At that time, source Zashchita VTsMK, medical aviation was operating permanently in 40 regions, however, in three of them, only with one-off applications.
In seven regions, the role of an air ambulance was played by helicopters of the Ministry of Emergency Situations of Russia, in six by regular civil aviation transport.
Things went somewhat better with the take-off sites: out of a total of 234 units, 118 could be described as equipped, of which only 19 were located near clinics.
The pilot regions of the centralisation project were Khabarovsk Territory, Sakha Republic (Yakutia), Arkhangelsk and Amur regions.
In 2016, the Ministry of Health of the Russian Federation adopted a profile priority programme, according to which 34 regions with hard-to-reach territories could receive a federal subsidy for the purchase of medical aviation services.
For this purpose, the regulator set aside more than 10 billion roubles in the budget until 2020.
In July 2017, at the MAKS air show in Zhukovsky (near Moscow), the Heli-Drive medical team presented President Putin with a brand new Ansat with a medical module as a prototype for the main board of the future NSSA.
Russia, the idea of centralising HEMS and MEDEVAC medical services finally gained its operational contours in autumn 2017
Anatoly Serdyukov, the head of Rostec State Corporation’s aviation group, became its ambassador.
The parameters of the project envisaged the organisation of a single federal operator of medical aviation services – with its own fleet, consisting mainly of domestic helicopters with medical modules, a common dispatch centre and a set of standards based on world best practices.
The implementation mechanism of the project was originally conceived as a ‘mutual infrastructure’: the provision of aircraft to the regions in return for the guaranteed inclusion of a medical evacuation fee in the compulsory medical insurance system.
At the same time, the JSC National Air Ambulance Service was established, 25% of which was received from JSC Rychag, owned by Rostec, and the remaining 75% from the Fund for the Development of Air Ambulance
Launched with Vladimir Putin’s approval in January 2018, the NSSA six months later received single-supplier status from the government, allowing it to contract with regions if they so wish.
The operator also received a unified all-Russian hourly flight rate: 295,000 roubles for long-haul Mi-8s and 195,000 roubles for light Ansats.
There was one problem: equipping the HEMS fleet in Russia
In September 2018, subsidiaries of Rostec Group of Companies – Russian Helicopters JSC, NSSA JSC and Aviacapital-Service LLC – signed a contract to supply 104 Ansats and 46 Mi-8AMT helicopters with medical modules.
The cost of the agreement was estimated at 40 billion roubles.
Under the contract guarantee, Rostec planned to raise 30 billion roubles through its wholly-owned subsidiary JSC RT-Finance by issuing exchange-traded bonds with a maturity of up to 15 years.
The first eight helicopters – four Ansats and four Mi-8AMTs in a special red and yellow livery – were shipped to the operator in February 2019.
It seemed that nothing could interfere with the flight trajectory of the NSSA until the planned downsizing, especially since the priority project for the development of sanitation aviation was immersed in the National Healthcare project, and the sole-supplier status for the operator was extended by the government until 2021.
In addition, the NCSA could optionally exercise the right of general contractor-aggregator: the company had to fulfil at least 30 per cent of the state order on its own, and to fulfil the rest of the order, hire subcontractors.
HEMS in Russia, an analysis of progress in the period 2017 – 2021
To find out how the air ambulance market has been transformed with the advent of the HCSA, the Analytical Centre analysed EIS procurement contracts for medical evacuation services concluded in the last five years.
To do this, using the zakupki360.ru service, the procurement contracts announced from 1 January 2017 to 31 December 2021 with OKPD 22.214.171.124 (services for transporting passengers by aircraft on charter flights) and 51.10.20. 000 (services for the chartering of aircraft with crew), which mentioned the keywords ‘medical care’ or ‘aero-ambulance’ in any variants, as well as the main array – 86.90.14.000 (ambulance services) and 126.96.36.199 (works for the provision of medical care), in contracts that contained the keyword ‘aviation’.
The specialised market of state orders was financed through two channels: from the federal budget (in 2021, 5.2 billion roubles were reserved for these purposes, in 2022, another 5.4 billion roubles were planned to be allocated) and from the regions.
HEMS, the value of helicopter services in Russia has grown to 43.641 billion roubles in the past five years
As of 2018, the increase was multiple: from 3,886 billion roubles in 2018 to 7,552 billion in 2019, and then from 11,657 billion in 2020 to a record 16,672 billion in 2021.
Only 74 suppliers have appeared on the market over the years, while TOP25 companies provide 92% of contracted services.
The volume of purchases under Federal Law 223, which does not provide for the mandatory publication of an agreement with contractors and therefore does not allow their ownership to be established, was 2.554 billion roubles.
The TOP25 leader is supposedly NSSA JSC (the market also has the eponymous NSSA LLC, renamed from Heli-Drive Medspas LLC), which gradually increased its contract volume from 10.7 million roubles in 2018 to 4.342 billion roubles in 2021.
However, the expansion of the NSSA, which is developing under the patronage of a strong partner in the nationalisation regime, cannot even be called child’s play.
Here are just a few examples.
In January 2021, the NSSA won a contract with the Nenets District Hospital named after N.I. RI Batmanova, and literally the very next day, at the conclusion of the deal, it was discovered that the NSSA could not supply the airplanes.
The consequence? “The new operator was simply not allowed to land helicopters at the local airport. So, in essence, the winner of the competition was deprived of the opportunity to work,’ explained a source from the Rostec Group of Companies.
The conflict was resolved by terminating the contract at the initiative of the NSSA.
A similar story, albeit with a different outcome, happened in Tyumen: there, in November 2021, the NSCA won a tender with the region’s traditional supplier, JSC UTair – Helicopter Services, with a bid price of 139.9 million roubles.
However, the Regional Clinical Hospital No. 1, which acted as the customer, signed a contract with UTair, justifying the decision with evidence that the NCSA would not be able to fulfil the contract as it did not have access to the landing sites.
The NCSA, however, has pointed out that in its view the problem is a different one, namely that pockets of resistance to the centralisation of the service are due to the position of those local airlines that have never specialised in aviation, but enjoy the support of state customers who profess the principle ‘money should stay in the region’.
The NCSA is trying to counteract the restrictive conditions for regional competitions exclusively with legal methods, the company assures.
In April 2019, in Order No. 236n, the Ministry of Health of the Russian Federation introduced a standard for air ambulance equipment in the Procedure for the Provision of Emergency Medical Care: the required list included ventilators, breathing and resuscitation equipment, packaging and a medical module with a stretcher.
The regulation allowed artists with unequipped parts to be excluded from the state order.
And in September 2019, the regulators approved a standard contract for the performance of aerial work for the provision of medical care, which became a mandatory form from February 2022, implying the preparation of terms of reference for public procurement.
However, for five years on NSSA’s road to total market conquest, more serious problems have arisen than skirmishes with individual competitors or negative-minded customers.
It is a question of building one’s own fleet. The initial plan to purchase 150 helicopters, which would instantly turn HCSA into one of the country’s largest suppliers of all helicopter transport, stalled almost immediately: financial institutions were not ready to lend to the new company without guarantees and warranties.
As a result, instead of the 50 aircraft planned for 2019, the federal operator received only eight.
The situation only improved at the beginning of 2021.
After receiving guarantees from the Government of the Russian Federation and the Rostec State Corporation, NSSA signed two contracts with JSC PSB Avialeasing for the supply of 66 helicopters – 29 Mi-8MTV-1s and 37 Ansats – for a total of 21.4 billion roubles.
There were also failures at the manufacturer – KVZ, for which the NSCA state order was the largest in 30 years.
Deliveries only improved in mid-2021, when 14 brand new helicopters were shipped to the company.
As of 1 February 2022, the NSSA fleet already consisted of 22 vehicles: 11 Ansats and 11 Mi-8s each.
HEMS in Russia, the shortage of its helicopters forced NSSA to increase the share of subcontracts
In 2020-2021, the company signed contracts worth 2.2-2.7 billion roubles per year.
The further growth of single-source turnover in 2021 was also achieved mainly by attracting airlines that operated in the regions before the arrival of the NCSA as a partner.
In the Novgorod region, for example, RVS JSC signed a subcontract, in the Altai – AltaiAvia territory (22nd place, 0.323 billion roubles), and the cost of a flight hour in secondary contracts was often 10-20 thousand roubles lower than the main price.
The NCSA explains the difference, albeit insignificant, by their costs for infrastructure and the introduction of air ambulance standards in the regions, whereas subcontractors simply fly and are exempt from such costs.
Experienced players compensate for the shrinking scope in the state order market by developing new niches.
For example, RVS JSC, one of NSSA’s main competitors in medical aviation, partnered with Medsi Group in May 2021 to create a medical evacuation service for patients in the network’s Moscow clinics.
The agreement involves organising air transport from the Moscow region and other regions to the Otradnoye clinical hospital site or the RVS base in Odintsovo, from where patients will be sent by ambulance to the group’s hospitals.
It is assumed that the cost of the service will start from 15 thousand roubles, depending on the location and flight time.
According to Sergey Khomyakov, deputy general director of RVS, the cooperation will take air ambulance services in Russia ‘to a new level of quality’.
The need to develop a single, centralised IT platform to coordinate HEMS activities in Russia
Among the actually applied tasks of the NSSA is the development of an IT platform on which a centralised HEMS aviation dispatching system will be built.
In February 2019, at a meeting at the Ministry of Health of the Russian Federation, an instruction was formulated to integrate the subsystem ‘Emergency and Emergency Medical Care Management’ into the Uniform State Health Information System, including the air ambulance module within it.
The contractor for the development of the Uniform State Health Information System until 2021 remained the same Rostec.
Moreover, in the summer of 2019, according to Kommersant’s aviation sources, Rostec consolidated a controlling stake in the NCSA.
So far, the sole supplier status has not been extended to the NSSA.
According to the agency, there are still no plans to cease federal funding for medical aviation: the development of the service is included in the list of national goals until 2030, however, the burden of expenditure on the construction of heliports will still be borne by the region.
However, the possibility of co-financing these facilities under another federal project – ‘Safe and High-Quality Routes’ – is under consideration.
New sanctioning circumstances have increased the NSSA’s risks in the fleet formation line: in March 2022, it was discovered that the Canadian division of the American Pratt & Whitney had suspended the supply of PW207K engines to KVZ, on which Ansat fly.
The domestic analogue – the VK-650V ‘engine’ developed by ODK-Klimov – exists only in an experimental version, and its certification was not expected until 2023.
One of the options considered in the industry, in addition to accelerating the procedures for the VK-650V, is the co-option of the VK-800V power plant for Ansat’s needs.
However, the Kazan helicopter plant intends to produce 44 Ansat helicopters in 2022 – most likely, some of them will be assembled from stock.