Medical aerial evacuation as European emergency response capacity: Analysis and way forward

The combination of in-depth desktop research on all the UCPM countries, 15 targeted interviews, semi-structured survey and regular consultations of experts allowed to collect data on the existing capacities of 27 out of 34 UCPM Countries4. For the seven remaining countries, namely Czech Republic, Hungary, Iceland, Montenegro, North Macedonia, Serbia, Slovenia, no sufficient information was found on available sources and contact were not successful. 1 Treaty on the Functioning of the European Union 2 https://erccportal.jrc.ec.europa.eu/ERCmaps/20190131_DM_VoluntaryPool_offered_CECIS.pdf 3 Article 4(12) of Decision No 1313/2013/EU provides that “Participating State means a third country participating in the Union Mechanism in accordance with Article 28(1).” 4 For the purpose of this study, UCPM Countries will stand for both EU and non-EU countries that participate to the UCPM. 5 The information gathered confirmed that for a majority of Union Civil Protection Mechanism (UCPM) Countries5, there are two critical gaps in terms of Medical Aerial Capacities for the transport of patient during major crises. Firstly, 7 out of 15 UCPM Countries interviewed confirmed lacking public aerial fixed-wing capacities for the transport of multiples (more than 4) patients during large scale events. Indeed, except for three UCPM Countries, namely Turkey, Romania and Poland which do have civilian public aircraft to transport up to four patients, there is no public civilian fixed wing capacity able to transport multiple patients within the 27 UCPM Countries analysed. The only countries who confirmed not having a capacity gap for the transport of multiple patient are those who can rely on military cargo transport capacities (France, Spain, Italy, United Kingdom, Turkey, etc.). Nota Bene: On the request of DG ECHO, a distinction has been made between public civilian and public military aerial capacities during the research. One of the objectives of the study was to map public civilian (operated by non-military personnel) capacities. The data highlighted that most of the UCPM Countries do not have public civilian aircraft but often rely on military aerial capacities. This is why they have been included in the mapping of capacities but distinctly of public civilian capacities. 5 To date, all EU Member States, as well as 6 Participating States (Iceland, Norway, Serbia, North Macedonia, Montenegro and Turkey) participate to the UCPM 6 If UCPM Countries tend to currently rely on external capacities to transport multiple patients (such as service providers, loans from other countries or military organisation), the consultation of UCPM Countries representatives and MEDEVAC experts among the Member States showed a growing interest in a more sustainable and European solution. The second capacity gap identified is MEDEVAC capacities for the transport of highly contagious patients. The 2014 Ebola outbreak in West Africa led several UCPM Countries such as Norway, Luxembourg or Germany to develop dedicated capacities and equipment for the transport of Highly Infectious disease (HID) patients. During the outbreak, the time needed to set-up the capacities and obtain certifications for those capacities was so long that most of the transport of HID patients was performed by a U.S. private company (Phoenix Air). The countries who decided to set-up a capacity solely dedicated to the transport of HID patients such as Germany or Luxembourg dismantled it a year after because of the elevated maintenance costs. Other countries such as France, Spain and the United Kingdom relied on their military aircraft and CBRN/HID equipment and protocols to transport a limited number of patients, but do not have a dedicated capacity for HID patients. Five UCPM Countries (Bulgaria, Estonia, Germany, Ireland, Romania) clearly stated that they have a capacity gap for the transport of HID patients and according to the data collection a dozen of other UCPM Countries do not have any capacity for such MEDEVAC scenario. An on-going project led by the Nordic countries to develop a joint capacity for the transport of HID patients demonstrates that pooling resources for this very specific capacity could be interesting for countries who cannot dedicate an important budget to build this capacity at national level. In order to respond to these two gaps identified, a series of solutions and recommendations have been proposed to foster the actions already implemented by the Commission, with the Voluntary Pool, to set-up a MEDEVAC capacity under rescEU. These recommendations aim at increasing and harmonising in the long-term UCPM Countries European MEDEVAC response capacities with the support of the European Commission. Recommendation #1: The European Commission should continue encouraging UCPM Countries to pool existing capacities for the transport of both HID and non- HID patients by developing strong incentives, in particular the partial refund of recurring costs and support for the certification processes. UCPM Countries with existing capacities (public or private) Short-term 7 Recommendation #2: The European Commission should study the set-up of a dedicated funding mechanism for UCPM Countries to secure aerial response capacities through contract services with commercial airlines or specialized service providers in view of integrating the resulting capacities into the Voluntary Pool or rescEU. UCPM Countries with major capacity gaps/shortages Short to medium term Recommendation #4: The European Commission should study the set-up of a dedicated funding mechanism for UCPM Countries to acquire public aerial capacities equipped for the MEDEVAC of HID and/or non-HID patient matching the minimum technical requirements of the Voluntary Pool or rescEU. UCPM Countries with a shortage of civilian public capacities Long-term Recommendation #3: The European Commission should study the set-up of a dedicated funding mechanism within rescEU for UCPM Countries to develop/acquire MEDEVAC modules (HID and non-HID) and use existing capacities. UCPM Countries with existing modular capacities not dedicated to MEDEVAC Short to medium term 8 2 USEFUL DEFINITIONS CBRN patients – CBRN stands for Chemical, Biological, Radiological, and Nuclear issues that can be harmful through their accidental or deliberate release, dissemination, or impact. “CBRN patients” refers to patients contaminated by hazardous chemical, biological or radioactive substances and or materials6. Civil protection – Civil protection assistance consists of governmental aid delivered in preparation for or in the immediate aftermath of a disaster in Europe and worldwide. Aid takes the form of in-kind assistance, deployment of specially equipped teams, or experts in assessing and coordinating support in the field7. ERCC - The Emergency Response Coordination Centre (ERCC) is the heart of the EU Civil Protection Mechanism and coordinates the delivery of assistance to disaster-stricken countries, such as relief items, expertise, civil protection teams and specialised equipment. The Centre ensures the rapid deployment of emergency support and acts as a coordination hub between all EU Member States and the 6 additional UCPM Countries, the affected country, and civil protection and humanitarian experts.8 HID patients – Patients with a Highly Infectious Disease (Ebola, SAR, etc.). ICU patients – Patients in need of intensive care or high dependency care9, requiring dedicated medical equipment, support and personnel such as severe burn victims, trauma patients, etc. Lightly Injured Patients – Patients whose medical condition allows them to sit during an aerial evacuation. MEDEVAC – For the purpose of this study, the MEDEVAC acronym stand for Medical Aerial Evacuation. The transport of patients by aircraft to a health facility, with dedicated medical personnel to provide care to the patient during the flight. rescEU – rescEU entails a new European reserve of capacities which initially includes a fleet of firefighting planes and helicopters. However, rescEU’s scope goes beyond forest fires and it is expected to include response to other threats such as medical emergencies or chemical, biological, radiological, and nuclear incidents. Stretchers – Patients that must be immobilised on stretchers, a light frame made from two long poles with a cover of soft material stretched between them, used for carrying people who are ill, injured during medical aerial evacuation10. 6https://ec.europa.eu/home-affairs/sites/homeaffairs/files/what-we-do/policies/crisis-and-terrorism/securing-dangerous- material/docs/cbrn_glossary_en.pdf 7 Definition of the European Commission, DG ECHO 8 https://ec.europa.eu/echo/what/civil-protection/emergency-response-coordination-centre-ercc_en 9 http://www.md.ucl.ac.be/didac/hosp/architec/UK_Intensive_care.pdf 10 Cambridge Dictionary 9 UCPM - The EU Civil Protection Mechanism’s objective is to strengthen cooperation between UCPM Countries in the field of civil protection, with a view to improving prevention, preparedness and response to disasters. Voluntary Pool (or EERC European Emergency Response Capacity) - The European Civil Protection Pool brings together resources from 23 UCPM Countries, ready for deployment to a disaster zone at short notice. These resources can be rescue or medical teams, experts, specialised equipment or transportation. Whenever a disaster strikes and a request for assistance via the EU Civil Protection Mechanism is received, assistance is drawn from this pool. 10 3 OVERVIEW OF THE METHODOLOGY OVERALL APPROACH The objective of this Final Report is to present the key results and outcomes of the study, as well as suggest minimal technical and quality requirements for the development of a European MEDEVAC capacity. 11 METHODOLOGY OF THE STUDY A series of key tasks were implemented to conduct the study based in-depth data collection, gathering the lessons learnt and return of experience collected from UCPM Countries. Task 1: Assess patient needs and define MEDEVAC scenarios The first step consisted in conducting a series of interviews to define the principal patient needs on which to base the European capacities with experts in the following fields: • Emergency Medical response. • Crisis management and Civil Protection. This data collection phase led to the identification of 4 potential main patient needs for which a European capacity(ies) would be relevant: • Light injured patients. • Patients on stretchers. • Patients in needs of intensive care. • Highly Infectious disease (HID) patients. The research team then conducted desktop research to identify and select past crises and disasters to identify the response requirements used and the best practices which could apply for each scenario associated. This resulted in a sample of 12 relevant crises, which were chosen to provide a representative/balanced overview regarding the following criteria: • Location: EU/Europe; outside EU. • Nature of incident: fire, earthquake, tsunami, pandemic, etc. • Scale of the crisis: number of casualties; number of European citizens to transport. • Patient needs: lightly injured patients, patients on stretchers, patients in need of intensive care, HID. • Availability of data. The analysis of the past major crises highlighted a series of key elements to support the definition of scenarios which could require a European MEDEVAC capability. Based on the insights and inputs collected from the experts and the desk research, 2 response scenarios within rescEU were drafted: • Scenario 1: European MEDEVAC capacity for the transport of Highly Infectious Disease Patients: mid to long range cargo airliner. 12 • Scenario 2: European MEDEVAC capacity for the transport of non-HID Patients: mid to long range modular airliner. Task 2: Analyse existing options and conduct an overview of current approaches and capacities The first step consisted in reviewing existing aerial MEDEVAC modalities used by the 34 UCPM UCPM Countries to define the main approaches and capacities deployed in case of a major crisis. The overview was conducted by implementing three activities in parallel: • Desktop research; • A semi-structured survey; • Targeted interviews. These combine activities allowed to collect data for 27 countries out of 34 UCPM Countries. NB: Countries for which contact were not successful and limited data was found in open source: Czech Republic, Hungary, Iceland, Montenegro, North Macedonia, Serbia, Slovenia. The prime focus of the research was to understand the current approach towards MEDEVAC for each country, the responsible authority in case of major crises, the type of aerial capacities used and identify potential gaps. The second step consisted in conducting desktop research to define resources needed for each approach and to collect data on the response requirements. The research aimed at collecting operational data from various resources to be taken into account for the set-up and use of a MEDEVAC capacity such as the vector (the aircraft), the 13 human resources (aircrew, medical team) and/or the equipment (technical and medical equipment, consumables). The third step aimed to evaluate and analyse the various capacities and approaches identified. Two activities were conducted in parallel: • A series of phone interviews and a tailored survey sent to MEDEVAC experts within UCPM Countries; • Internal analysis, evaluation processes and consultation of associated experts. These activities led to the collection of stakeholder feedbacks and lessons learnt on the different approaches, their costs and their feasibility. This phase resulted in a differential analysis of the approaches highlighting: • The main benefits and added value; • The limits and constraints; • The challenges. The final step consisted in the analysis of input gathered from the experts and the desktop research to draft solutions adapted for the development of a European MEDEVAC capacity within the two scenarios identified in the previous task. Task 3: Propose recommendations Preliminary solutions were presented to DG ECHO along with the results of Task 2. The presentation led to fruitful discussions on solutions' feasibility, or their ability to respond to a small scale or large-scale event. Based on DG ECHO’s feedback and input, along with the finalisation of the overview of the capacities and cost analysis, the Project Team refined the initial modalities. Starting from these modifications, the solutions were put in perspective based on their feasibility in short- or long-term horizon, and the severity of the crisis for which they could be used. This phase led to the harmonisation and drafting of four solutions for the aerial medical transport of HID patients and four solutions for the aerial medical transport of non-HID patients, each adapted to a particular timeframe and crisis level. 14 In a second step, a SWOT analysis was built for each solution by answering the following questions: • What is this solution’s competitive advantage? • Which existing factors support it? • What do others perceive its benefits to be? • What can undermine the feasibility and deployment of the solution? • Are there other existing issues/difficulties? • Which current / future trends could be supported by the solution? • Which actors are likely to be positively impacted by the solution? • What future obstacles could prevent from deploying this solution? • Are there environmental/structural/political factors that could jeopardise the feasibility of the solution? • Do the technology / skills on which the solution is based risk becoming outdated? Following the analysis of the SWOT the project team devised initial recommendations for DG ECHO to set up a rapidly deployable European MEDEVAC capacity adaptable to the crisis intensity level and time frame. The recommendations were shared with internal experts for a first review to collect their feedbacks and gather their observations on the feasibility of the recommendations. Based on their comments, the recommendations were refined and enriched before being finalised. Task 4: Suggest minimal technical and quality requirements Building on the overview of past crises identify in Task 1 and the overview of UCPM fixed-wing aerial capacities of the UCPM Member in Task 2, the project team elaborated a classification of the capacities according to several criteria: • Type of capacity: type of plane (short, medium, long-haul aircraft, configuration); • Patient transport capacity: number of patients and patient needs (lightly injured, stretchers, ICU, HID patients); • Aircrew: number of pilots, co-pilots, etc; • Medical personnel: number of doctors, nurses, medical technicians, etc; • Deployments requirements: time needed for the plane to be ready for departure; • Deployment radius: geographic zone in which the plane can operate; • Comments: other qualitive information collected. The data collected was integrated into a structured database. The analysis of the raw data saw the emergence of several key elements at this stage: • The type and configuration of the aircraft is logically adapted to the number of patients, their pathology and the flight duration; 15 • The composition of the aircrew depends on the type of aircraft used and the standards followed (commercial airline standard, professional organisation standard (IATA), national legislation); • The composition of the medical team depends on both the number and pathology of patients to be transported and the standards/guidelines followed; • Deployment timeframe can vary from 3h to 48h depending on the operator and the relevant authority’s requirements; • The deployment radius logically depends on the type of plane used. Drawing from the results of the previous step, a series of interviews were conducted to collect additional information on the technical and qualitative requirements applied during major crises during which MEDEVAC operations took place. Internal and external experts from CEIS’s and DG ECHO’s networks were contacted to be interviewed. Questions were drafted to validate quantitative and qualitative criteria and identify possible lessons learnt for each of the two cases: • Scenario 1: MEDEVAC of HID patients • Scenario 2: MEDEVAC of non-HID patients. At the beginning of the interview, the consultant briefly presented the context of the study, followed by key questions to discuss and validate the research hypothesis and identify potential gaps. This phase resulted in series of key findings and operational elements to draft the preliminary requirements starting from DG ECHO template, a table with the following elements: • Main characteristics of the capacity o Main task; o Optional tasks. • Transport capacities o Patients; o Medical team per 24 hours activity, working in two shifts; o Flights abilities. • Main components: o Aerial transport vector; o Configuration; o Flight crew per 12-hour shift; o Medical team per 12-hour shift; o On-board equipment; o Storage and maintenance; o Standard Operating Procedures (SOPs). • Availability o Deployment; o Range (flight length in time). Drawing from the data and information collected during the previous steps, the minimal requirements based on average of capacities and lessons learnt were suggested. 16 Draft tables with the preliminary requirements were sent to internal experts. Then a conference call was organised with experts to further discuss the requirements and receive additional feedback, before finalising the minimum requirement. This phase allowed the production team to draft the following requirements for two types of capacities within rescEU and consolidate the final report. Additional information on existing standard, certification and SOPs were included. 17 4 KEY RESULTS IDENTIFICATION OF PATIENT NEEDS The consultation of both internal and external experts led to the identification and validation of 4 main categories of patient needs which could require a response under the UCPM rescEU capacity. The data collection process allowed to highlight numerous specific medical characteristics that would require dedicated medical equipment’s and trained physicians, but the associated transport characteristics remain the same. • Single patient or small number of lightly injured patients are evacuated by commercial airliner or service providers (insurance companies) within a national level of response; • Small scale events and domestic medical evacuation are managed by national capability or Member States solidarity and do not require EU level response; Patient Needs Medical Cases Medical Characteristics Transport characteristics Level of response Aerial capacity Light injured patients Single classic medical or trauma pathology Single patient with classic medical pathology without complication NA National Out of scope Exceptional emergency Small number of victims with light injuries NA National Out of scope Numerous victims with light injuries Walking wounded patients who can be seated Voluntary Pool or rescEU* Modular short to long range airliner Stretchers Exceptional emergency Numerous victims with severe injuries or paralytic patients Patients who have to be transported on stretchers Voluntary Pool or rescEU* Patient in needs of intensive care Complex pathology Single or multiple patient with pathology requiring complex care Patients in need of advanced system support during the aerial transport Voluntary Pool or rescEU* Highly infectious disease patients Complex pathology Single or multiple patient with highly infectious disease Patients requiring isolation/special handling for transport (isolation pod/container) Voluntary Pool or rescEU* Modular medium to long range cargo airliner Single or multiple patient which have been contaminated by a chemical, biological, radiological or nuclear agent * The level of response would depend on the severity of the crisis (n° of patients, severity of injuries, distance from Europe…). The threshold under which a crisis would require a response from the Voluntary Pool or rescEU will be further studier when defining the requirements. 18 RESPONSE SCENARIOS 4.1.1 Scenario 1: Highly Infectious Disease Patients Scenario ID Name MEDEVAC of HID Patients Location EU/Europe or outside EU. European country or a distant Third Country where there are European victims. Airport landing environment National/international Airport with suitable landing environment for a cargo plane. • Runways of appropriate length and condition; • Refuelling facilities. Crisis context Pandemic or outbreak of a Highly Infectious Disease (Ebola, SAR, etc.) or CBRN contamination (incident or attack) in a European country or in a Third Country with European citizens infected/contaminated. Local civil protection and emergency medical teams are at full capacity or do not have the necessary equipment to locally treat the infected/contaminated patients. A request is sent to the ERCC to activate the UCPM to organise medicalised transport of EU patients to first/second treatment care facility in Europe. Relevant authorities Crisis management authorities of the country hosting the capacity, ERCC, competent authorities from the European patients’ home country, competent authorities from the European country that will host the patients (if different). Objective Mobilise rescEU MEDEVAC capacity to transport European HID patients to a HID certified care facility in the EU. Patient needs characteristics (and/or) • Patients with highly infectious disease transmittable by air; • Patients with highly infectious disease transmittable by fluids; • Patients contaminated by CBRN agents. Patient needs – healthcare continuum - generic scenario Description Requirements ante MEDEVAC • Isolate and manage the patient(s) in a first treatment centre to confirm the diagnosis/contamination; • Confirm admission to an appropriate facility in a centre of medical excellence (if possible). 19 • Confirm flight route (Countries formal acceptance of flying over their territory with a HID patient); • Safely transport the isolated patient(s) in a dedicated ambulance to a suitable airport; • Assist the patient(s) into an isolation pod/dedicated container; • Load the container onto the plane; • Conduct security and technical checks. Requirements during MEDEVAC • Trained medical team to provide care to the patient(s) without breaking the infection/isolation protocol. Requirements post MEDEVAC • Transport of the patient(s) from the plane into an isolation area in an appropriate treatment facility; • Decontamination of the plane (if needed depending on the nature of the isolation container); • Incineration/decontamination of any contaminated or potentially contaminated equipment. MEDEVAC response capacity requirements Configuration & main components Cargo plane able to load container/isolation pod for HID patients: • Dedicated technical and medical equipment; • Communication systems: o Radio communication systems for day and night operations with a directed or minimal relay of transmission between the authority controlling the MEDEVAC operation, the aircraft and the hosting care facility. Aircrew • Aircrew team adapted to the timeframe of the flight Trained Medical Personnel Required profiles: • A Medical Director responsible for supervising, evaluating and ensuring the quality of medical care • Doctors: ICU/Emergency with prehospital experience and aviation physiopathology training with experience in HID • Nurse: ICU/Emergency with prehospital experience and aviation physiopathology training with experience in HID • Technicians: ICU/Emergency with prehospital experience and aviation physiopathology training Protocols • SOP(s)/procedures to isolate the patient(s) 20 • SOP(s)/procedures to provide care for the patients (during transport and flight) • SOP(s)/procedures to transfer the patient(s) to an isolated area within the hosting treatment facility • SOPs/procedures to decontaminate the plane • SOPs/procedures to decontaminate the equipment. Lessons learned and best practices Findings • HID patients need dedicated transport to ensure that the infection protocol is not broken • Transport of HID patients required dedicated SoPs for the decontamination of the plane and equipment Main OSINT sources Indicative Source https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5346232/ Air Medical Transport, H. Rodenberg, Ira J. Blumen, and S. H. Thomas Interviews 21 4.1.2 Scenario 2: Non-Highly infectious disease patients Scenario ID Name MEDEVAC of non-HID patients Location EU/Europe or outside EU. Airport Landing Environment National/international airport with suitable landing environment for a cargo plane: • Runways of appropriate length and condition • Refuelling facilities. Crisis context Natural disaster, major incident or large-scale crisis in a European country or in a third country which result in high number of European citizens injured. Local civil protection and emergency medical team are at full capacity or do not have the necessary equipment to locally treat the patients. A request is sent to the ERCC to activate the UCPM to organise medicalised transport of EU patients to first and/or second treatment care facility in Europe. Relevant Authorities Crisis management Authorities of the Country, ERCC, Competent authorities from the European patients’ home country, Competent authorities from the European country which will host the patients (if different). Objective Mobilise the rescEU MEDEVAC capacity to transport European Non-HID patients: • Numerous lightly injured patients • Patients on stretchers • Patients in need of intensive care. Patients’ Needs characteristics • Numerous lightly injured patients: patients whose medical condition is stable enough to allow the patients to be seated during the flight. • Patients on stretchers: patients that need to be immobilized on stretchers during aerial transport. • Patients in need of intensive care: patients in need of intensive care or high dependency care11 which require dedicated medical equipment, support and personnel such as highly burned victims, trauma patients, etc. 11 http://www.md.ucl.ac.be/didac/hosp/architec/UK_Intensive_care.pdf 22 Patient needs – Healthcare continuum scenario Description Requirements ante MEDEVAC • Stabilise patients in a first treatment centre; • Safely transport of the patients in a dedicated ambulance to a suitable airport; • Assist the patients onto the plane. Requirements during MEDEVAC • Trained medical team to provide dedicated care during the flight. Requirements post MEDEVAC • Transport of the patients from the plane to an adapted ambulance; • Transport of the patients to the dedicated care facility. MEDEVAC response capacity requirements Configuration & main components Cargo plane able to transport sitting patients, patients in stretchers and patients in ICU. • Dedicated technical and medical equipment; • Communication systems: o Radio communication systems for day and night operations with a directed or minimal relay of transmission between the authority controlling the MEDEVAC operation, the aircraft and the hosting care facility. Aircrew • Aircrew team adapted to the timeframe of the flight. Trained Medical Personnel • A Medical Director responsible for supervising, evaluating and ensuring the quality of medical care; • Doctors: ICU/Emergency with prehospital experience and aviation physiopathology training; • Nurse: ICU/Emergency with prehospital experience and aviation physiopathology training; • Technicians: ICU/Emergency with prehospital experience and aviation physiopathology training. Protocols • Policies and procedures for categorisation of severity; • Policies and procedures for priority of movement; • Policies and procedures for medical and technical capabilities needed according to the medical needs of the patients. Lessons learned and best practices Findings • Lightly injured patients, patients on stretchers and patients in need of intensive care can be evacuated in the same plane 23 depending on the configuration of the plane (modular) and the plane’s transport capacity. • Other sub-categories within non-HID patients such as severe burn victims, paediatric patients, patients with advanced system support will need a dedicated plane. They will also need dedicated medical and technical equipment and specifically trained medical team. Main OSINT sources Indicative Source https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5346232/ interviews OVERVIEW OF EXISTING CAPACITIES The medical evacuation and transport of citizens during major crises is the primary concern for the Countries of the Union Civil Protection Mechanism. MEDEVAC operations are often conducted under the supervision of several governmental entities such as Ministries of the Interior, of Health, of Defence or the entity in charge of Emergency management. The map below presents an overview of the fixed-wing capacities identified within the 34 UCPM Countries. The overview provides information on the number of civilian public aircraft dedicated to MEDEVAC and military transport aircraft dedicated for MEDEVAC or which can/could be configurated for MEDEVAC upon request. Nota Bene: This overview has been built from data collected from information available in open source and input provided by representatives of the UCPM Countries. For 7 countries, information has not been found or contact did not succeed (see chapter 4 Methodology), and are highlighted in dark grey for N/A. 24 List of existing capacities identified (overall overview) 2 91 Civilian state-owned aircraft Military state-owned aircraft 3 4 6 1 19 3 3 12 2 2 Commercial airliner/ service provider aircraft Other capacity 5 48 69 47 2 1 14 104 47 8 UCPM members approaches & capacities 25 List of existing capacities identified per approach Civilian state- owned aircraft 2 2 2 UCPM members with Public (civilian) capacities 26 Military state- owned aircraft 4 6 8 3 48 14 UCPM members with Public (military) capacities 27 96 Military state- owned aircraft 3 19 3 69 47 UCPM members with Public (military) & Private capacities 28 Commercial airliner/service provider aircraft 5 UCPM members with only Private capacities 29 12 Commercial airliner/service provider aircraft 5 UCPM members with Private capacities 30 1 Other capacity 1 UCPM members with other capacities 31 4.1.3 Observation 1: UCPM Countries rarely rely on public (civilian) capacities for major crisis. Based on the data collected at this stage, it appears that very few countries have public (civilian) fixed-wing aerial capacities dedicated to MEDEVAC. According to the desk research, only 9% of the UCPM Countries confirmed having public (civilian) fixed-wing aerial capacities dedicated to MEDEVAC, namely Poland, Romania and Turkey; Several reasons were highlighted by other countries for choosing other modalities: • Geography: The length and surface of the national territory tends to be a strong incentive or on the contrary a limit in the definition of the aerial capacities to be used. Countries with a smaller territory tend to rely on rotary-wings capacities which are a flexible and less costly option to perform medical transport of patients. • Cost: The overall cost to develop/acquire and maintain aircraft capacities dedicated to MEDEVAC tend to be seen as too important compared to the use of other approaches, in particularly since such capacities for large scale event or major crisis are not required on a daily basis (high impact, low probability events). 4.1.4 Observation 2: UCPM UCPM Countries who have public (civilian) aircrafts dedicated to MEDEVAC often rely on twin-engine aircraft with small transport capacities According to the information provided by the three UCPM countries who have public (civilian) fixed-wing capacities, they operate small twin-engine aircraft which can accommodate a maximum of 2 to 4 passengers and can cover short to medium flight lengths. 32 • Romania: One Cessna Citation 5 (1 patient at a time) and one Piper PA-42 Cheyenne III (1 patient at a time)12 • Poland: One Piaggio P.180 Avanti and one Piaggio P.180 Avanti II13 • Turkey: Two turbo jets, equipped with stretcher and intensive care unit for up to 4 patient out-a-time. NB: The classification of aircraft based on their range raised internal debate within the project team about the definition of short, medium and long-haul aircraft. In aviation, the flight length is defined as the distance of a flight. Commercial flights are often categorized into short-, medium- or long-haul by commercial airlines based on flight duration, although there is no international standard definition and many airlines use airtime or geographic boundaries instead. Table 1: Short, medium and long-haul typologies (examples): distance and geographic zone Short haul Medium haul Long haul Association of European airlines Europe North Africa, Middle East Americas, sub- Saharan Africa, Asia, Australia Air France Domestic (France) Europe/North Africa Rest of the world Eurocontrol Up to 1 500 km 1 500 to 4 000km Longer than 4 000km For this study, to keep the focus firmly on patient needs, DG ECHO recommended the team to follow a classification based on flight duration (time) as follows: Table 2: Short, medium and long-haul typologies: flight duration Short-haul flight: Under 3 hours Medium-haul flight: 3 to 6 hours Long-haul flight: 6 to 12 hours Ultra-long-haul flight: Over 12 hours 12 http://www.revistamedicinamilitara.ro/wp-content/uploads/2016/07/RJMM-vol-CXIX-nr-2-din-2016.25-28.pdf 13 Technical specifications available at https://www.lpr.com.pl/en/about-us/piaggio-180/ 33 UCPM Countries tend to rely on state-owned capacities able to fly up to 6 hours. 4.1.5 Observation 3: UCPM Countries tend to use military capacities and/or rely on contract services with commercial airliner and service providers for both HID and multiple non-HID patients To respond to major crises resulting in mass casualties or HID patients, 19 UCPM Countries confirmed relying on military aerial assets and/or contract services with commercial airliners and service providers on a case-by case basis: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Lithuania, Luxembourg, Malta, Norway, Poland, Portugal, Romania, Spain, Sweden, The Netherlands, The UK, Turkey. Armed Forces often have transport cargo and modular aircrafts which can be used for the medicalised transport of multiple patients. According to the data collected, 17 UCPM Countries rely on military aerial capacities: Austria, Belgium, Bulgaria, Denmark, France, Germany, Greece, Italy, Lithuania, Norway, Poland, Portugal, Romania, Spain, The Netherlands, The UK, Turkey. They tend to use on an average 2 to 3 military aircraft which can accommodate sitting patients, patients on stretchers and ICU patients. Military cargo aircraft are also used for exceptional emergencies such as the transport of multiple critically burnt patients (Romania, 2015) or transport of HID patients (Ebola pandemic, 2014-2015, France, Germany, UK). According to the data collected, 9 out of 17 UCPM Countries who rely on military aerial assets also rely on aerial capacities from the private sector: 34 This modality can take two different forms: • Framework contract services with one or several commercial airliners or a service provider: the country secures assets through a framework contract with one or several commercial airliners or service providers. The contract is usually based on an annual fee and when a capacity is requested for an MEDEVAC operation, the country pay flight hours for the duration of the mission; • Contract services on a case-by-case basis with a service provider or commercial airliner: depending on the emergency, the country awards a contract to a commercial airliner or a service provider to request a service of emergency medicalised transport. In addition, 3 UCPM Countries only rely on aerial capacities form the private sector: Ireland, Sweden, Finland. These three countries have a framework contract with a national commercial airliner who provides aircraft configured to the government’s needs. Finally, some countries rely on other assets such as aerial capacities operated by the police or border guards, or capacities from another country or a military organisation such as NATO. • Croatia: One Challenger CL-604 used for the president, the prime minister and other ministerial level officials that is used from time to time with special approval for transplant medicine or single-use medical transport in case of extreme urgency • Estonia: One Beechcraft B300 (4-5 seats), operated by the Police and Border Guard Board, under the Ministry of Interior and for major crisis, “Civilian mechanisms like bilateral agreements with neighbouring countries, and the UCPM would most probably be preferred. However, NATO’s support is definitely an asset”; • Latvia: no fixed-wing capacities, use of NATO aerial capacities if needed; Key Finding 1: The main public (civilian) aerial capacities currently operated by UCPM Countries are short to medium range aircraft with reduced patient transport capacities. Key Finding 2: The only aerial fixed-wing capacities which can accommodate more than 7 passengers are military cargo aircraft or assets provided by commercial airliners or services providers through contract services. 4.1.6 Four main approaches identified The overview of the capacities used by the UCPM Countries revealed 4 different approaches: • The use of public (civilian) aircraft dedicated to MEDEVAC; 35 • The use of military aircraft: dedicated to MEDEVAC or cargo which can be configured for passenger transport or MEDEVAC; • The use of civilian aerial capacities through contract services with commercial airliners or service providers; • The use of assets from another country (civilian or military) or from a military organisation. The lessons learnt collected from the relevant stakeholders and additional input gathered from the desk research can be summarised as follows: A general assessment of each approach based on the lessons-learnt and return of experience was conducted according to several criteria: • Availability: On an average, the countries relying on this approach can use their capacity? o Grade: 1 (rarely, capacities are not fully allocated for civilian major crisis) to 3 stars (always, capacity fully dedicated to civilian major crisis); • Range: On an average, the countries relying on this approach can use their capacity for long flight haul. o Grade: 1 (only for short flight haul) to 3 stars (for long to ultra-long flight haul); • Deployment: On an average do the countries relying on this approach can use their capacity rapidly. 36 o Grade: 1 (not rapidly deployable, more than 24 hours) to 3 stars (rapidly deployable, less than 24 hours); • Maintenance: On an average do the countries relying on this approach have to support important cost to maintain their capacity. o Grade: 1 (low cost) to 3 Euro symbols (important cost); • Overall Cost: On an average do the countries relying on this approach have to support an overall important cost to setup and sustain the capacity? o Grade 1: (low cost) to 3 Euro symbols (important cost); 4.1.7 Observation 1: The use of state-owned aerial capacities guarantees autonomy, availability and the upkeep of skills and expertise The ownership of national dedicated civilian aerial MEDEVAC capacities can seem to be the best approach to deploy an adequate response in case of a major crisis. It ensures available, rapidly deployable capacities fully dedicated to major emergencies. Aerial assets can be developed and/or purchased according to the precise needs of the country: civilian jets, modular twin-engine aircrafts, cargo aircrafts, etc. This approach ensures that public sector (civilian or military) expertise and skills are retained. This approach maintains a strategic capacity and allows the country to conduct its MEDEVAC operation in total autonomy without depending on a third party. ! X Availability Range Deployment Maintenance Cost Civilian state- owned €€€ €€€ Military €€€ €€ Commercial airliner or service provider Non applicable €€ Loan of another country/military organisation Non applicable Non applicable Approaches - Analysis and lessons learnt 37 4.1.8 Observation 2: the use of state-owned civilian or military capacities is costly The development and maintenance of a national aerial MEDEVAC capacity (civilian or military) bears a variety of costs: • Development and/or acquisition costs; • Maintenance and storage costs; • Other costs: human resources, technical and logistics, administrative, etc; According to one of the interviewees, the annual flat rate of their framework contract with a commercial airliner is € 300,000, while the purchase of the same aircraft would cost € 101 million, in addition to maintenance and other costs. The cost analysis was the main reason for the country do decide to rely on the use of private sector capacities rather than develop and maintain their own national capacities. 4.1.9 Observation 3: The use of military capacities can limit aircraft availability but leverages military experience and skills Military cargo aircraft, be they dedicated to MEDEVAC or multi-mission, will always give priority to military operations. UCPM Countries who rely on military assets are aware that they run the risk of unavailability of military aircraft if these are already deployed for a military operation. This also explained why they tend to also combine the use of military assets with contract services with service providers on a case by case basis, to cover capability gaps. Air ambulances in Armed Forces date back the start of World War I, when British forces in Turkey first used a biplane to transport a wounded soldier to a medical facility for treatment. The flight required 45 minutes to complete and saved the patient an arduous 3-day journey by land14. Nowadays, EU Member States’ Armed Forces have dedicated capacities to medically transport and evacuate injured soldiers. They often rely on rotary-wing capacities, more adapted to transport patients from the point of injury to a safe location for first care treatment (CASEVAC) but they also use fixed-wing assets from military jets to multi- mission cargo aircraft to transport patients back to national territory (STRATEVAC)15. Some UCPM countries decided to rely on the expertise and experience of their Armed Forces, which gain proven skills and developed robust processes by conducting MEDEVAC operations for injured soldiers. They cooperate with them to organise MEDEVAC during large-scale events. In these cases, the Armed Forces provide not only the aerial capacity and the pilots but can also provide the medical personnel. Mixed civil-military teams are also 14 http://www.airambulanceone.com/history-of-air-ambulances/ 15 https://www.military-medicine.com/article/3329-the-aeromedical-evacuation.html 38 a possibility, with personnel from the ministry of health or the relevant civilian crisis management department or medical personnel from NGOs. By relying on military assets, countries can have access to larger and amortised capacities, able to transport more patients. 4.1.10 Observation 4: The use of private capacities guarantees availability on demand The main added value of the use of private sector aerial capacities, according to interviewees, is availability on demand. Availability and ability to be deployed in a certain amount of time is a contractual obligation between the government and the service provider or commercial airliner. Another benefit raised by interviewees is that there is no need to have dedicated facilities to host the aircraft and store the equipment. The maintenance of the aircraft is also not a concern for the Authority. The service offers can include a wide range of options: the provision of experienced pilots, medical teams, etc. However, the decision to externalise a response capacity to a private operator raise the question of the loss of strategic skills within the public organisation. CAPACITY GAPS ANALYSIS 4.1.11 Capacity gaps identification based on the overview of existing capacities According to the overview of existing capacities within the 34 UCPM Countries, it seems like there are no civilian state-owned capacities for the transport of mass casualties. These capacities are too costly to develop/acquire and maintain, this is the reason why UCPM Countries usually rely on military transport cargo aircrafts or aircrafts from commercial airliner or service providers with larger transport capacities. There is also a shortage of permanent capacities for the transport of HID patients. Several UCPM Countries developed a dedicated capacity which was not maintained in a long-term because of the costs (Luxembourg, Germany). 4.1.12 Capacity gaps according to the UCPM Countries In addition to the overview of their current capacities, 15 UCPM Countries where asked to confirm if they have an aerial capacity gap for MEDEVAC at the moment. The two aerial capacity gaps raised by UCPM Countries are aerial capacities for the transport of mass casualties and for the transport of HID patients. • Aerial capacities for the transport of mass casualties: 5 out of 15 members interviewed confirmed they lack capacities for the transport of mass casualties: Bulgaria, Croatia, Estonia, Ireland, Romania; 39 • Capacities for the transport of HID patients: 7 out of 15 members interviewed confirmed they lack capacities for the transport of HID patient: Bulgaria, Croatia, Estonia, Germany, Ireland, Romania, Sweden; According to the interviews and survey conducted, 5 UCPM Countries confirmed they have no capacity gap: Austria, France, Italy, Spain and Turkey. Nota Bene: The 3 other countries which replied to the survey (Belgium, Luxembourg and Malta) did not answer the question but the data collected from open source about their current capacities confirmed that they are facing similar gaps. These two gaps identified are in line with the response scenarios needs defined in the previous phase. DIFFERENTIAL ANALYSIS AND COSTS 4.1.13 “All-in” versus modular approach: modularity to foster preparedness An analysis of the capacities currently used by the UCPM Countries, along with the input from MEDEVAC experts and stakeholders led to the identification of key elements on the configuration of MEDEVAC capacities. Major disasters and crises often lead to unpredictable damages and consequences. Crisis management and Civil Protection authorities cannot anticipate the exact number of patients or the pathologies which will lead to an aerial Medical evacuation. Patient needs can be very different from one crisis to another and will require specific equipment and resources. As a consequence, the “all-in” approach does not seem adapted to the development of a European rescEU aerial MEDEVAC capacity. It would require a capacity adapted to all types of patient needs, which would be both costly and complex to develop and maintain. Building on lessons learnt from past crises, a modular cargo aircraft would be more adapted if it can accommodate either: • Non-HID patients: seats for lightly injured patients, stretchers, or specific modules for patients in need of ICU, modules for severe burn victims or paediatric patients, etc. • HID patients: Isolation containers, pods or other systems which may be developed in the near future. Modularity means more flexibility in adapting the aerial capacity to the crisis. A modular approach is therefore based on two assets: • The vector: a modular cargo aircraft 40 • The equipment adapted to patient needs: kits, modules, stretchers, support systems, medical equipment, drugs and reusables, etc. Both the vector and the equipment need to be stored and maintained. 4.1.14 The role of private versus public resources 4.1.14.1 Overview of the costs to develop a capacity The development of an aerial MEDEVAC capacity encompasses three series of costs: fixed costs, recurring costs and other costs. Fixed costs: the development versus acquisition of vectors and MEDEVAC modules Fixed costs include expenses which only occur once or very punctually. In this case, the fixed costs for the setting up of an aerial response capacity would be the development or acquisition of a vector (one or several aircraft(s)) and the development or acquisition of the modules (one or several HID isolation pod(s), ICU module(s), stretcher(s), etc.). • Development vs acquisition of an aircraft The development of an aircraft from design to production, testing and certification is a long, complex and costly process. The overall cost of developing aircraft is directly linked to the level of production and units sold. Development costs and unit price: illustrations Boeing 777 Airbus A330 Units sold 1,616 (March 2019) 9,027 (30 September 2019) Development programme costs $5 billion $2 billion (1984) Unit cost Boeing 777-200ER: $306,6 million (2019)16 A320: $101,0 million (2018)17 Joint development programme tends also to be more costly than a capacity developed by a single provider. As an illustration, the overall A400M programme was estimated at 20 billion euros in 2003 for an initial order of 174 aircrafts but actually reached 30 billion euros in 201718. However, commercial airlines rarely pay catalogue prices but instead tend to benefit from important discounts based on the size of the order. A study conducted by Ascend Worldwide and published in Challenges19 highlighted that discounts range from 35 to 60% for the biggest commercial airlines. 16 http://www.boeing.com/company/about-bca/#/prices 17 https://www.airbus.com/content/dam/corporate-topics/publications/backgrounders/Airbus-Commercial-Aircraft-list-prices-2018.pdf 18 https://www.challenges.fr/entreprise/defense/l-airbus-a400m-l-avion-qui-valait-30-milliards_567663 19 https://www.challenges.fr/salon-du-bourget/le-vrai-prix-des-avions-d-airbus-et-de-boeing_10040 41 Aircraft unit costs: Price index versus market price (source: Ascend Worldwide, 2013) Boeing 737-800: Airbus A320-200 Price index on catalogue $89,1 million $91,5 million Market price after discount $41,8 million $38,75 million A third approach can also consist in leasing aircrafts from a manufacturer. According to a study conducted by Alex Philip, Director of Marketing Airline Economic Analysis at Boeing in 2016,20 direct purchase versus leasing approach have both their benefits but with different costs to be taken into account for an airline: Direct Purchase Leasing Characteristics • Airline pays advance payments directly to manufacturer • Airplane is financed with loan secured by a mortgage • The airline gains equity in the airplane as it pays down the loan NB: Several financial institutions usually participate in the loan • The airline gains equity in the airplane as it pays down the loan • The airline gains equity in the airplane as it pays down the loan • Airline leases the aircraft from the lessor • Airline usually pays maintenance reserves to the lessor • Airline returns airplane to lessor when lease ends • Airline may have option to renew lease of purchase aircraft at fair market value Costs • Capital costs o Advance payments o Cash down payment (equity) o Principal and interest payments • Maintenance costs o Paid directly to maintenance • Leasing costs o About 0,8 to 1 % of aircraft cost per month o Actual leases are determinated by aircraft supply and demand • Maintenance costs 20 https://www.iata.org/whatwedo/workgroups/Documents/ACC-2016-GVA/ACC2016_Alex_PHILIP.pdf 42 provider or performed in house. o Reflective of maintenance honeymoon, mature phase, and aging phase • Residual value o Sale of aircraft at fair market value at end of study period or end of economic life offsets initial capital costs o Paid to lessor and available for scheduled maintenance o Typically, equal to mature maintenance cost for aircraft but can vary widely o Excess may be withheld at end of lease to fulfil return conditions • Security deposit o Typically, equal to 3 month +/- of lease payments o Returned to airline at end of lease For the transport of HID patient, operators (public or private) also had to take into account expenses for the adaptation/modification of the aircraft. As an example, Luxembourg Air Ambulance had to modify its 3 Learjet 45, an operation which cost around €100.000 per aircraft. • Development vs acquisition of a module (HID and non-HID) Development and acquisition of HID isolation module and related equipment Since the start of the Ebola Outbreak in West Africa, public actors, service providers, university hospitals and research centres have intensified their work on the development of isolation modules for the safe transport of HID patients. At the beginning of the Ebola crisis, there were very few aircraft equipped for the transport of HID patients21. The UK Air Force had been working on this issue for several decades22 but the solutions currently used by the service providers are relatively recent. Several systems were developed to quickly respond to the growing demand (see case-studies in annex). These systems were usually single-use solutions relying on impermeable transparent plastic sheeting in a cargo plane with containment unit (isolation bubble) or tent. In the last couple of years, more robust and long-term solutions were developed, which can be re-uses or transport several patients at a time and sometimes do not require the aircraft to be decontaminated or for the medical personnel to wear Personnel Protective Equipment (PPE)23. 21 http://www.cidrap.umn.edu/news-perspective/2014/09/very-few-aircraft-equipped-evacuate-ebola-patients 22 https://wwwnc.cdc.gov/eid/article/25/1/18-0662_article 23 https://www.who.int/medical_devices/meddev_ppe/en/ 43 Phoenix Air or EpiGuard have developed dedicated systems, which is a costly process as illustrated in the case-studies in annex. As an example, EpiGuard was founded in 2015 and commercially launched the EpiShuttle in 2018. The total development cost to bring the EpiShuttle to market was approximately € 4 million (including soft funding)24. Price and costs According to the nature of the module, which can range from isolation bubble to full container/sarcophagus, and from single or multiple patient transport capacity, the unit cost is variable. As an illustration, the unit cost for a complete and ready to use EpiShuttle is € 37.500. After using the EpiShuttle to transport a highly contagious patient, some parts like filters, gasket, and mattresses must be replaced as part of the decontamination procedure. EpiGuard sell this complete kit as the EpiShuttle Disposable Kit for € 850. Beyond this, no medical or technical equipment is required, although they sell some equipment such as stretcher adapters and medical racks to ease transportation. The "bubble" stretcher” included in the isolation system provided by Luxembourg Air Ambulance costed €15.000 per unit. Development and acquisition of non-HID modules and related equipment The MEDEVAC kit market is very competitive with numerous providers in the civilian sector. The supply side of this market features a strong presence of SMEs. These SMEs tend to have a stronger national client base and small revenues from exporting their products. Costs of modules can greatly differ from one provider to another, but the products are mature and there are multiple European providers. The non-HID modules and kits can encompass various medical equipment such as: Air Ambulance Equipment § ICU module, stretchers, § Minimum Equipment § Multi parameter vital sign monitor w/defib-pace § Backup Monitor § AED § Ventilator § Electric seringues (X2) § Mucous suction unit § Vacuum mattress § Cervical collar § Splints (set of 3) § Medical bag (w/equipment) (est.) 24 Interview EpiGuard. A complete case study about the use of the EpiShuttle is provided in annex. 44 § Nurse bag (w/equipment) (est.) § Burn bag § Stretcher system (w/loading ramp) § Portable O2 bottles § Personal protective equipment (PPE) (X2) § Misc (pillow, sheets, blankets, transfer mat etc) § Admin equipment According to a service provider, the air ambulance equipment for the transport of one patient in need of intensive care cost on an average 260.000€ per flight25. Specialist equipment (as needed) § Difficult airway management § Ultrasound § ECMO § Baby Pod § Incubator An illustration of detailed equipment costs is provided in annex. Recurring operating costs: Personnel, maintenance & consumables Recurring costs encompass general and operating expenses and are generally seen as indirect costs. For the setting of an aerial response capacity, the recurring operating cost would be cost of personnel (aircraft crew and medical team), the cost of aircraft maintenance and the cost of consumables (aircraft consumable and medical consumable). Personnel expenses o Aircraft Crew: § Pilot wages and benefits for each MEDEVAC mission: According to the German pilot association Cockpit, starting salaries at Ryanair are between €25,000 and €30,000 a year. After five years, co-pilots can earn €70,000. Experienced captains make a maximum of €130,00026. The wages can be very different according to the country, the airline, the operator (public, private) and pilots’ average wage also increases depending on the size of the aircraft and the routes flown27. o Medical team: § Flight doctors’ wages & benefits. Flight doctors wages also depend according to their country, their organisation (public/private hospital, NGO, independent, service provider, etc.). 25 See an illustration of detailed list of cost per equipment in annex. 26 https://www.dw.com/en/being-a-pilot-isnt-what-it-used-to-be/a-45038289 27https://www.icao.int/MID/Documents/2017/Aviation%20Data%20and%20Analysis%20Seminar/PPT3%20- %20Airlines%20Operating%20costs%20and%20productivity.pdf 45 According to Zip recruiter, the Belgium national wage average for flight doctors is $190, 673 annually28. They must be experienced in ICU/Emergency with prehospital experience and aviation physiopathology training. § Flight nurses’ wages & benefits: Flight nurses’ wages also depend according to their country, their organisation (public/private hospital, NGO, independent, service provider, etc.). According to Zip recruiter, the Belgium national wage average for a flight nurse is $81, 093 annually29. Flight nurses must be registered nurses and have a specialty in ICU/Emergency and with prehospital experience and aviation physiopathology training. Finally, a crucial recurring cost which need to be integrated in personnel expenses are continuous training costs. For both the medical team and aircrew, a specific and continuous training is key whether it be for the transport of patient in need of intensive care or even more for the highly contagious patient. Maintenance expenses Maintenance expenses usually include direct airframe and engine maintenance cost, plus “burden” or overheads (hangars and spare parts inventory). According to the data collected by IATA’s Maintenance Cost Task Force (MCTF), airlines spent $67,6 billion on Maintenance Repair and Overhaul (MRO), representing around 9,5% of total operational costs30. Although maintenance costs, as a percentage of airplane-related operating costs (AROC), will vary — depending on such factors as airplane type, average flight segment length, and airplane age — typical maintenance costs range from approximately 10 to 20 percent of AROC. Large carriers, for example, have maintenance budgets in excess of $1 billion31. As an illustration, the annual maintenance costs of a C130J-30 is $7, 350 million32. • Aircraft consumables: Fuel, electricity. Nota Bene: these expenses vary according to the type of aircraft used, patient needs (medical equipment system electricity consumption) and the duration of the flight. • Medical consumables. Other costs As series of other costs must be taken into account: • Continuous training costs for both aircrew & medical personnel • Insurance fees for the aircraft and personnel (in particular for the transport of HID patient) • Risk premium for pilots and medical staff (in particular for the transport of HID patient) • Aircraft servicing costs (ground handling, landing fees, etc.) 28 https://www.ziprecruiter.com/Salaries/Flight-Medicine-Physician-Salary 29 https://www.ziprecruiter.com/n/Flight-Nurse-Jobs-Near-Me?near_me_location=Brussels,BE 30 https://www.iata.org/whatwedo/workgroups/Documents/MCTF/MCTF-FY2016-Report-Public.pdf 31 http://www.boeing.com/commercial/aeromagazine/aero_15/costs_story.html 32 https://fr.wikipedia.org/wiki/Airbus_A400M_Atlas#cite_note-refJ-38 46 • Certification process costs33 • etc. 33 Certification process see https://www.air-ambulance.com/press/id/26/air-ambulance-and-medical-equipment-regulations CEIS | MEDEVAC as EU Emergency Response Capacity 47 | 107 4.1.14.2 Comparative costs analysis of the approaches based on returns of experience Comparative costs analysis of the approaches for the transport of HID patient: Public versus private 34 Sources: URL: https://hcpn.gouvernement.lu/en/actualites.gouvernement%2Bfr%2Bactualites%2Btoutes_actualites%2Bcommuniques%2B2015%2B03-mars%2B12-ebola.html and https://luxtimes.lu/archives/12692-luxembourg-helps-repatriate-suspected-ebola-patient; Cost of use of state-owned permanent capacity Cost of capacity from a service providers HID Case-study 1: Germany Case-study 2: Luxembourg Approach and use-case: Germany developed an Ebola capacity in 4 months, namely an Airbus A340-300 "Robert Koch", built from a Lufthansa plane in cooperation with the Robert Koch Institute (RKI) for the aerial medical transport of HID patient. Approach and use-case: Luxembourg Air Rescue (LAR), a private company, received financing from the Ministry of the Interior to place 1 MEDEVAC Ebola configured plane (a Learjet XR45 with an Air Ambulance Isolation System and "bubble" stretcher) in CECIS (2014-2016)34. Cost: • Around 700.000€ per transport of patient • € 1,5 million/month to maintain the capacity. Cost: Transport of 1 Ebola patient cost € 160.641,00 (with 85% refund from the European Commission. (deployment cost) Recurring costs: Ensure availability of crew and medical personnel in 12h (turnover & training: 12 doctors, 12 nurses, 20 pilots, technicians) Lesson learnt: The development and maintenance of aerial capacities solely dedicated to the transport of HID patients is very costly considering the fact that it is only used it for a very small number of patients. Thus, the ad-hoc capacity was dismantled after 6 months because of lack of German HID patients to transport, and it was deemed too expensive to maintain a dedicated capacity Lesson learnt: The solution offers maximum flexibility when a fast answer is required for a limited number of HID victims. In the case of this evacuation, the plane with the required configuration and relevant equipment was immediately available, as were the experienced crew and medical teams familiar with procedures and standards to respect. However, it was estimated as too costly to be maintained (cost of personnel training and personnel turnover), which is why the capacity was removed from the pool and the contract with LAR terminated. Nowadays, it would take a minimum of 3 weeks for LAR to relaunch the capacity (time necessary to train the personnel) and in 2020-2021, the “bubble” acquired will be obsolete and it will take more time for LAR to acquire new ones (developed in the UK). CEIS | MEDEVAC as EU Emergency Response Capacity 48 | 107 Comparative costs analysis of the approaches for the transport of non-HID patient: Public versus private Cost of use of state-owned permanent capacity Cost of capacity from a service providers Non- HID Case-study 3: Romania Case-study 4: Sweden Approach and use case: Romania use military state- owned planes to ensure the aerial medical transport of victims during major crises. In October 2015, hundreds of people were severely burnt in a nightclub in Bucharest after a major fire. Approach and use case: Since 2006, the Swedish National Air Medevac (SNAM) concluded a service contract for medical evacuation operated by Scandinavian Airlines (SAS). Following the Mumbai attacks, SNAM used a SAS passenger aircraft (Boeing 737-800 converted in 6 hours by SAS into a large-scale air-ambulance and staffed by trained medical personnel. When the mission was completed, and in accordance with the SNAM organisation plan, the plane was restored to its original condition no later than 12 hours after the previous one. Cost: • The cost of operating a CJ27 airplane per hour, based on approximately 400 hours of flight a year, is € 5,000 (without salaries, personnel). Cost: • In 2008, the total cost of the Mumbai mission was SEK 5,7 million or € 525,997. According to a commercial operator "it would have cost just as much as if the mission were carried out with small ambulances with space for one patient per plane, e.g. Lear Jet SNAM stands out as more cost-efficient when considering the quality of care, the space and the expertise offered by the SNAM flight, as well as the possibility to transport significantly more patients in one flight"35. • The service contract costs annually SEK 1,760 million or € 162,412.99 million without the cost of flight hours for each mission. Lesson learnt: In Romania, it is cheaper to use military state-owned MEDEVAC planes in the event of a major disaster, which are already paid off and used for other mission, epecially regarding maintenance and storage costs. Service providers are more expensive regarding indirect costs. Lesson learnt: The SNAM can fly anywhere in the world, on a very short notice, and is able provide a high level of medical ability in evacuating injured persons after a great accident or terrorist attack. Said differently, the SNAM/SAS solution offers experienced medical staff with high quality equipment and aircraft. However, time restriction associated with the rental of the plane creates more pressure on the medical crew because one extra-hour spent is an hour to pay. This constraint reduces the flexibility of the solution, especially when administrative procedure and decision-making process are lengthy. CEIS | MEDEVAC as EU Emergency Response Capacity 49 | 107 PROPOSED SOLUTIONS SOLUTIONS PROPOSED FOR THE VOLUNTARY POOL AND RESCEU FOR THE TRANSPORT OF HID PATIENTS CEIS | MEDEVAC as EU Emergency Response Capacity 50 | 107 SOLUTIONS PROPOSED FOR THE VOLUNTARY POOL AND RESCEU FOR THE TRANSPORT OF HID PATIENT BASED ON CRISIS SEVERITY AND TIME HORIZON CEIS | MEDEVAC as EU Emergency Response Capacity 51 | 107 SOLUTIONS PROPOSED FOR THE VOLUNTARY POOL AND RESCEU FOR THE TRANSPORT OF NON-HID PATIENT CEIS | MEDEVAC as EU Emergency Response Capacity 52 | 107 SOLUTIONS PROPOSED FOR THE VOLUNTARY POOL AND RESCEU FOR THE TRANSPORT OF NON-HID PATIENT BASED ON CRISIS SEVERITY AND TIME HORIZON CEIS | MEDEVAC as EU Emergency Response Capacity 53 | 107 SWOT ANALYSIS 4.1.15 Analysis of solutions for a European MEDEVAC capacity for HID patient Solution 1: Pooling of existing UCPM Countries civilian and military state-owned capacities equipped for MEDEVAC of HID patients and capacities secured through framework contracts with commercial airliners and/or service providers which offer a transport service for HID patients. Solution 2: European funding for UCPM Countries to secure, via a framework contract, services with commercial airliners and/or service providers which offer a transport service for HID patients Solution 3: EU funding for the development and acquisition of HID Medevac kits (containers/pods, equipment’s) and use of existing civilian and military state- owned capacities or contract services with commercial airliners CEIS | MEDEVAC as EU Emergency Response Capacity 54 | 107 Solution 4: EU funding for the development and acquisition of HID Medevac kits (containers/pods, equipment) and for the acquisition of civilian and/or military capacities by one or several UCPM Countries CEIS | MEDEVAC as EU Emergency Response Capacity 55 | 107 4.1.16 Analysis of solutions for a European MEDEVAC capacity for non-HID patient Solution 1: Continue pooling of existing UCPM Countries state-owned aerial capacities (civilian and military) with dedicated kits, modules and equipment’s and existing UCPM Countries aerial capacities secured through contract services with commercial airliners and service providers; Solution 2: European funding for UCPM Countries to secure, via a framework contract, services with commercial airliners and/or service providers which offer a transport service for non-HID patients Solution 3: EU funding for the development and acquisition of Medevac Kits (stretchers, medical equipment’s) and use of existing civilian and military state- owned capacities or contract services with commercial airliners CEIS | MEDEVAC as EU Emergency Response Capacity 56 | 107 Solution 4: EU funding for the development and/or acquisition of civilian state- owned aerial capacities and standardised kits, modules and equipment; RECOMMENDATIONS 4.1.17 Recommendations for Solution 1 – (Continue) Pooling Capacities for MEDEVAC of HID and Non-HID Patients Recommendation #1: The European Commission should continue encouraging UCPM Countries to pool capacities for the transport of both HID and non-HID patients by developing strong incentives, in particular the partial refund of recurring costs and support for the certification process. CEIS | MEDEVAC as EU Emergency Response Capacity 57 | 107 According to the results of the study, the only currently existing civilian public aerial capacities, (namely those of Romania, Poland and Turkey), do not meet the requirements defined in the UCPM Implementing Decision (2014/762/EU, Annex II). However as highlighted in the capacities overview, several countries have aerial capacities which could be included both in the Voluntary Pool or in rescEU: military transport aircraft dedicated to MEDEVAC or which can be configurated with MEDEVAC modules, or aerial capacities secured by UCPM Countries via contract services with commercial airlines. These capacities, if pooled, could offer a rapidly deployable MEDEVAC response from different regions of the EU with amortized aircraft and experienced medical teams and crews. Since the launch of the implementation Act for a MEDEVAC module within the UCPM, only one module was registered (Luxembourg, Ebola module with LAR as a service provider) but decommissioned 2 years later because of the high costs of maintaining the capacity (as illustrated in Draft report 4). The main reason raised by interviewees not to maintain their dedicated capacities was a matter of resources. To meet the minimum technical requirements as defined in the Implementation Act (2014/762/EU), which require an availability for departure within a maximum of 12 hours after the acceptance of the offer, the capacity module needs to include enough medical personnel for 24/7, 365 availability, and ensure that the personnel (medical and crew) are continuously trained and the equipment ready. The Implementation Act for the Voluntary Pool allows the refunding of deployment costs (up to 85%) but not of recurring costs, a major downside according to UCPM Countries and operators. à The European Commission should study new incentives to convince UCPM Countries who have MEDEVAC capacities (public or private) to register them in the Pool and ultimately within rescEU: • Study the added value of modifying the Implementation Act for the Voluntary Pool to include a partial refund of recurring costs (training of medical personnel and aircrew, maintenance, etc.) for capacities matching the minimum requirements. • Include a partial refund of recurring costs in the rescEU Implementation Act Nota Bene: The refund could be proportional to the availability of the aircraft. - Capacities fully integrated in the Voluntary Pool, available 24/7 and 365, which can be deployed in 12 hours for non-HID patient and in 24 hours for HID patient could receive a refund of 85% for both deployment and some of the recurring costs. - Capacities fully integrated in the rescEU, available 24/7 and 365, which can be deployed in 12 hours for non-HID patient and in 24 hours for HID patient could receive a refund of 85% for both deployment and some of the recurring costs. - Capacities which could be requested on demand but are also used for other purposes, such as military capacities, could receive a refund of 85% for deployment costs and a special grant for recurring cost if they have been used under the UCPM during the year. CEIS | MEDEVAC as EU Emergency Response Capacity 58 | 107 • The European Commission could offer to UCPM Countries willing to register their MEDEVAC capacity (public or private) in the Pool or rescEU to facilitate the certification process of the modules, medical team and aircrews via the participation in European exercises such as MODEX, or supporting financially of administratively the certification process for aircraft with EASA. Nota Bene: The certification process for aircraft, personnel and equipment is long and costly, in particular for the transport of HID patient. “The time needed for us to obtain our certification for our Ebola Module with EASA and finalise the administrative process was so long, that we were able to only use it twice whereas Phoenix Air conducted more than 80% of all Ebola patient transport during the outbreak. The European certification process was a liability and prevented us [European service provider] from answering the demand in time.” The European Commission support could provide an incentive for UCPM Countries to register their public capacities but also to convince private Operators who concluded a contract with a UCPM Countries to integrate the Pool or rescEU. 4.1.18 Recommendations for solution 2 – EU funding for UCPM Countries to secure capacities through contract with private sector Recommendation #2: The European Commission should study the set-up of dedicated funding mechanism for UCPM Countries to secure aerial response capacities through contract services with commercial airlines or service providers and integrate the resulting capacities in the Voluntary Pool or in rescEU. As illustrated in the capacities overview, there are important differences between UCPM Countries in their MEDEVAC capacities. France for instance relies on 11 MEDEVAC modules for the transport of ICU patients and lightly injured patients, and solutions for the transport of Highly contagious patients, but could also convert more than 90 military cargo aircraft on demand. Estonia, at the other end of the spectrum has no fixed-wing aerial capacities for MEDEVAC, for the transport of mass casualties or of HID patients. For countries with a confirmed capacity shortage, the main constrain is the cost of developing or acquiring and then maintaining such capacities (as illustrated in Draft Report 3 - Options). This is especially true for capabilities dedicated to low-probability, high- impact crises. Acquiring and maintaining an expensive dedicated MEDEVAC capacity for a long duration, to respond to an event seen as unlikely (mass casualties) or for a very small number of patients (Ebola) is difficult to justify economically and politically. As a result, several UCPM Countries, such as Sweden, Finland, or Ireland, have opted for framework or service contracts with commercial airlines or service instead of maintaining their own capacities. CEIS | MEDEVAC as EU Emergency Response Capacity 59 | 107 Leveraging these countries’ experience, services from private operators could provide a quick response to medical transport needs for exceptional emergencies. à The European Commission could develop a dedicated funding mechanism to support countries or groups of countries willing to secure MEDEVAC capacities through a framework contract with a private operator. The amount of the funding could be adapted according to different cases: • Up to 60% refund on the framework contract annual fees for a capacity which match the minimal technical requirements of the implementation Act of the Voluntary Pool and will be registered in the Pool; • Up to 70% refund on the framework contract annual fees for a capacity which match the minimal technical requirements of the implementation Act of rescEU and will be registered in rescEU. To encourage both UCPM Countries and private operators, it will be important to remind that as soon as registered in the Pool or rescEU, they may be able to benefit from the partial refund of deployment cost and recurring costs as proposed in Recommendation#1. Nota Bene: A noteworthy initiative which could be also studied, is the launch of a call within rescEU for a framework contract for the transport of HID patient which could be financed by the UCPM Countries. The call could be opened to European consortiums. 4.1.19 Recommendations for solution 3 – EU funding for the development/acquisition of Module and use of existing capacities Recommendation #3: The European Commission should study the set-up of dedicated funding mechanism within rescEU for UCPM Countries to develop MEDEVAC modules (HID and non-HID) and support the use of existing modular capacities not dedicated to MEDEVAC. Throughout the data collection to identify current approaches and existing capacities, it was noted that several UCPM Countries owned several or numerous cargo transport aircraft which could be configured to conduct MEDEVAC missions. As an illustration, Germany owns 2 Airbus A340-300, 3 Airbus 319, 31 A400M, 4 Global express 5000, 29 Transall C160 and has ordered 3 Global express 6000, 3 C-130J Super Hercules, 22 A400M and 3 A350. Bulgaria owns one A319, 1 Pilatus PC-12,1 Antonov An- 24, 2 Let L-410, 3 Alenia C-27J, 1 Antonov An-2 and 1 Falcon 200 all operated by their Ministries of Defence. Those aerial capacities are primarily dedicated to military operations and not configured for MEDEVAC. CEIS | MEDEVAC as EU Emergency Response Capacity 60 | 107 à The European Commission could create a dedicated funding mechanism for the development or acquisition of MEDEVAC module (for both HID and non-HID) by one or several UCPM Countries and support the use of existing modular capacities. The amount of the funding could be adapted according to different cases: • Up to 60% refund on the development and/or acquisition of a HID module and adaptation of a capacity which match the minimal technical requirements of the implementation Act of the Voluntary Pool and will be registered in the Pool; • Up to 60% refund on the acquisition of a non-HID module and adaptation of a capacity which match the minimal technical requirements of the implementation Act of the Voluntary Pool and will be registered in the Pool; • Up to 70% refund on the development and/or acquisition of a HID module and adaptation of a capacity which match the minimal technical requirements of the implementation Act of rescEU and will be registered in rescEU. • Up to 70% refund on the acquisition of a non-HID module and adaptation of a capacity which match the minimal technical requirements of the implementation Act of rescEU and will be registered in rescEU. Nota Bene: Non-HID modules/kits are a mature market for which it does not seem useful to develop additional equipment, and therefor to for the Commission to refund development cost. To encourage both UCPM Countries and private operators, it will be important to remind that as soon as registered in the Pool or rescEU, they may be able to benefit from the partial refund of deployment cost and recurring costs as proposed in Recommendation #1. The implementation of these proposal could benefit from the experience of the Nordic Countries who launched a project to co-develop a HID module which could be integrated in an aircraft provided by SAS (Swedish commercial airliner) via a framework contract. This project aims to providing several countries with a flexible capacity and share the costs. 4.1.20 Recommendations for solution 4 – EU funding for the acquisition of Module and capacities Recommendation #4: The European Commission should study the set-up of dedicated funding mechanism for UCPM Countries to acquire public aerial equipped for the MEDEVAC of both HID and non-HID patient matching the minimum technical and quality requirements of the Voluntary Pool or rescEU. CEIS | MEDEVAC as EU Emergency Response Capacity 61 | 107 The Nordic Project for the transport of HID patients relies on the use of capacities from the private sector. However, some UCPM Countries expressed their intention to find long term publicly sourced solutions to their MEDEVAC capacity gap. As presented in the analysis of the different approaches (Draft Report – Options) and highlighted in the SWOT analysis of solution 2, the externalisation of MEDEVAC capacities to a private operator may lead to the loss of certain key skills in the public sector. Some UCPM Countries may be intent on keeping these skills within their organisations. One another note, some UCPM Countries depend on military organisations (e.g. NATO) or other countries’ public or private capacities to respond to specific patient needs such as the transport of multiple patients (Ireland with the U.S., Romania with NATO) or the transport of HID patient (Phoenix air used for 80% of the medical evacuation of European citizen during the 2014-2016 Ebola Outbreak in West Africa). These situations raise the question of the availability of the capacity (for NATO military aircraft for instance) and of the externalisation of a strategic capacity to a third country which is not a member of the UCPM. à The European Commission could propose a dedicated funding mechanism for the development and/or acquisition of a MEDEVAC module (for both HID and non-HID) and facilitate the acquisition of aerial capacities by several UCPM Countries. The amount of the funding of the development/acquisition of modules could be adapted according to different cases: • Up to 60% refund on the development and/or acquisition of a HID module which match the minimal technical requirements of the implementation Act of the Voluntary Pool and will be registered in the Pool; • Up to 60% refund on the acquisition of a non-HID module which match the minimal technical requirements of the implementation Act of the Voluntary Pool and will be registered in the Pool; • Up to 70% refund on the development and/or acquisition of a HID module which match the minimal technical requirements of the implementation Act of rescEU and will be registered in rescEU. • Up to 70% refund on the acquisition of a non-HID module which match the minimal technical requirements of the implementation Act of rescEU and will be registered in rescEU. Facilitate the collaborative acquisition and sharing of MEDEVAC aerial capacities matching the technical requirements of the Voluntary Pool or rescEU. à The European Commission could facilitate the acquisition of aerial capacities by a group of UCPM Countries by supporting the establishment and CEIS | MEDEVAC as EU Emergency Response Capacity 62 | 107 implementation of collaborative projects to pool and share modular aircrafts which could be configurated for MEDEVAC by: § Offering a forum for identifying common capacities response needs and potential synergies at regional level; § Giving a political impulse; § Providing a financial, technical, legal and operational expertise; Nota Bene: - Non-HID modules/kits are a mature market for which it does not seem useful to develop additional equipment, and therefor to for the Commission to refund development cost. - The aviation market is mature and propose a wide range or aircrafts which could meet the minimal technical requirements of both Voluntary Pool and rescEU, reason why it does not seem useful to develop additional aircraft, and therefor to for the Commission to refund development cost. To encourage both UCPM Countries, it will be important to remind that as soon as registered in the Pool or rescEU, they may be able to benefit from the partial refund of deployment cost and recurring costs as proposed in Recommendation#1. MINIMAL TECHNICAL AND QUALITY REQUIREMENTS FOR RESCEU 4.1.21 Quality and technical standard, certifications and standard operating procedures. Air ambulance operator (public or private) are following different quality and technical standards, use certified equipment and implement standard operating procedures (SOPs) for the medicalised transport of patient. CEIS | MEDEVAC as EU Emergency Response Capacity 63 | 107 4.1.21.1 Aircraft and cabin crew standards Whether in a public or private service provider case, aircrafts, pilots and cabin crew deployed for a MEDEVAC operation must be compliant with the following rules set up by the European Union Safety Aviation Agency (EASA): Documents Description Link Regulation on common rules in the field of civil aviation and establishing a European Union Aviation Safety Agency, and amending Regulations (EC) No 2111/2005, (EC) No 1008/2008, (EU) No 996/2010, (EU) No 376/2014 and Directives 2014/30/EU and 2014/53/EU of the European Parliament and of the Council, and repealing Regulations (EC) No 552/2004 and (EC) No 216/2008 of the European Parliament and of the Council and Council Regulation (EEC) No 3922/91 Basic regulation for civil aviation, including medical certification of aircrew. https://eur- lex.europa.eu/legal- content/EN/TXT/PDF/?uri=C ELEX:32018R1139&from=E N Regulation laying down technical requirements and administrative procedures related to civil aviation aircrew pursuant to Regulation (EC) No 216/2008 of the European Parliament and of the Council Technical requirements and administrative procedures related to civil aviation aircrew. https://eur- lex.europa.eu/legal- content/EN/TXT/PDF/?uri=C ELEX:02011R1178- 20190109&from=EN Regulation laying down technical requirements and administrative procedures related to air operations pursuant to Regulation (EC) No 216/2008 of the European Parliament and the Council Technical requirements and administrative procedures related to air operations. https://eur- lex.europa.eu/legal- content/EN/TXT/PDF/?uri=C ELEX:02012R0965- 20140217&from=EN Regulation amending Regulation (EU) No 452/2014 as regards the deletion of templates for the authorisations issued to third country operators and for the associated specifications Regulation related to third countries operators (TCO). https://www.easa.europa.eu/si tes/default/files/dfu/Commissi on%20Regulation%202016.1 158.pdf CEIS | MEDEVAC as EU Emergency Response Capacity 64 | 107 Regulation laying down airspace usage requirements and operating procedures concerning performance-based navigation Regulation laying down airspace usage requirements and operating procedures concerning performance-based navigation. It applies to providers of air traffic management/air navigation services (ATM/ANS), and operators of aerodromes (hereinafter ‘providers of ATM/ANS’) that are responsible for putting in place instrument approach procedures or air traffic service (ATS) routes, where they provide their services. https://eur- lex.europa.eu/legal- content/EN/TXT/PDF/?uri=C ELEX:32018R1048&from=E N Regulation amending Implementing Regulation (EU) No 923/2012 as regards the update and completion of the common rules of the air and operational provisions regarding services and procedures in air navigation (SERA Part C) and repealing Regulation (EC) No 730/2006 SERA - Standardised European Rules of the Air. https://eur- lex.europa.eu/legal- content/EN/TXT/PDF/?uri=C ELEX:32016R1185&from=E N Regulation laying down a list classifying occurrence in civil aviation to be mandatorily reported according to Regulation (EU) No 376/2014 of the European Parliament and of the Council Regulation related to occurrences related to the operation of the aircraft, technical conditions, maintenance and repair of the aircraft, air navigation services and facilities, aerodromes and ground services. https://eur- lex.europa.eu/legal- content/EN/TXT/PDF/?uri=C ELEX:32015R1018&from=E N Regulation laying down implementing rules for the airworthiness and environmental certification of aircraft and related products, parts and appliances, as well as for the certification of design and production organisations (recast) Regulation related to initial airworthiness. https://eur- lex.europa.eu/legal- content/EN/TXT/PDF/?uri=C ELEX:02012R0748- 20150721&from=EN Regulation on additional airworthiness specifications for a given type of operations and amending Regulation (EU) No 965/2012 Additional airworthiness specifications. https://eur- lex.europa.eu/legal- content/EN/TXT/PDF/?uri=C ELEX:32015R0640&from=G A CEIS | MEDEVAC as EU Emergency Response Capacity 65 | 107 Regulation on the continuing airworthiness of aircraft and aeronautical products, parts and appliances, and on the approval or organisations and personnel involved in these tasks (recast) Continuing airworthiness. https://eur- lex.europa.eu/legal- content/EN/TXT/PDF/?uri=C ELEX:02014R1321- 20190305&from=EN 4.1.21.2 Transport of patients There is no harmonised European Standard Operating Procedures (SOPs) related to the aerial transport of patients regardless of the actor considered (military, public or private service provider). • Certification and license for pilots, doctors, nurses and technicians are usually issued by the home country of the individual considered. For instance, in France, the Direction Générale de l'Aviation Civile (DGAC) is in charge of issuing certification for flight doctor, while the Organisme pour la Sécurité de l'Aviation Civile (OSAC) delivers aircraft mechanic license. • There is an obligation of insurance for every MEDEVAC operation. Doctors are usually responsible for all medical gestures, while engineers are responsible for the aircraft as such. The responsibility mechanism can be very complex in case of a litigation, especially if there is an accident in a third country. Despite the absence of common SOPs, quality standards charts are developed by professional associations. The most commonly followed are: • EURAMI – European Aero