A flight to the hospital from the scene of your accident might be seen as a miracle. When your life is on the line, getting into the air is usually the quickest route to that care.

But there are some associated challenges.

One is that there might not be a helicopter available. And not because it is busy, but because it doesn’t exist where you live.

Here is a look at various emergency air medical operations around the globe.

India

It’s difficult to pair up the numbers — population versus helicopter emergency medical service providers. You think about a number like 1.3 billion and pair that with the number 1. That’s a major disparity. And that single provider in India has but three helicopters.

The company, Aviators Air Rescue, is one of many medical transportation companies in India. But like the others, it provided transportation on a non-emergent basis — scheduled transports between hospitals, or between distant airports and hospitals, or from outside the country to inside, using mostly chartered aircraft. Emergency transportation, as part of a response to an injury, at the site of a car crash or motorcycle mishap or workplace accident, was not something available in India. But in January, Aviators Air Rescue began providing that service.

With a major stake provided by Air Medical Group Holdings of Lewisville, Texas, Aviators Air Rescue placed three Airbus H130s, outfitted for emergency response, at each of its bases in Bengaluru, Hyderabad and Chennai. These cities are clustered in the south of the country, and the combined aircraft serve a population of about 250 million.

When Germany got its first EMS helicopter in 1970, christened Christoph I, its population was about 78 million. Now there are about 80 aircraft serving a population of 82 million. In round numbers, it progressed from one helicopter per 80 million people to one helicopter per 1 million. Coincidentally, India’s first foray into the field of helicopter EMS has Aviators Air Rescue serving 83 million souls per aircraft. It’s a small start for a very large country. But at least it’s a start.

Holding India back has been the lack of wealth across most of the population. Per capita income was only $1,570 in 2013, yet a fully equipped helicopter costs the same, if not more, in India than it does in Australia or Kenya or anywhere else in the world. So how do you bring the latest in modern medical transportation to the hundreds of millions of households that, even among the middle class, earn only $10 to $50 per day? And poor rural households, accounting for two-thirds of the population, earn perhaps one-fourth of that.

Because health insurance in India does not include emergency air transport — and why would it if no such service existed? — even those with insurance would face the full cost of a flight. Aviators Air Rescue’s approach is a subscription model. The annual premium for an individual is $47, and a family of four costs $94, which covers up to five hours of medical transport, including organ transports. According to Arun Sharma, managing director at Aviators Air Rescue, the company must greatly increase the subscriber base just to support the current program, much less expand it.

One factor slowing subscriber growth is cultural. Sharma pointed out that people in the vicinity of an accident will rush to assist the injured. They might drag a man from a crumpled truck or pick up a woman thrown from a motorcycle, and hustle them by car or truck or autorickshaw to the nearest clinic or hospital. Extrication by non-trained personnel can inflict additional injury or harm. This poses an unexpected challenge: changing that behavior so trained responders can do their jobs. Of course, the responders have to get there, and especially away from the population centers, roads are often poorly maintained and may be crowded with slow-moving traffic. Helicopters, of course, are a natural solution to these problems.

Sharma’s goal is a 30-minute response time anywhere in the country within the decade.

United States

In the U.S., the numbers are definitely in favor of available patient care, but that brings its own challenges. When the use of helicopters advanced from military medical operations and ad hoc deployment for civilian emergency response to services by and for civilians, what began as a single aircraft operating from one base in 1972 had grown to 39 aircraft at 32 bases by 1980. A decade later, the industry was six times larger. It more than doubled in the decade after that.

That was the year 2000. Today more than 1,000 helicopters from nearly 900 bases serve the nation. Per capita, there is one helicopter for every 300,000 people. That would seem a good thing, and is, in terms of availability.

A problem with such a large number of helicopters, however, is pricing of the service. When offerings get crowded in population centers, it can result in too many aircraft chasing the emergencies and, thus, fewer calls per aircraft.

Paychecks, lease payments, insurance, utilities and training all keep coming due, whether aircraft fly or not, so those accumulating costs must be recovered in fewer, now more expensive, flights.

There are pricing pressures born of changes in services, but there is also the steady increase in the cost of aircraft and equipment and the training to operate them. Some of those increases are for improvements in efficiency, while most are focused on safety.

In 2014, the FAA issued a final rule that affects helicopter operations in general, with some elements applicable to what are termed helicopter air ambulance certificate holders. There are more than 20 rule changes that have, or will, go into affect. Chris Eastlee, president of the Air Medical Operators Association, called out four signal requirements being phased in one year at a time beginning in 2015. They are tighter definitions concerning VFR and IFR conditions with a concomitant push for IFR operations regardless of weather; changes in operational control centers related to staffing; installation of helicopter terrain avoidance and warning systems; and installation of flight data monitoring (FDM) systems. The first three have been implemented across the board, and the FDM requirement is to be met by April 2018, though many operators have been complying with the upgrades in advance.

In some cases, flight times have increased as healthcare providers consolidate specialties into fewer locations, farther than the nearest hospital. In rural America, flight times are on the rise as clinics and hospitals have closed due to funding cuts brought on by the recession and consolidation in the upper echelons of healthcare companies. An extra five minutes of flight time may not sound like much, but when added to what used to be 10, the extra minutes and dollars add up.

Compounding the cost issues in the U.S. is the state of insurance coverage for helicopter emergency transportation. Stories regularly appear where patients are billed tens of thousands of dollars for a quick trip to the hospital. Eastlee, who is also VP of government relations for the Association of Air Medical Services, pointed out, “AAMS is working to reform Medicare reimbursement rates and bring those in line with actual costs. Medicare pays about 60% of average service, while Medicaid can be as low as 35%, or in some states, like Pennsylvania, a mere 2%.”

Those low reimbursement rates are also a challenge for suppliers. If aircraft operators are faced with reduced revenue and margins, plus increasing costs for equipment, staffing and training, they have less to invest in newer aircraft. Mike Slattery, president of United Rotorcraft, said, “It is doubtful that we will see renewed growth in the market until reimbursement issues get addressed.” He said he expects these conditions to put pressure on HEMS completion centers as they upgrade airframes to keep up with those changes in regulations and operations.

There are, however, some imminent changes that will reduce the need for emergency transportation. A concept called mobile integrated healthcare is aimed at improved patient care, but also combats the increasing costs of helicopter emergency services, as well as other factors contributing to higher healthcare costs, by bringing more services to patients in or near their home.

Eileen Frazer, executive director of the Commission on Accreditation of Medical Transport Systems, pointed out the impact on HEMS may not be immediately evident. It comes about through healthier patients needing less emergency transportation. “We see a lot of reduction in helicopter transports, but also ground transports, as more local or home-based care comes into existence.”

Over-serving in terms of aircraft and operators, which is driving prices up, should have worked itself out with market forces pushing efficiency up and costs down, she said. That has not happened.

Finally, safety issues remain a concern for operators. Ira Blumen, medical director and program director at the University of Chicago Aeromedical Network, and an expert on air medical transportation, cited 340 HEMS accidents since 1972, with more than 220 since 1998. According to the NTSB, there were at least 174 patients and crewmembers killed in accidents from 1998 to late 2014.

Of course, training is required by the FAA mandate for operating any aircraft, though few requirements are specific to HEMS flight crews. Mission-specific operational training, then, is often conducted within the operator’s organization, perhaps supplemented by companies like FlightSafety International or Priority 1 Air Rescue.

FlightSafety long ago incorporated crew resource management, aeronautical decision-making and situational-awareness training in what Mark Ozmer, its regional director of training operations, termed “the aviator’s skill set.”

Of more recent heritage, but steeped in search and rescue, emergency medical and tactical operations, Priority 1 Air Rescue is a specialized training company. It has offices in Malta and Canada, plus what it labels Search & Rescue Tactical Training Academies in Arizona and France. It not only trains clients, backed by years of actual experience in these fields, but also can help launch an operation from the ground up.

Canada

Despite great similarities between the U.S. and its northern neighbor, HEMS in Canada works quite differently and much more safely.

In the 40 years since the inception of HEMS in Canada, the nation has experienced a single fatal accident. Part of its success has been training, part of it staffing and part of it how the aircraft are tasked and the costs covered.

Robert Blakely, former VP and general manager of EMS operations with Canadian Helicopters, points out that unlike in the U.S., healthcare in Canada is universal. All residents are covered and that includes transportation, even if by emergency helicopter. Further, Canadian provincial health ministries contract for HEMS services to cover their entire provinces for periods typically between five and seven years. A single provider is chosen from competing bids and is paid per that contract, which covers flying and not flying. There is no pressing financial need to launch a mission — if a flight is required, medically, and the risks are acceptable in terms of weather and terrain and all the rest, it flies. If the flight is not medically necessary, or the conditions are too risky, it doesn’t fly.

And when it flies, it is with two pilots. Every time. In a helicopter with two engines. Every time. Pilots are IFR-qualified, and the aircraft are appropriately equipped. “They train like the airlines do for IFR, so it’s totally not an issue,” commented Blakely. The certifications and training required by the provincial governments exceed those of their federal government.

Each province devises its own plans for HEMS coverage, including how many aircraft need to be available for immediate service, and those numbers are relatively small compared to the U.S. For instance, Alberta has three aircraft for its 4.2 million residents, Saskatchewan has two, Manitoba has one, and Nova Scotia has one staffed aircraft for its 940,000 people, though a new contract is being let that will provide two aircraft for 15 years.

The largest province, by population, is Ontario, with 11.6 million people and 11 aircraft to support them. Unfortunately, it was its then-new HEMS provider, Ornge, that suffered the fatal accident. Unlike how it had provided helicopter service in the past, Ontario chose to cut short its contract with the existing provider and stand up its own quasi-governmental service and manage everything internally.

This radical departure was against the advice of multiple parties, led to charges of fraud and mismanagement and, ultimately, an aircraft and its crew were lost. That was 2013 and Ornge has since made strides in management and operations, though it is still dogged by the legal fallout from its shaky beginnings. A criminal probe wrapped up earlier this year, and court proceedings related to the crash commenced in April.

Europe

European countries provide HEMS with a range of approaches. England, Wales and Northern Ireland are served by aircraft supported by charities, and their populations are justifiably proud of the aircraft and crews. With Scotland’s three aircraft (two government-funded, one by charity), the nearly 50 aircraft serve 64 million people.

In Germany, two civilian companies and the Interior Ministry provide HEMS coverage. One company is Germany’s largest automobile club, ADAC; the other is a nonprofit. Between them they fly roughly 80 aircraft.

France, like Canada, contracts for regional coverage with private providers for multi-year terms. Poland, with helicopters serving in EMS through its Lotnicze Pogotowie Ratunkowe, operates aircraft from strategically located bases under the direction of individual cities or counties, paid for by the national government. Norsk Luftambulanse serves both Norway and Denmark with 12 aircraft. Luxembourg has its own service with six aircraft. RWI