Katie McInerney and Yogeeta Manglani’s Blog

The Role of Transport in Health Systems – A Roadmap

January 6, 2013

Bonjour!

Greetings from Dakar, where Katie and I are spending a few days taking in the sights and sounds of West Africa before starting our internship in The Gambia with Riders for Health. Founded in the late 1980s by motorcycle enthusiasts Andrea and Barry Coleman, Riders plays a critical role in the health system of countries where it operates, by providing rural populations a means to reach health facilities, lack of which is often the greatest bottleneck to receiving life-saving care. Riders manages more than 1,200 vehicles in nine sub-Saharan African countries.

According to the World Health Organization, between 40 and 60% of people in developing countries live more than eight kilometers away from a health facility. However, despite this disparity, issues related to transportation have been underemphasized in global health dialogue, as they do not fall under the purview of a designated stakeholder within the health system. Governments have typically been biased toward large-scale transport systems such as roads and ports, while non-profits have been deterred from implementing transportation projects due to the capital costs involved. This has led to a vacuum in intermediate transportation such as ambulances, motorcycles and bicycles for accessing, and being accessed by, health services.

In recent years, the emergence of social enterprises such as Riders has provided reason for optimism. Rather than rely solely on donor funding, these organizations have designed innovative business models to ensure long-term sustainability. Riders for Health generates enough revenue to sustain its operations, either by charging on a cost-per-kilometer basis to manage government fleets, or by owning and maintaining their own fleets and loaning them out to governments.

Over the next few weeks, we will be working with the Monitoring and Evaluation and Finance teams at Riders to evaluate their ambulance referral system in The Gambia, with a focus on the Lower River Region. One of the key indicators currently used by Riders to evaluate their referral system is cost-per-kilometer. As part of our internship, we have started conducting a literature review to explore other indicators that could be used and look forward to being on the ground in The Gambia to expand on our research.

Hello from Serrekunda, The Gambia!

January 8, 2013

After a quick 20 minute flight from Dakar, Yogeeta and I have settled into our hotel on the beach in the beautiful country of The Gambia. We were met at the airport by Ken, the Riders for Health Monitoring and Evaluation officer, who we will be working with for the next three weeks.

We began our first day of work by meeting a number of Riders for Health staff. Along with the Program, Country, and Financial Directors, we met the head drivers and mechanics of the motorcycle and trekking vehicle fleets, the fuel and supply logistics coordinators, the security team, and the administrative support team.  As “Auntie T,” the Gambian Country Director said, “we are a big family and we make working seem fun.”  We already feel like part of the family!

Yogeeta and Katie with their colleagues at Riders for Health in The Gambia

We have busy three weeks ahead of us learning about Riders and writing a report assessing the ambulance referral system before and after the inception of the Transportation Asset Management System (TAM).  This week we will be meeting with public health officials from the Ministry of Health and Social Welfare.  Next week we will be attending the inauguration of the Riders for Health training center and we will be traveling to the Lower River Region to visit a number of health centers.  We are looking forward to further exploring The Gambia and providing Riders for Health with a report that will help improve their already outstanding system.

Maternal Death Audit at Fajikunda Health Center

January 9, 2013

Today, Katie and I visited our first health center in The Gambia. Riders for Health was invited to attend a Maternal Death Audit review meeting at Fajikunda health center, one of the major health centers in the western part of the country. The meeting provided useful insight into the maternal health situation in The Gambia and highlighted the important role that transportation and timely referrals play in preventing maternal deaths.

A woman outside the Fajikunda health center waits for her daughter who was in labor inside the facility

A woman outside the Fajikunda health center waits for her daughter who was in labor inside the facility

The meeting agenda consisted of an in-depth review of two specific maternal death cases that occurred in Fajikunda in the last quarter of 2012. Attendees included representatives from Fajikunda health center, the Reproductive and Child Health services unit and doctors from Royal Victoria Teaching Hospital in Banjul as well as from surrounding health centers. The purpose of the meeting was to bring together stakeholders and receive feedback as to how these cases could be used as lessons moving forward to achieve the MDG target of reducing maternal mortality in The Gambia from the current figure of 400 deaths per 100,000 live births to 265 deaths per 100,000 live births by 2015.

The case presentations were very comprehensive and consisted of detailed information about treatment administered to the patient. In the first case, death was attributed to premature rupture of the membrane and a failure to induce labor in a timely manner, while the second was due to mismanagement of malaria during pregnancy. While there is usually an interplay of factors leading to maternal mortality, delay in transportation to a larger health facility and lack of coordination in referrals were identified as key areas for improvement.

Representatives from Fajikunda health center explained that they often ran out of fuel for the ambulances, and were forced to ask patients to pay to be transported to the hospital. Their request to Riders for Health to increase the weekly amount of fuel provided to them revealed that they were not aware that the Ministry to Health, and not Riders, decided the quantity provided. Ken Diako, the Monitoring and Evaluation Officer at Riders, explained that the ceiling had been set according to 2008 fuel prices, and recent price hikes had worsened the shortage.

Fortunately, in the next few months the health center is scheduled to be covered under Riders’ Transport Asset Management (TAM) program, which has already been rolled out in the eastern provinces and has ensured adequate fuel supply, along with timely maintenance and trained drivers. This will be instrumental in strengthening the health system and increasing the availability of timely and adequate care for mothers and children in the country.

Field Trip to the Lower River Region – Days 1 and 2

January 17, 2013

After several days of preparation and anticipation, Katie and I are finally out in the field, collecting data in “the provinces”, as the rural areas east of the greater Banjul area are often called. Our base is in Mansa Konko, which is where the Riders field office for the Lower River Region (LRR) is located, and we will be traveling as far as Bansang hospital (see map below) in the Central River Region (CRR) for our data collection.

Map of The Gambia

Map of The Gambia

We have visited 4 health centers in the LRR in our first two days here – 3 minor facilities (Kwinella, Jappineh and Bureng) and one major facility (Soma) that serves as the referral node for the minor facilities. Our focus has been on interviewing the officers-in-charge regarding emergency referrals, and in particular, how the TAM program has impacted of ambulance availability and management at their facility.

As this is the first data collection experience, this trip has been a tremendous learning opportunity, in terms of creating and piloting the survey questions as well as communicating with the health workers to gather the highest quality of information possible. Given Riders’ longstanding relationship with the health centers and the positive experience that all of them have had with the organization, the officers-in-charge have been more than cooperative in helping us gather the required data.

The Lower River Region research team: Buba, Katie, Ken, and Yogeeta

The Lower River Region research team: Buba, Katie, Ken, and Yogeeta

For me, the most striking aspect of our visits to the facilities so far has been the tangible presence of international donors such as the Global Fund, World Bank, UNICEF and UNFPA, visible through health education posters, health units sponsored by them, or the many donated vehicles bearing their number plates. It is exciting to witness the programs that we read about in our classes actually being translated into improvements in health outcomes at an individual level.

Field Trip to the LRR – Day 3

January 18, 2012

As public health students, we love data – big data, small data, quantitative data, qualitative data – anything that can provide measurable evidence of program impact. So for us, our meeting today with Dr. Mamady Cham, CEO of Farafenni hospital and champion of data collection, was especially exciting.

Dr. Cham is a maternal health expert and has been in the field of public health for over 25 years. He has held a variety of positions in the health system, from serving in the Ministry of Health to working with the Reproductive and Child Health Services Unit, to now heading one of the biggest hospitals in the country. One of his priorities at the hospital has been to digitize all health records. During our interview with him, he mentioned that the lack of trained biostatisticians and epidemiologists in the Ministry of Health is a key reason for the lack of adequate data regarding public health trends in The Gambia.

Interestingly, Dr. Cham was also responsible for implementing a national referral protocol (see image below), including designing the template for referral log books, which are now maintained by all health facilities and are a central part of our data collection. He was very appreciate of the impact that Riders has had on improving health outcomes in The Gambia, particularly maternal health, and stressed that the organization should focus on continuous quality improvement.

Dr. Mamady Cham, CEO of Farafenni Hospital, was responsible for implementing a national referral protocol in The Gambia

Dr. Mamady Cham, CEO of Farafenni Hospital, was responsible for implementing a national referral protocol in The Gambia

The Evolution of Riders for Health

January 20, 2013

Yogeeta and I were lucky to be at Riders for Health during for the inauguration of the Riders for Health Training Center at the main office in Kanefing.  The center was built in only 4 months.  A number of important stakeholders were at the inauguration included the Minister of Health, the British High Commissioner, a member of the British parliament, and Andrea and Barry Coleman, founders of Riders for Health.

Andrea and Barry both spoke about the evolution of Riders for Health, allowing me to gain a better understanding of the extent to which the organization has had an impact on the community beyond the availability of transport. Barry told us about the first female technician. The male technicians were not sure she could handle the job but they voted to give her a shot—she was great. Riders now has many female technicians and riders.  As Barry said, just because no one has done it before, doesn’t mean it isn’t possible.

Riders is proving time and time again that improvement and progress are possible. During our meeting with Barry and Andrea they discussed the increase in demand for medical service resulting from Rider for Health transportation. In the beginning of the program, there was an inadequate number of qualified medical personnel to provide services for even common illnesses.  As a result of the increased demand for services brought on by the availability of transport, and increased confidence in medical care, the number of health workers in The Gambia has increased over time. Therefore, the program has an impact on the larger economy of The Gambia.  After getting to know a number of the staff members at our hotel, it is apparent that there is a lot of untapped ambition within the country.  People strive to go to school to learn and obtain jobs that would allow them to make a difference in their community. Most people don’t have the means to afford quality education.  Organizations like Riders for Health provide trainings and job opportunities for those who may not have had them otherwise.

Yogeeta and I learned firsthand the importance of the driver training that will take place in the new center.  We traveled “up country” to visit seven health centers in the lower river and north bank regions.

One health center was 24 miles off the main road.  The unpaved local road was in such poor condition that it took us 90 minutes to reach the health center.  While we were being jumbled around in the back seat, the driver was expertly handling the terrain. An emergency referral case (e.g. prolonged or breached labor) would have to travel that same road to reach a facility that handles more complex cases.

We could barely handle it as healthy passengers, let alone after 24 hours of labor!  I hope we will be able to quantify the extent to which Riders has improved health of Gambians with the data we collected during our visits!