Health Research Program
Author(s):
Oluwaseun Aladesanmi*, Andrew Storey^
Organization:
*Associate Program Director, Maternal Newborn Health, Clinton Health Access Initiative. ^Senior Director, Maternal Newborn Health, Clinton Health Access Initiative

Emergency care systems, including functional emergency transport systems (ETS), are an important component of any functioning health system to manage acute illness and injury, including acute complications of pregnancy. This was recognized at the 72nd World Health Assembly where WHO urged member states to provide universal access to safe, high-quality, needs-based emergency care for all.1

Photo credit: Healthy Newborn Network

Lack of emergency transport, and in some cases routine transport, remains a barrier to accessing lifesaving health services in most sub-Saharan African countries.2,3,4,5  This is especially true during obstetric emergencies where prompt care can mean the difference between life and death.

Countries are at very different stages in provision of emergency transport. In many sub-Saharan African countries ambulance services are often inadequate and unable to cover urban areas. In rural communities this is compounded by bad roads and long distances between health centers and villages. The COVID-19 pandemic has placed  additional strains on ambulance services. Countrywide lockdowns have also restricted movement and limited public transport availability. 

In this blog we argue that a well-run, community-led ETS can provide emergency transport for patients, particularly women and newborns during birth complications, to appropriate levels of care in a timely manner; support wider efforts to avert significant numbers of maternal and neonatal deaths; and play an important role while efforts are underway to develop emergency care and transport systems in country. 

Strengthening referrals and community Emergency Transport Systems

Governments, implementers, and donors are seeking solutions to improved referrals and ETS at the community level. For example, Clinton Health Access Initiative’s (CHAI) Maternal, Newborn and Reproductive Health program in Ethiopia, Nigeria, Zambia, and Uganda works with government ministries, communities, transport unions, and other partners to design and pilot community-owned and managed systems using motorbike ambulances (MBAs) and other public private partnership transport initiatives to move patients and strengthen referral systems. The model emphasizes community acceptance and ownership to ensure the programs are sustained well beyond donor involvement. Volunteer community emergency transport workers or “riders” are residents of the community, licensed, trusted, available, and literate; riders work with first responders -persons/groups with informal backgrounds/training volunteering their time to save lives at the community level- to ensure 24/7 emergency coverage.

Deploying community motorbike ambulances

Photo credit: Clinton Health Access Initiative

Based on experiences deploying 394 MBAs in Africa, CHAI has designed a phased holistic and sustainable approach to deploying MBAs. This approach is hinged on a number of supply and demand components including community engagement, oversight, an emergency identification system working with trained first responders, timely and functional transport, linkage to health facility networks, protocols, documentation, and seamless communication across all levels.

Community owned and managed MBAs provide transport to the nearest health facility during an emergency with purpose-designed or modified motorcycles, or tricycles with a side or a back mounted stretcher. Trained volunteer riders operate the vehicles to safely and comfortably transport patients and accompanying responders. MBAs come in varying models, prices, and quality. Local markets often support affordable, sustainable options.

The deployment approach is critical to ensuring ownership and sustained operations. Recently, in Uganda, locally manufactured MBAs were deployed to communities, thus eliminating shipping costs, saving time, and improving sustainability by making training, maintenance, and replacement parts available locally.

Enabling partnership with transport unions to establish Emergency Transport Systems

Photo credit: Clinton Health Access Initiative

This ETS model engages with established private systems, such as taxi unions, to complement ambulance services. Public/private partnerships between communities and local transport unions can bridge community level emergency transport gaps. Riders volunteer their vehicles and time during emergencies to transport women and their newborns to the nearest health facility at little or no cost, instead receiving non-financial incentives such as local recognition. For example, in Nigeria CHAI worked with the National Union of Road Transport and National Commercial Tricycle and Motorcycle Owners and Riders Association of Nigeria to expand coverage of the emergency transport scheme.

Successes in developing community Emergency Transport Systems

There have been several documented accounts of these systems saving lives in a number of African countries. A well-managed ETS represents a valuable resource when ambulance services are not available, there are disruptions to public transport services or even restrictions in movement, as seen today as a result of the COVID-19 pandemic.

By supporting volunteers who live in the communities in which they operate, systems are closer to patients during an emergency and staffed by people who understand the local context. The volunteers are trusted and recognized by community leaders, beneficiaries, and law enforcement. They are also easily distinguished, with ID cards, vehicle stickers, and T-shirts/hats that are useful during times of restricted movement.

Community emergency transport systems can save lives when implemented using a holistic and sustainable approach with strong emphasis on local ownership and sustainability. As part of wider MNCH programs, and emergency care services CHAI continues to expand sustainable and contextually appropriate ETS models across sub-Saharan Africa.


References
  1. Seventy-second World Health Assembly: Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured. https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_R16-en.pdf 
  2. Oguntunde, O., Yusuf, F. M., Nyenwa, J., Dauda, D. S., Salihu, A., & Sinai, I. (2018). Emergency transport for obstetric emergencies: integrating community-level demand creation activities for improved access to maternal, newborn, and child health services in northern Nigeria. International journal of women’s health, 10, 773–782. https://doi.org/10.2147/IJWH.S180415 
  3. Anastasi, E., Borchert, M., Campbell, O. M., Sondorp, E., Kaducu, F., Hill, O., Okeng, D., Odong, V. N., & Lange, I. L. (2015). Losing women along the path to safe motherhood: why is there such a gap between women’s use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda. BMC pregnancy and childbirth, 15, 287. https://doi.org/10.1186/s12884-015-0695-9 
  4. Kisiangani, I., Elmi, M., Bakibinga, P., Mohamed, S. F., Kisia, L., Kibe, P. M., Otieno, P., Afeich, N., Nyaga, A. A., Njoroge, N., Noor, R., & Ziraba, A. K. (2020). Persistent barriers to the use of maternal, newborn and child health services in Garissa sub-county, Kenya: a qualitative study. BMC pregnancy and childbirth, 20(1), 277. https://doi.org/10.1186/s12884-020-02955-3 
  5. Shiferaw, S., Spigt, M., Godefrooij, M., Melkamu, Y., & Tekie, M. (2013). Why do women prefer home births in Ethiopia?. BMC pregnancy and childbirth, 13, 5. https://doi.org/10.1186/1471-2393-13-5