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 efficient emergency transport systems (ETS), are an important component of any functioning health system to manage acute illness and injury, including acute complications of pregnancy. The World Health Organization (WHO) recognized this at its 72nd World Health Assembly, where it 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, 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 the availability of public transport.

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 bridge the gap while countries develop emergency care and transport systems.

Strengthening referrals and community Emergency Transport Systems

Governments, implementers, and donors are seeking solutions to improve referrals and ETS at the community level. In Ethiopia, Nigeria, Zambia, and Uganda, the Clinton Health Access Initiative (CHAI), through its Maternal, Newborn, and Reproductive Health program, is working  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 volunteer first responders -people or groups with informal background or training in emergency response- to ensure round-the-clock coverage to save lives in the community.

Deploying community motorbike ambulances

Photo credit: Clinton Health Access Initiative

CHAI has designed a phased holistic and sustainable approach to deploying MBAs hinged on a number of 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 move 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 transportation gaps. Riders volunteer their vehicles and time during emergencies to deliver 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

Photo credit: Clinton Health Access Initiative

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 we are seeing 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 or 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 maternal, newborn, and child health 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