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The Road Not Taken

By Ngwarati Mashonga

In September, 2009 British Prime Minister Gordon Brown pledged to a fund that would provide free health care to 10 million people in some of the world's poorest countries. This is an impressive ambition, and removing fees would undoubtedly remove one of the barriers that prevent people accessing health care. However, if a health worker could not travel to families in a rural village, it makes little difference how free treatment is.

A lack of reliable transportation currently constrains the performance of health delivery organizations across Africa. It is, of course, not the only constraint to access but it is a fundamental problem. Yet, without addressing the issues of reliable transportation, overcoming the other constraints will still not result in the complete health-care coverage that could play such a key role in the development of Africa.

The Missing Link

Transportation is so often the missing link in health-care programs across Africa. By improving their transport capabilities, organizations can increase the number, distribution and retention of health workers. With access to reliable transport, the amount of time that health workers are able to spend in the field or at the community level increases.

Despite the obvious benefits of reliable vehicles for delivering health care, there is still an overwhelming tendency of vehicles to break down in Africa after a very short proportion of their intended mechanical life. This is due to a widespread misunderstanding of the precise needs and nature of vehicles in hostile conditions and harsh terrain, allied to an acute and extremely damaging shortage of vehicle maintenance infrastructure in Africa.

Development agencies and the ministries with whom they work often misunderstand or critically underestimate the funding needed to run a vehicle for its natural lifespan and/or do not have the necessary immediate funding or the appropriate techniques required. The upshot of this is that precious resources are wasted and health-care goals are not reached.

One of the key problems African governments face is that they are often ill-equipped to be ‘intelligent' purchasers from the private sector. This can lead to the buying-in of poor service at a high cost. In-house management is unsatisfactory as the competence or capacity for specialist vehicle maintenance in hostile conditions is not available.

Similarly, for many other NGOs, vehicle management is not a core competency and yet the vehicles are vital to meet their goals. High costs, unreasonable ‘down time,' and often the loss of relatively new vehicles through negligence is a common consequence, and has a negative outcome on the health of the people served, especially those most isolated. It also has negative impact on the agencies' and governments' abilities to retain and motivate health workers, a factor widely known to weaken health systems still further.

Organizations working in global health and those responsible for - or linked to - health systems have responded to the need for transport for the delivery of health care in a range of ways, such as purchasing expensive vehicles without attending to management and maintenance; trying to strengthen the fleet management capacity within the ministry of health; and, contracting out to the for-profit sector.
These alternative methods have not proved successful. In these circumstances, governments and agencies should not be afraid to use the expertise of organizations whose sole purpose is fleet management.

There is absolutely no reason why vehicles should break down in Africa. If the appropriate vehicles have been selected by buyers, performing the regular maintenance programs recommended by the manufacturers will ensure that the vehicle never breaks down during its mechanical lifespan. Yet, if vehicles are not managed correctly - from both the technical and the usage points of view - they will fail. And that has nothing to do with the harshness of the conditions. Unmanaged, they would fail just as quickly in Washington, London or Melbourne as they will in Banjul, Maseru or Harare. And, as in the developed world, a broken vehicle is far more expensive to repair, than it is to service it regularly and replace parts before they fail.

Over 20 years, Riders for Health has been developing systems of routine outreach maintenance, reliable systems for the ordering and delivery of replacements parts, and a network of workshops. There is a forceful case for Riders' not-for-profit fleet management model. There are a few other pockets of good maintenance in isolated cases in Africa but they are not replicable or sustainable and so far it is only Riders that has developed a comprehensive system capable of meeting the widespread need.

Saving money as well as lives

By consolidating the running of all of an organisation's or department's vehicles into a single fleet, it will not only ensure the availability of the right vehicles where they are needed, the organisation will also make substantial cost savings.

First, by combining their fleet into a single budget line, costs can be clearly identified rather than being scattered and hidden. Second, by ensuring that vehicle fleets are standardised and include as few different makes and models of vehicles as possible, the organisation can save money. By not purchasing vehicles in an ad hoc and uncoordinated manner, buying replacement parts is easier, quicker and the organisation benefits from economies of scale. But to make the right choices it requires an intelligent purchaser. The wrong purchase of a large fleet would be a huge and costly mistake.

These benefits can be seen in Riders' program in the Gambia. In 2009, the ministry of health signed an agreement which saw Riders own and manage the entire fleet of outreach vehicles for the ministry. This public-private program, run on a not-for-profit basis, allows both parties to concentrate firmly on their core-competency. It means that the health service knows that it will have reliable transport, allowing it to set its goals with conviction, and the savings made from better purchasing, and from removing the costs associated with unexpected vehicle breakdowns can be better targeted at health-care delivery.

Accurate testing = effective treatment

It is not just delivering medication, or providing emergency treatment that requires reliable transport. In November 2009, the World Health Organisation changed its advice on antiretorviral drugs, suggesting that people should have access to them earlier to improve their effectiveness. But knowing that people need antiretrovirals is dependent on knowing they are HIV positive, and as soon as possible. In so much of Africa, timely and accurate sample testing is impossible because, without transport, the samples never reach the laboratory in the first place.

If it takes six weeks for the samples to reach the laboratory, how long will it take for the results to arrive back at the clinic? Without testing, those that could benefit from treatment will never be identified. The hundreds-of-billions of dollars that are spent in the world's leading universities and research centres are being wasted because the results of their research do not reach those that will benefit.

In Lesotho, Riders has launched a program of sample couriers. With a network of motorcycle couriers, Riders can ensure that turnaround time for samples is consistently within one week. This is a comprehensive sample courier service, which supports the decentralisation of the health service, strengthening local health-care provision. And because samples can be transported in temperature-controlled, shock-proof containers, when they do arrive at the laboratory, they are suitable for testing.

Riders for Health is now expanding this program into Zambia, where the scattered population and poor infrastructure means that a reliable testing program is almost impossible. Other countries in Africa, which are planning nationwide testing schemes, are now planning to build systems of reliable transportation, based on intelligent vehicle purchasing, reliable maintenance, and thorough training, into their programs before they get under way.

Any program for delivering health care in Africa must incorporate the systems of transport which will make them possible. It must have established networks of workshops and outreach technicians to provide monthly services on every vehicle, and we have a logistics system that means technicians have replacement parts when they need them.

A profound benefit

Ambitious and noble targets set by governments or institutions are important, but they must be matched by a commitment to strengthening systems of reliable transport for health-care systems.

A broken vehicle not only means that communities will go without health care, it is also a senseless waste of valuable resources. A waste that could be prevented. There is not a single country in Africa that would not profoundly benefit from reliable transport. Ministries of health would be able to reach everyone, no matter where they lived. National immunisation campaigns and disease eradication targets would actually be met. Children would become healthier. Education would improve. Economies would grow.

A lack of transport infrastructure, or a failure of vehicles, is no longer an excuse for a program to fail in Africa. The solution has been developed, tested and proven.

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Ngwarati Mashonga is operations director at Riders for Health