Access to urgent health care in rural areas: complex, but not impossible
Four years ago, I went from being perfectly well to seriously ill within the space of 12 hours. It all happened so quickly that it took me a while to figure out what was going on. The first clue was that I simply did not have the energy to do a “sun salutation,” a foundational part of my yoga practice. I was spending the weekend at my sister’s house in New Jersey, USA, on my way from a yoga retreat in the Caribbean back to Ghana. My niece was keen to learn as much yoga from me as possible before I left. But it was a massive effort for me to transition from a “downward-facing dog” pose to standing upright, so we called it off for the evening. A few hours later, my body was burning hot like I had never experienced before; my temperature was 103 degrees Fahrenheit (i.e. 39.5 degrees Celsius). I took some anti-fever medicines and went to bed, completely puzzled about why my body was behaving so bizarrely.
By morning, every part of my body ached including my eyes. I could barely walk; I was most comfortable lying flat on my back with my eyes closed. Clearly, I could not travel to Ghana that day; I needed prompt diagnosis and treatment. As a physician, I knew that I wasn’t sick enough to need emergency transport in an ambulance with sirens blaring. Yet, I certainly was too sick to drive myself. My sister was already at work but her nanny was at home, so she drove me to the hospital, Saint Barnabas Medical Center in Livingston, New Jersey, four miles away. Within a few hours, I was diagnosed with dengue fever, colloquially known as “breakbone fever” because of the severe joint pain associated with it. I was stable: there was no evidence of bleeding (the worst sign of dengue infection). But there was no assurance about how the illness would evolve over the next few days. So I was admitted for supportive treatment (e.g. intravenous fluids, pain medicine etc.), as there is no cure for dengue. Three days later, when my body had started mounting a decent enough immune response to counter the destruction the dengue virus was wreaking, I was discharged to recuperate at my sister’s house with clear instructions to return immediately if things worsened. Eleven days later I was on a flight back to Ghana, 10 pounds (or 4.5 kg) lighter and still weak, but definitely on the road to a full recovery.
Thinking back on this life-threatening episode, I realize that four key factors made it easy for me to get to the hospital early enough to be helped: 1) I had health insurance through my employer that covered both outpatient and inpatient services and even emergency health transportation; 2) I happened to be in a town that was large enough to have a hospital only four miles way, a quick 10-minute drive on a good road; 3) I had family nearby who were supportive of my seeking modern health care promptly and were able to drive me to the hospital; and 4) I had confidence in the hospital because my sister had received good quality care there in the past.
For so many families living in the rural areas of sub-Saharan Africa, some or all of these factors are missing. Having to pay for clinical care out-of-pocket at the point of service is a huge obstacle to seeking health care; you never know how much it will cost or if you have enough money to pay for it at the time of the service. Fortunately, Ghana has had national health insurance for about a decade, which has helped. However, for serious illnesses, in the remote rural areas of Northern Ghana the nearest hospital is likely to be more than 30 kilometers (almost 19 miles) away, and the only vehicles available are bicycles and motorbikes. Distance is only one barrier; bad roads (or no roads) are another. Furthermore, family members may be wary of modern medicine and may discourage you from seeking health care until it’s too late.
Even in rich countries with all the infrastructure and amenities, judicious use must be made of ambulance services, as they are a scarce and expensive resource. In low- and middle-income countries like Ghana, this is even more crucial. The Ghana National Ambulance Service, established in 2004, has grown since then from seven to 165 ambulances with 1,650 trained emergency medical technicians. While we now have at least one ambulance in every district of Ghana, the ratio of ambulances to population size is still below internationally recommended standards for our population of almost 25 million people. At the rural district level, ambulances are typically reserved for emergency referrals from clinics to hospitals; they rarely go to the community level to transport sick people from their homes to the hospital. This makes sense, given the scarcity of this precious resource and the challenges of finding people’s homes at the community level given our nascent residential address system.
So what do rural families do when they have an urgent health situation in their homes or on their farms? They walk, bike, or if there is a motorbike owner in the community, plead for a ride on the back. However, that only works if you are healthy enough to sit up and tolerate a motorbike ride on a bumpy road for long periods. This makes it impossible for a woman in active labor or a person with severe abdominal pain that is aggravated by movement, sudden blinding headache with dizziness, severe malaria, or, in my case, dengue fever. If one cannot sit on a bicycle or motorbike, the only other options are the minivans and trucks that ply the main roads on market days. However, on non-market days those vehicles are typically parked and are prohibitively expensive to hire to transport a single person. There is clearly a need for urgent health transportation at the community level. It is this gap that MAZA, a new social enterprise established in Ghana in April 2015, is seeking to fill.
MAZA, which means “quickly” in Hausa (the most widely spoken language in West Africa), provides an innovative transportation solution at the community level that is safe, accessible, affordable, and reliable. MAZA supplies multi-use passenger motorized tricycles at the community level and ensures their availability and reliability for urgent health transportation through a roster system, powered by mobile technology. We subsidize the cost of motorized tricycles to drivers who “work-and-pay” to own the vehicle over a two-year period. In return, the drivers agree to be on call for health transportation two days a week – and are otherwise free to use the vehicle for other income-generating opportunities such as transporting passengers to local markets. MAZA vehicles are multi-purpose by design so that they can meet other important transportation needs, such as taking people to market or transporting farm produce, when there is no urgent health crisis. This approach makes the vehicles more useful to the communities and allows MAZA to be sustainable.
MAZA also structures demand for health transportation with health education, subscribing families through various incentives, and using mobile money savings and pre-payment to reduce usage barriers during an urgent health crisis. In a crisis, the family calls MAZA’s hotline and the nearest driver on call that day is dispatched to transport the sick person to the clinic or hospital.
Figure 1: MAZA’s urgent health transportation solution
In partnership with the Ghana National Ambulance Service, the Ghana Health Service, and the National Catholic Health Service, MAZA seeks to transform how families prepare for urgent health transportation needs at the community level and how quickly they can access modern health care when they get seriously sick. For emergency health transportation needs requiring the skills of emergency medical technicians, MAZA will liaise with the national ambulance in the district to effect a smooth handover of patients where feasible.
MAZA is launching on December 17, 2015, in Chereponi District in Northern Region. This district has a population of approximately 53,000 that is spread across about 1,000 square kilometers. Women in this district seek modern health care at high rates during pregnancy but not during labor and delivery, the most vulnerable period for both mother and baby. This gap is driven largely by geographical and transportation barriers to accessing health care, since the clinical care for pregnant women is provided free through the National Health Insurance Scheme. And sociocultural barriers to modern health care appear to be relatively low, since care seeking for non-urgent health concerns is high. With the subsidized transportation price and the pre-payment system, MAZA’s transportation solution will make access to urgent health care in rural areas that much more achievable.
The author is the founder and CEO of MAZA. She can be reached at ntwumdanso@mazatransport.org.
You may learn more about MAZA at www.mazatransport.org.
