Introduction and Literature Review
The significant contribution of transport and mobility to development and the livelihoods of poor people is widely recognised. However, the development sector is yet to fully acknowledge and understand the role of transport in improving poor people’s health. In the context of the need to step up development activity to meet the Millennium Development Goals, a better understanding of the relationship between mobility and health becomes a priority.
Research on mobility and health has concentrated on northern and high income settings and on issues such as transport and safety, environmental health and the international diffusion of infections. In the Bibliography and Electronic Resources pages you can find a number of documents that are related to Mobility and Health in an industrialised Northern setting. The literature review below concentrates on what is available in low-income countries.
Transport, mobility and access to health services in low-income countries
Although for many of the world’s poor rural population mobility is key to accessing and being accessed by biomedical health services and technologies, this issue has received scant research attention. Prior to the recent drafting of the WHO Global Report on Transport and Health (to be published soon) and development of the World Bank Transport and Health webpage (click here), mobility in terms of access to health services was not central to development reports and evaluations. In terms of research mobility, rather than forming a central study focus, tends to be referred to as a sub-issue of other health concerns. However, the crucial role of appropriate, affordable and timely transport in accessing health care is increasingly being raised by major development organisations and initiatives. In 2005 the Millennium Project Report to the Secretary General, the direct and indirect relationship between transport and health was referred to on numerous occasions. Among other bilateral agencies, USAID (2004) has highlighted the importance of transport for urban poor populations (especially slum dwellers) accessing health facilities, which tend not to be located in disadvantaged areas of cities. Indeed in developing methodology to assess health vulnerability, USAID cited the cost of transport as one of its vulnerability criteria.
Construction of feeder roads providing motorized transport that connect 45 villages in the Darfur region of Sudan are reported to have influenced measurable impacts on community health, such as a rise in the immunization of children. The study found that road provision enabled the equipping and supply of health outlets, and that access to services and technologies was further improved by a concurrent revolving drug fund. It is also apparent from this research that while women’s travel time to health faculties was reduced in some locations, in others women continued to contend with a full day’s journey to their nearest health centre (for more information see Musa 2002).
A study conducted in the village of Vanathavillu in the north-western Province of Sri Lanka illustrates that even where rural communities are better served with intermediate and motorized transport and a paved road, transport of those who are too ill to travel by bus is prohibitively costly. Added to this is the problem of gaining access to medical staff once the health outlet has been reached. Due to the low ratio of health workers to the populations they serve, villagers need to travel early and queue for many hours if they are to have any chance of being seen by qualified medical staff (for more information please see Wettasasinghe and Pannila 2002)
In a review of the literature on access barriers that reduce demand for health services in low-income countries, regard distance and time to be indirect and opportunity costs that influence the uptake of health services (Ensor and Cooper 2004). For many rural poor, the lack of local health resources entails long and slow journeys that enforce breaks in subsistence activities and loss of wages. In many low-income countries the direct costs of transport constitute a substantial proportion of the overall expenditure on health care. Transport costs of accessing health facilities have been calculated to represent 25% of the total outlay on health in north-east Brazil (Terra de Souza et al 2000) and 28% in Cameroon (Sauerborn et al 1995). In a study of the costs of TB care for households in urban Tanzania it was found that households spent between US $ 13 and $20 accessing drug therapy during their short-course treatment using the cheapest forms of transport. Research findings from Bangladesh reveal that in the breakdown of patient costs, travel to service centres requires the greatest financial outlay of all health costs after expenditure on medicines.
For HIV/AIDS patients undergoing treatment, the costs of transport to health facilities represents an extreme burden on financial resources already under strain from reduced income and productivity of patients and their carers. In Chad, a study revealed the costs of transportation using public services to be the second greatest expenditure for AIDS patients after that of medicines. Problems of mobility combined with poverty have been identified as directly disrupting anti-retroviral treatment among HIV-positive people in rural Zimbabwe. This illustrates that mobility is a central issue in achieving Millennium Development Goal 6 (“combat HIV/AIDS, malaria and other diseases”. Indeed, McCoy et al (2002) in their report on the implementation of 18 Prevention of Mother to Child (HIV) Transmission (PMTCT) services in South Africa identify the lack of affordable transport and long distances between pregnant women’s homes and health outlets to be a major challenge to continuity of care and monitoring of maternal and child health. This further highlights the crucial role of transport in the maintenance antiretroviral therapy and other drug regimens such as directly observed treatment short-course for tuberculosis (DOTS).
Costs, distance from health outlets and logistical difficulties such as finding an intermediate or motorised vehicle for patient transportation, are linked with inhibited use of biomedical services (Ensor & Cooper 2004; Hodgkin 1996; Raghupathy 1996) and delayed health-seeking behaviours, both of which are factors implicated in reduced health outcomes and increased morbidity and mortality in case studies from Vietnam (Ensor 1996) and Zimbabwe (Fawcus et al 1996). With regard to Millennium Development Goals 4 and 5 (reducing child mortality and improving maternal health) poor mobility and inaccessibility of antenatal services act to exclude poor rural women from maternity facilities in low-income countries such as Thailand (Raghupathy 1996), the Philippines (Schwartz et al 1993) and Uganda (Amooti-Kaguna & Nuwaha 2000). This in turn impacts negatively upon broader initiatives towards safer motherhood, equitable access to health and reducing maternal and neonatal mortality. Grieco (2005) sets out some of the transport issues surrounding maternal mortality in Africa.
In Bangladesh, which suffers from extremely poor indicators of maternal and neonatal health, the ICDDR,B (International Centre for Diarrhoeal Disease Research, Bangladesh) reports distance (which also infers access and transport) to present a major barrier to accessing both facility- and home-based health services (ICDDR,B 2005). For women with obstetric requirements a distance of 1 km between the home and health outlet was found to be a pronounced determinant of peri-natal service delivery. Beyond this distance the number of births attended by a midwife, either in a health facility or at home, is found to decrease by half.
Matin et al (2002) report that women experience better access to health services and improved service provision by outreach workers in areas of rural Bangladesh that are near all-weather roads. This study highlights the difficulty of access to emergency obstetric care and the lack of safer motherhood services at the village level, which are further complicated by cultural issues that mediate female mobility. Poor women are therefore less likely than their male relatives to have direct contact with health care providers and as a consequence, receive less accurate and “remote” diagnoses via symptom-reporting by male relatives, rather than face-to-face consultation and examination by qualified health professionals.
In the Un Special Session on Children in 2002 the importance of improving emergency transport, especially roads, was highlighted as a prerequisite to skilled birth attendance and maternal and child health. Although patient movement has not formed a central focus of studies on peri-natal outcomes in cases of obstetric complications and emergency, a few identify a lack of mobility and transport to be a causal factor in maternal and neonatal disability, morbidity and mortality. In Ethiopia Hamlin (2004) identified a clear causal relationship between the development of fistulae (vaginal perforations into the bladder or rectum) in cases of obstructed labour where there transportation to appropriate health facilities is inadequate. Transportation problems have been shown to contribute to peri-natal mortalities in the Gambia (Cham et al 2005), Brazil (Terra de Souza et al 2000), and in Ghana, Nigeria and Sierra Leone (Thaddeus & Maine 1994). The timing of medical interventions in cases of obstetric emergencies is decisive in preventing maternal and neonatal death and disability. The “three delays” model developed by Thaddeus and Maine (1994) set out in figure 1 identified key time periods in peri-natal complications during which delays can occur that have direct consequences for maternal and neonatal survival. Although not directly specified, the transport and mobility of pregnant women are clearly key components of the three delays model of maternal mortality that is pertinent in low-income countries. Travel costs and inadequate transport infrastructure, combined with poverty and distance from health outlets are implicit in two of the three factors affecting health service utilization and maternal health outcome set out in this model. These in turn impact upon all three phases of delay identified to be determinants of maternal and neonatal survival, from the initial decision to seek medical care, to the identification of and arrival at a health outlet and finally receiving timely and appropriate care.
Figure 1: The three delays model of maternal mortality (source: UNFPA 2005, after Thaddeus and Maine 1994)
Although the three delays model is used by many agencies including UNFPA (2005) to plan interventions to address maternal and neonatal mortality in low-income countries, very little research actually focuses on the transport and mobility aspects of these delays. One study, however, conducted by Shehu et al (1997) in rural north-western Nigeria identified vehicle and fuel shortages, combined with a lack of willingness of owners and drivers to transport women for affordable fares, to contribute to delays in transportation to appropriate health facilities in cases of obstetric complications. In response to this, the multi-disciplinary research team devised an intervention to train and sensitise drivers belonging to a local transport union to the needs of women requiring transport for emergency obstetric care. In addition to this, a revolving emergency fuel fund was established. The outcome of this intervention-based research was that drivers began to transport acute obstetric cases to health facilities without securing prior payment and fares charged were considered to be reasonable by patients. Although the study was post hoc, there was evidence to suggest a marked reduction in delays between the onset of complications and obtaining the necessary transport to an appropriate health facility. The study concluded that emergency medical transport can be markedly improved without high investment in designated ambulances and drivers. Although revolving fuel funds tend to become depleted by eventual misuse, commercial drivers at the community-level were shown to be successfully mobilized to provide timely and affordable transport crucial to reducing the delay in obtaining care in obstetric emergencies.
It is not only poor rural women who experience barriers to transport to access health services. Shresthova et al (2002) in a study of personal and professional transport use among a women’s trade unions association in India found that in the majority of cases, women and their families used public buses or walked to health outlets. The fact that the data for this study grouped together walking with travelling by bus does not throw much additional light on this poorly research topic. However, Shresthova at al’s research reveals that women participating in the study were less likely to hire a rickshaw in cases of personal health emergencies (8%) than for other family members (14%), which illustrates that even where intermediate forms of transport are available to access emergency health services, even better-off professional women are less likely than other family members to use them.
The complex interplay between health and mobility influences and is influenced by many other factors. It is assumed that by stimulating the rural economy for example a greater proportion of the population are able to afford preventive and curative health care (Vlassoff et al 2004) as well as improving nutrition and access to health information. Research suggests that this process commences by enabling rural people to access technological inputs to raise agricultural productivity, broadening livelihood options by improving urban-rural linkages with wage-labour opportunities and opening up urban markets to rural producers (Musa 2002; Richards 1984; Thapa et al 1995). Whatever the mechanisms might be, in Bangladesh it is reported that while maternity services are provided free by the state, 29% of births at the upper end of the economic scale are delivered by a qualified attendant, compared with only 12% of those occurring in the poorest strata of society. The report identifies the cost of transport and travel to maternity facilities along with associated expenses, such as food, to deter poorer rural women from delivering in designated health centres (ICDDR,B 2005).
Economic development has another implication - as paradoxical as it may seem, vulnerability to HIV infection is associated with economic development as well as with poverty (Collins & Rau 2000; Mutangadura & Webb 1999). These factors are in turn linked to mobility in low-income settings, which further increases the risk of exposure to HIV. Guinness and Kumaranayake (2002) propose a model where “hotspots of HIV” (as the authors term them) can develop at any of the points along routes within the mobility and migratory system. These hotspots are defined as key points where mobile people engage in high-risk behaviours with each other and those of the communities through which they pass or stay in. Dislocation from their homes acts to increase vulnerability to infection in a number of ways including displacement from social cultural norms and the adoption of risky behaviours, exploitation as a result of poverty and social vulnerability, as well as limited access to health and social services.
A broadening of livelihood options offered by transport and communications is regarded to raise the value of education and stimulate literacy and skills development among rural people. Road provision arguably directly enables children from more isolated areas to access school (Caldwell et al 1988; Rao 1994; Sainath 1995) and supports provisioning of educational establishments and their staffing (Richards 1984). Vlassoff et al (2004) argue that improvements in education have potential health benefits, including better access to health knowledge and awareness of infection, transmission and prevention that translate into improvements in health. These in turn, they reason, improve productivity and reduce expenditure on curative services, which act together to raise the living standards and well-being of adults, which reduces the incidence of orphaned and sick children. Although not straight forward there is growing evidence that school attendance among girls is key to reducing morbidity, mortality and fertility (LeVine et al 1994; Mason 1993; Sen 1997).
Overall evidence emerging from the sparse literature on health and mobility suggests that motorised transport is not used widely by poor rural communities to access health services. Indeed, Seddon and Shrestha (2002) report that only 2% of those interviewed along the Bhimdhunga-Lamidanda road in Dhading district of Nepal were travelling in the course of seeking health advice or attention.
A positive exception to the above forms Riders for Health who has developed the Uhuru, a specially designed motorcycle and sidecar with a pop up seat for women in threatening labour.
The above literature overview demonstrates that the introduction of the International Networked Research on Mobility and Health is timely and opportune. Soon 24 case-studies and research can be added and will help moving forward the debate on the links between mobility and health in the developing world.
For the full article please down-load the following: Mobility and Health: The Impact of Transport Provision on direct and Proximate Determinants of Access to Health Services. An article by Dr Kate Molesworth, Swiss Tropical Institute. January 2006. Click here to download (PDF 2.87MB - PLEASE NOTE THIS IS A LARGE DOWNLOAD)
