Case studies from Africa

Assessing the health impacts of the rural roads programme Pistes Rurales in East Burkina Faso

Study by Christel Jost and Brahim Kere

Background

Burkina Faso finds itself among the poorest countries on the HIPC (Heavily indebted poor countries). This is even more pressing in rural areas and manifesting itself in food insecurity, unreliable access to water and reduced mobility which makes economic development difficult and access to basic services and infrastructure even impossible during rainy seasons. In this context opening up areas are of key importance and building rural roads can help stimulate economic activity. This study looks at the impacts of increased mobility and rural roads on access to health services by comparing villages that are accessible versus inaccessible villages.

Overall and Specific Objectives

The overall objective is to deepen the knowledge of the social and health impacts of the rural roads programme on vulnerable communities especially women and children. More specifically the project aims:
1.To analyse the behavorial and life changes in those villages that are part of the rural roads programme versus villages that are not. This will include gender-disaggregated data collection and analysis.
2. To highlight the impact and benefits of the rural roads programme with a particular focus on social and health indicators.
3. Train the target communities with other key actors and stakeholders in the village on the impacts of the Pistes Rurales programme in where needed find solutions and/or alternatives for potential negative impacts as well as validate positive impacts.

Methodology

The study covers a number of villages that are part of the Pistes Rurales programme versus villages that are not for the comparison group. For all methodologies the project uses a participatory approach ' méthode active de recherche participative' or MARP (PRA in English). The results will be triangulated to capture the different opinions, views, data and results of the various target communities and key informants and draw overall conclusions and analysis. The project uses a representative sample of rural and urban communities, e.g. two communities per province are selected. People are selected according to gender and different socioprofessions, such as farmers (disaggregated by animal husbandry and vegetable/fruit traders).

Expected Outcomes of the Research

The general goal of the study is to provide not only the target community but also other stakeholders and decision-makers with detailed information on the impacts of mobility on health
1.  The reasons and underlying factors of the social and behavorial changes related to the rural roads programme have been identified and shared with the communities to be able to better serve them.
2. The target communities has been sensitised and informed on the health impacts of the rural roads programme and the to-be-adopted measures.
3.  The various stakeholders have been informed of the results of the study and have been influenced to adopt these in their overall development strategy.

Information Dissemination and Advocacy Strategy

The Pistes Rurales programme will bring this study to the attention of the local, regional and national authorities, civil society organisations and the relevant health and transport authorities in the region. Other stakeholders will be kept abreast throughout the study and at the end of the study the results will be disseminated through a workshop whereby stakeholders at local, regional and national level will be invited to ensure a large dissemination and lobbying policy.

Safe Transport of Critical Patients in Rural Ethiopia

Study led by Taye Berhanu, Dr. Aberra Gobezie and Mrs. Tiruwork Liyew

Background

The majority of Ethiopians, about 85 per cent, live in rural areas. Mobility and health are, among others, critical problems to the rural poor, reflecting the one side of the poverty spectrum. People living in mountainous and river areas far from the main road network face even more access challenges. Among the most vulnerable people are women, children and persons with disabilities. Therefore the research will be carried out in Oromia Regional State, Mojo and its surroundings, a rural area which is most representative. This area is selected for the following reasons:-

• There is a wide range of traditional means of transportation in use, mainly stretchers and horse/donkey carts, providing services to transport patients to clinics/hospitals. These are also the causes of secondary damages.
• There are many challenges with mobility, including poor mobility due to lack of transportation means.and possible interventions to tackle the problems in the research area can be extrapolated and applied in other rural areas;
• The area comprises of multi-ethnic communities with a wide variety of  traditional health practices

Overall and Specific Objectives

1. The overall objective of the study is to increase knowledge of, and improve access and mobility of poor rural communities to, health services and facilities
2. To enhance awareness among rural communities on how to transport patients to clinics and health facilieis.
3. To develop dialoguing, lobbying and advocacy platform for local and national transport and health stakeholders.

Methodology   

The methodology of the study shall include, but not be limited to the following:-

• Field Survey - A rapid assessment of the means of transportation available for patients and their potential effects will be undertaken through interviews or questionnaires to be developed for women, medical personnel, local authorities and the people residing in the area, as well as  in different clinics/hospitals.
• Desk Research – Various policy and research papers will be examined to see whether or not the mobility and health issue is fully or partially addressed in the context of rural development or the overall poverty reduction strategy. In addition the project will research to what extent the aspects of gender and vulnerable people have been mainstreamed.
• Primary Data Collection –Medical data will be used to analyze real and anecdotal evidence of complications arising from poor positioning or improper transportation.  Most of this evidence will be collected from the health centres.
• Interview –A structured questionnaire will be used to interview different government officials, including health and transport experts, at federal, regional and sub-district level.
• Pictures – Still and video camera will be taken to show the various means of transportation  in the rural areas.

Expected Outcomes of the Research

The overall activities of the research will have the following specific outcomes and achievements.

• Twenty government officials, health professionals, women and other stakeholders from different organisations will be interviewed. These stakeholders will subsequently be involved in a feedback workshop to review the results of the research and to debate ways of advancing key recommendations.
• A dissemination workshop will be conducted at the national level as an activity of the NFG together with IFRTD.
• A final research report will be  prepared and disseminated through the ENFG , IFRTD,  Mobility and Health and other networks
• The initial or implementation stages of the research work will help planners, executioners, beneficiaries (particularly women), to have a better understanding of the causes and solutions of health-related transport problems of critical and high risk patients and about  the close relationship between  mobility and health.

Obstetric fistula and transport access to emergency obstetric care services in Sidama zone, Southern Ethiopia

Study led by Mulu Muleta and Solomon Abebe

Background

Lack of road infrastructure and transport service is said to affect access to emergency obstetric care service and hence said to contribute towards occurrence of obstructed labor, uterine rupture, sepsis and death. Moreover, for every single mother dying, more than 30 others survive, but suffer from severe injuries and complications like uro-genital fistula, infertility, chronic pelvic inflammatory disease and nerve damage.

Accessing institutions with emergency obstetric care service (EMOC) is essential if women have to give birth under skilled attendance. Maternal health can be improved and maternal mortality ratio and morbidities can be reduced only if pregnant mothers can access skilled attendance during labor and especially during obstetric complications. Appropriate transportation services and road infrastructure might be critical if mothers have to access EMOC on time and hence improved maternal health and achieving the MDGs is to be materialised. Different economic, social, cultural and political problems might also complement to compromise life of mothers of reproductive age groups in general and mothers who encountered emergency obstetrics in particular.

Basing interventions on clearly understood problems is vital if the intervention has to bring the desired effect. Existing literatures failed however, to address this issue and it is timely to address the association between motility and health especially if we are concerned about the achievement of the MDG’s by the year 2015. This project therefore is planned towards this end, whereby the magnitude of transportation service and road infrastructure will be analysed in terms of maternal health issues associated. The study is intended to address knowledge gaps in both the transport and the health sector. The result of the study will be disseminated and will enlighten the responsible sectors so that they base their intervention on the existing problems.

Overall and Specific Objectives

1. The overall objective of the study is to increase knowledge of, and improve access and mobility of poor rural communities to, health services and facilities
2. To increase understanding of the links between health and mobility on  current health challenges in terms of maternal health and other illnesses and inequalities in Suba District, Kenya
3. To develop dialoguing, lobbying and advocacy platform for local and national transport and health stakeholders.

Methodology   

This will be a case controlled study analysing the association of rural road infrastructure and the transportation network in relation to accessing emergency obstetric care services during difficult labor. It is planned to be conducted in Sidama zone of southern region of Ethiopia, and it will involve obstetric fistula patients and laboring mothers who managed to access EMOC on time. Health professionals and Road Authority people will be involved in in-depth interview and focused group discussion.

1. Addis Ababa Fistula Hospital, Yirgalem Hospital, Yirgalem Hamlin fistula center, and Road Authority office in Southern region will be used to access study participants. Availability of transportation service and road infrastructure mapping will be done with the road Authority people.

2. Fistula patients coming to Yirgalem Hamlin fistula center and Addis Ababa Fistula Hospital from southern region (cases), Sidama zone and mothers under emergency obstetric care service at yirgalem maternity hospital (controls) from the same zone will be interviewed using structured interview format.

3. Information about home area of the mothers, distance they traveled, time lapsed to reach at an institution with cesarean delivery,  the basic road infrastructures, available transportation services, existing health facilities will be the main components of the questionnaire.

4. Other social, economic and political constraints mothers face will also be included in the questionnaire. The structured questionnaire will be translated to the local language and pre tested at the Addis Ababa Fistula Hospital.
5. The in-depth interview and focused group discussion with representatives of the above-mentioned groups will be done by focusing on constraints around mobility when health care is required in labour and /or during emergency in pregnancy.

6. Trained nurses will collect most of the quantitative data, however, the investigators will perform in-depth interviews and facilitate focused group discussion and collect the required information.  A total of four nurses will be involved in the project (one each from the Hamlin fistula center in Yirgalem and theAddis Ababa Fistula Hospital, and two from Yirgalem Hospital). Apart from data collection, they process ethical clearance from the regional health biro; organise in-depth interview, focused group discussions, the workshop; and disseminate the documents.
7. The data will be entered, cleaned and analyzed using SPSS soft ware.  Qualitative data will be either categorised, and coded into smaller groups, or used as quotation as it is when necessary.  The data will be processed and analysed using frequencies, means (SD), chi-square, and Odds ratio .The results will be organised and disseminated with special emphasis for all involved participants and to regional health biro and road Authority.
8. Ethical clearance will be obtained from regional health biro and the objectives, methodology and benefits of the study will be explained to all study participants and signed consent will be obtained. Participants are free to refuse to participate in the study or to refuse to answer questions they didn’t like to. Their denial to participate will not affect their treatment at all and the information they provide will be kept confidential.

Expected Outcomes of the Research

The study is expected to clearly show the existing problems around road infrastructure and transportation service, in relation to accessing the existing health facilities with emergency obstetric care services for laboring mothers. Most of the roads in the country are designed in the way that they connect main towns of the regions. Most of health facilities were built following these main roads. Accessory roads connecting small villages and farmers associations with the main roads are not at all in place. Great majority of the total population (85%) resides in rural Ethiopia. Only 50% of the general population can access primary health care service and only 10% of the three million deliveries per annum deliver at health institutions and receive assistance by skilled attendants. This study will investigate, however, if there is some link between the existing poor road infrastructure, poor transportation service and poor maternal health. This will help the policy makers and officials in the two sectors to clearly understand the problem and work in collaboration to achieve the MDG’s. 

Information Dissemination and Advocacy Strategy 

The study results will be disseminated as a report document to the regional health biro, regional road authority and to the community with the information through a dissemination work shop. All stakeholders, responsible officials and policy makers will be invited to this workshop to be held in the region. The final document will be distributed; the results will be presented and discussed with the workshop participants focusing on recommendations of effective and feasible interventions. The final report will include comments and suggested recommendations and will be distributed to the above mentioned biros and officials. Results will also be published and made available in mobility and health website.

Linkages Between Mobility and Health: The Case of Suba District, Kenya

Study led by Kenneth Odero , Jeffrey Maganya and Kaendi Muguti

Background

The proposed case study will be undertaken in Suba District in Kenya. Suba is one of the poorest districts in Kenya. The study looks at issues related with maternal health with an emphasis on HIV/AIDS, malaria, and gender disparities in relation to mobility.  Maternal mortality in Kenya remains high estimated at a national average of 414 in 2003. In some peripheral areas where access to health care is limited, the number is estimated at about 1000 per 100,000 live births.  The results of the study will contribute to increase knowledge at local and national level on mobility and health.

Overall and Specific Objectives

1. The overall objective of the study is to increase knowledge of, and improve access and mobility of poor rural communities to, health services and facilities
2. To increase understanding of the links between health and mobility on  current health challenges in terms of maternal health and other illnesses and inequalities in Suba District, Kenya
3. To develop dialoguing, lobbying and advocacy platform for local and national transport and health stakeholders.

Methodology   

The case study in Suba will use a combination of study methods with a view to eliciting comprehensive information on the linkages between mobility and health focusing on knowledge gaps.
1. This study will interview 250 purposively selected households to represent gender (especially female headed households) and the geographical diversity of the district as it relates to transport networks among other criteria. The sample will be drawn from clusters (divisions). A structured questionnaire will be used to gather information on the demographic information of the household, geographical access to the nearest health facility, mode of transportation, challenges (if any in accessing care) information on women in their reproductive age in the household and for those with children where their last child was delivered and reasons for this choice.
2. There will be specific case studies that focus on the experiences of women in terms of access to care, experiences of gender inequalities or discrimination, experiences of women with disabilities and the impact of this on themselves and their families.
3. Focus group discussions (FGDs) will be held with women and men in the different divisions in the district. It is expected that the information from the FGDs will highlight community issues in relation to mobility and health with specific emphasis on maternal health, gender, HIV/AIDS, malaria and access to health care.
4. There will be in-depth discussions with selected members of the key community based organizations especially those working with the communities in Suba in the areas of health (e.g. care-givers for people living with HIV/AIDS). In issues of mobility and health various sectors need to be involved in order to deliver appropriate health care. Interview schedules will be developed. 5. Interviews will be held with representatives of the Ministries of transport and communication on issues related to the transport network in the area, why the current neglect in the district in terms of different road networks and plans (if any) to address the current situation. Questions on their understanding on issues related to mobility and health will also be raised. Ministry of health staff in the district will also be interviewed.

Although this study will be undertaken using established social science research approaches, the emphasis will be on a participatory study that will allow extensive discussions with the communities with a view of ensuring that the outcomes can be used to begin to address their concerns. There will be two levels of case studies: Case studies on individual experiences with lack of transportation and the related health implications such as access and use of facilities, as well as case studies on any existing community-based initiatives that may form the basis of future interventions in mobility and health. An NMT may be purchased for local use to facilitate better knowledge generation from some case studies.

Expected Outcomes of the Research

1.  Increased the knowledge and discourse and a local and national level on transport, mobility and health
2.  Informed communities, knowledgeable of the linkages between mobility and health
3.  Documented and disseminated findings on the relationship between mobility/access and health.

Information Dissemination and Advocacy Strategy 

Involving the Ministry of Transport, Works and Health staff, Civil society organisations and communities is critical for raising awareness, knowledge sharing and policy discussions ion issues of mobility and health.  This will be done through working with the local National Forum for Rural Transport and Development in Kenya, The CRADLE (The Children’s Foundation) as well as through the Institute of Development Studies. After the completion of this research the team will use the information to develop a project idea for longer term policy changes that will be spearheaded by the three organisations.  They will have debriefing at the local level at the completion of the research to community and district level staff. This information will also be shared with relevant national level officials of line ministries through discussions and publications, and will also be shared electronically with other NGOs working in the area of health, transport and mobility through mail servers.

What’s the impact on maternal health of using the Ingobyi traditional stretcher as the main IMT in rural areas of Rwanda? The case of Gatsibo District

Study led by Aziza Benegusenga and Francine Rutagengwa

Background

The infrastructure for health services is progressing relatively as planned according to the rehabilitation and reconstruction phase which was developed after 1994. However the mode of transport for sick patients has not been addressed. People walk long distances and rarely use IMTs to access rural clinics. The most utilised IMT is the ingobyi a traditional stretcher made of bamboo and carried on the shoulders of 4 people. This is why a study on the impact of the ingobyi on maternal health is needed.

Overall and Specific Objectives

1. Gathering and providing information on the usage of the ingobyi as the predominant IMT for sick patients.
2. Promoting and raising awareness of the impact of the ingobyi on maternal health.
3. Developing solid recommendations to enable the decision-makers in the health and transport sector to prioritise rural transport improvements.

Methodology

The methodology used in this research is based on the méthode Accélérée de recherche participative (MARP) or in English PRA. The team will develop a communication process that is relevant to the various stakeholders in the health and transport sector in order to gather the information. In the course of the research a comfortable ambiance will be created so that the communities involved will not feel like a research object but instead as a partner. This will ensure that the community will take ownership will use the results to lobby and influence local decision-makers. The team will mainly work with women, men who transport pregnant women and other sick people by the ingobyi, the staff at the health centres, central and local authorities engaged in the health and transport sector.
The team will use the following tools : direct observation, focus group discussions, individual interviews, life testimonies. To ensure detailed analysis the team will triangulate by using a variety of tools such as semi-structured interviews, cartes, transects.  The team will also do a small desk review to look for French literature related to transport and health in general and maternal and child health in particular.

Expected Outcomes of the Research

1. The number of sick people and pregnant women transported by the ingobyi is known (this will include the number of people who died along the way).
2. The population in Gatsibo understand the importance of the ingobyi. The local authorities are aware of the ingobyi.
3. The recommendations for improvements are included in both the transport and health sectors’ programmes.

Information Dissemination and Advocacy Strategy 

The team will disseminate the information on the web sites of IFRTD and the local NFG Rwanda web site. They are considering organizing a local workshop to disseminate the results to the local and central authorities including the Ministry of Health and the Ministry of Infrastructure. The results of the study will also be available at the resource centre of the Rwanda NFG which is accessible for people who take a general interest in rural transport and cross-sectoral issues.

"Improving access to healthcare & family planning concepts & services for rural communities in South Africa."

Mac Mashiri and team members from CSIR.

Background

The purpose of the study is to seek to understand the modalities of rural communities’ access to healthcare in the Sekhukhune District of South Africa, Limpopo Province in South Africa. It is important to note that more than eighty percent of Limpopo is classified as rural and it is one of the poorest provinces in South Africa. However, although it is one of the poorest districts in the country, it also has latent development potential. Generally, access to socio-economic opportunities, including access to health facilities, is difficult for most villagers. Sekhukhune District has not been spared by the HIV/AIDS pandemic. The study focuses on unravelling the challenges that persons living with HIV/AIDS face in accessing healthcare as well as profile the work undertaken by community home-based care givers & community development workers with a view to generating solutions to mitigate the spatial, institutional, financial, technological & other challenges that they face in effectively discharging their roles as care and information givers.

Overall and Specific Objectives

The purpose of this study is to improve rural communities’ access to healthcare, family planning and associated services, as well as development information by seeking to mitigate the spatial, institutional, financial, technological & other challenges that exist within a specific rural local authority.
1. Undertake an audit of the study area health transport function
2. Unpack challenges faced by communities to access health facilities & the implications of these service delivery blockages
3. Focus on improving service delivery by home-based care givers to persons with disabilities

Methodology

The study will involve an extensive literature review; structured and semi-structured interviewer-administered questionnaire surveys; discussions, observations; workshops; subjective condition assessment of the physical state of selected transportation infrastructure and services & health facilities. Local school leavers will be trained & employed in data collection.

The methodologies enumerated above will be employed [gender-sensitively] to investigate the challenges faced by rural communities, and in particular those living with HIV/AIDS with regard to accessing primary & secondary health care [bio-medical and/or traditional] in Sekhukhune District. In the same vein, research will be conducted into existing institutional, managerial, and operational structures of the district’s health transport sub-system as a backdrop to the main thrust of the project as indicated above.

The key research questions for the project will include, among others:
1. What are the main challenges faced by communities to access health facilities in general & in particular, persons living with HIV/AIDS, who are not necessarily considered emergency cases, but who require regular contact with the healthcare system?
2. What are the access thresholds to healthcare facilities in selected communities in Sekhukhune District and what are the implications of the service delivery blockages & subsequent backlogs in relation to community livelihoods?
3. Are there any seasonal differences in the healthcare impacts?
4. Are the concepts [& practice] of community home-based care & community development workers adequate to significantly improve healthcare delivery in general & persons living with HIV/AIDS, TB & malaria in particular?  

Expected Outcomes of the Research

The key outputs of the project will be as follows:
1.Inception report describing the conceptual framework, criteria for analysis, & data collection strategies for the case study in South Africa as a basis for discussion with stakeholders
2. Country case study & feedback workshop report synthesizing the findings of the study as well as illustrating causality spanning the health transport function & welfare domains
3. A framework for improving access to healthcare with emphasis on persons living with HIV/AIDS, TB & malaria
4. Concept note to leverage funds for an innovative, low-cost, & high impact demonstration project

Information Dissemination and Advocacy Strategy

In South Africa, there are at least 4 national departments can that make a significant impact on mobility & health i.e. Health, Transport, Provincial & Local Government & Science & Technology. Not only will these institutions be consulted in the process of undertaking the project, but they will also be invited to a workshop showcasing project results together with other stakeholders. The report will be given to the departments listed here as well as local authorities.

Lastly, it is envisaged that this work will be disseminated by the IFRTD and their partner organisations such as SDC, Skat, etc. It will also be hosted on the CSIR Built Environment website as well as NFG-SA webpage on the IFRTD website.
   
It is important to note that dissemination and communication on this project will be discussed with stakeholders and other ideas are likely to be generated.

Mobilising communities: strengthening transport systems for obstetric emergency cases in Tanzania

Rose Mlay and Helen Smith

Background

For pregnant women in rural Africa, delays in reaching health facilities are inevitable. When complications occur, unless transport is found quickly and women reach a facility providing essential obstetric care promptly, morbidity and loss of life are common outcomes. In Tanzania only 46% of women access skilled attendance during childbirth. Of the 46% only 34% of the rural women access skilled care. The Maternal and Newborn Mortality Ratios (MMR and NMR) have been stagnant for the past decade. The Demographic Health Survey (DHS) of 1996 the MMR was 529/100000 and NMR 35/1000. In 2005, the MMR was 578/100000 and NMR 32/1000 meaning this is an important time to carry out the study.

Overall and Specific Objectives

1.  The overall  objective is to strengthen community awareness of women’s needs, and mobilise support for locally available and functional transport for emergency referrals.
2. Explore the village options and needs for referral of a woman in need emergency obstetric care.
3. To learn about the ‘lived experiences’ of individuals and families who have developed their own means of overcoming transport barriers and the outcomes.
4. To explore the transport needs of pregnant women at the village and the potential options locally.

Methodology

We plan to use participatory qualitative methods with local leaders and selected community members at Luhungo Village in Mzinga Ward in Morogoro Region to explore local options and needs for referral of emergency obstetric cases. We will use critical incident narratives to learn about the ‘lived experiences’ of individuals and families who have developed their own means of overcoming transport barriers. Thematic analysis across several cases within a community will enable a comprehensive understanding of the important events and decisions made by pregnant women needing emergency transport to a health facility. Focus group discussions with community members, including men and women, will explore the transport needs of local pregnant women and the potential options locally.

Expected Outcomes of the Research

1. Detailed understanding of the referral transport needs of Luhungo Village to help seek funding to develop relevant, community led interventions to address the transport problem
2. Insight on events and decisions made by women who have experienced a need for emergency transport
3. The findings will feed into local awareness raising and advocacy, via the White Ribbon Alliance, on the importance of locally available and functional transport to access skilled health workers for emergency obstetric care.

Information Dissemination and Advocacy Strategy

The findings of the case study will be disseminated via national meetings of the White Ribbon Alliance for Safe Motherhood in Tanzania who are active advocates for safe motherhood in the region. The bi-annual meeting and regular communications of the Africa Midwives Research Network and Annual Meetings of the Tanzania Midwives Association and Association of Obstetric/Gynecologists and Medical Women Associations who are White Ribbon Alliance members will provide the opportunity for wide dissemination of findings regionally. The case study will be published in a relevant local journal as well is in the White Ribbon Alliance for Safe Motherhood in Tanzania Newsletter.

Assessing the feasilbity of a mobile doctor service for poor people living on the islands in Lake Victoria, Uganda

Paul Kwamusi and Alice Nganwa

Background

Dwellers in Lake Victoria Islands have very poor access to health services; for instance there are no hospitals and the available health units provide inadequate services especially obstetric care. The poor quality of health services has been blamed on biased health sector planning where hospitals have been established on the mainland. There has also been an argument that people living in the islands are fewer and therefore it is viable for the islanders should travel to the mainland to access better health services.
The Government of Uganda has recently adopted a new National Health Policy and under the Health Sector Strategic Plan (HSSP), a number of health units have been constructed in the islands to address the concern of health service delivery. These range from Grade II (sub-dispensaries with out-patient services only) to Grade IV (Health Centers with maternity services) depending on the medical services available. Despite the above intervention, the quality of health services has largely remained poor, one of the reasons being health workers are reluctant to live and work in the islands.

Overall and Specific Objectives

1. To document strategies for improving access to health services to island dwellers.
2. To identify the water vessel most appropriate for use in health care provision to Island dwellers.

Methodology

This will be an operational and action based research with four components to it.
1. Aa baseline survey of access to health care and knowledge attitude practices towards common health problems.
2. The health intervention. Based on out reaches, will consist of a package of services that will include health education, de-worming of children under seven, treatment of bilharzias, immunization, prevention of drowning and antenatal care and treatment of common ailments.
3. The third component is post intervention survey.
4. The fourth component is the validation of the most appropriate option of water vessels for use in delivery of the health services
The variables include; mobility and access issues towards health services, level of quality of service provision, the best vessel option  for health workers, the utilisation of life jackets, occurrence of water borne and water bred services

The qualitative data will be analysed with the EZ text package while the quantitative data will be analysed using the STATA statistical package. The Kisima island will be purposively sampled basing on population, population stability and distance from mainland. All patient treated will be entered into the study. The patients for the Focus Group Discussions will be identified randomly from the day’s patient register. 4 FGDs will be held one on the island during the visits to the island. A tool will be designed to capture data from the patients and it will include demographic data, socioeconomic measurements and health condition and its outcome. The outcome will be assessed by a resident community based health worker. Tools will be designed to guide FGDs and key informants interviews. It is estimated that the study will take one year with monthly visits to the islands for at least 8 months. The last 4 months will be used as phase for handing the service over to community health workers and the district authorities.

Expected Outcomes of the Research

1. Improved access to health care of islanders during the study period
2. Realistic strategies for improved heath service provision to islanders
3. Validation of appropriate water vessel for health care service delivery.

Information Dissemination and Advocacy Strategy

The research report will be disseminated to policy makers within the Ministries of health, transport and also the district leadership where the research was carried out through a meeting. Feed back will be given to the island’s leadership so that recommendations that can be implemented at their level are noted. The research finding s will be published in peer review journals on health care and on transport.If funding is available, radio programmes in districts with islanders and newspaper article will be used to further disseminate information.

"Bicycle for health: Appropriate mobility to improve Access to Health, rural Uganda "

Patrick Kayemba and team members from FABIO are taking the lead on this study.

Background

Uganda, East Africa, is a country with very limited access to health services. Transport is scarce and expensive, the distance to the nearest health centre can be up to 20 km and over 85% of the population live below the poverty line. FABIO developed an appropriate technology, a carrier for patients for bicycles to overcome these gaps of mobility. Over 300 bicycle ambulances have been distributed throughout the country, but due to the limited capacity we are yet to document and prove the effectiveness of this facility, in view of the rural poor. This study will take place in two rural districts to identify the cost benefit of the bicycle ambulance in comparison to other means of transport and to identify its optimal location, either on community level, at household level or at health centres, and the appropriate management systems. The study will examine the level at which the bicycle ambulance can improve the access to health services in the rural areas, in view of the transport costs, appropriateness to the road conditions and its contribution to improved maternal health and reduced child mortality as an alternative for addressing MDG 4&5. The outcomes will help to advocate for this mode of transport at local, national and international levels for support from the policy makers.  Since the Ugandan government has been focused till now, only on motorised transport, this study is aimed at influencing change of attitudes and policy, for improvement in the long run of access to health services.

Methodology

The study shall employ participatory Rural Appraisal tools. Each district will have a minimum of 10 bicycle ambulances, 5 in each, based at community level, household level, and health centres. The methods of research will include:
1. Records of usage and costs for a period of 6 months
2. Interviews with different stakeholders, like health workers, local council officers, patients, community members
3. Focus Group Discussions at community level
4. Own observations through field visits
5. Key informants

There will be different comparisons:
1. Between the different districts Kamuli/Bugiri, referring to the usage
2. The before/after comparison
3. Ownership mode: community, household, and health centre
4. Sustainability in terms of construction, management, maintenance, and repair
5. Attitudes for policy
The initial baseline survey will identify the access and alternative means of transport in these districts. The project will include the distribution of bicycle ambulances at household level. There are already existing bicycle ambulances at community level in the two Sub counties but which may not be enough. The research shall provide for 1 month to distribute the bicycle ambulances and to facilitate the beneficiaries with skills and kits for usage and maintenance. The final situation survey will take place after a period of 6 months for analysis. The before/after survey is used to measure how effective the bicycle ambulance works, given the different contexts and will use a variety of indicators to identify the efficiency of the bicycle ambulance: such as frequency of usage, costs for maintenance, charge for usage, details of patient (gender, age, sickness) etc.

Expected Outcomes of the Research

1. The research will provide the empirical evidence of the efficiency of the bicycle ambulance in addressing the mobility question to health.
2. The comparison of the different locations of the bicycle ambulance will identify the optimal location where to station the bicycle ambulance at household, community level, at camps or at health centres.
3. The result can be used as a baseline for increased support from other development actors, at international and national level, to improve and disseminate the former project of distributing bicycle ambulances in  Uganda and other developing countries.

Information Dissemination and Advocacy Strategy

FABIO the organisation Patrick works for has interacted with the ministry of health and shared the role of the bicycle and its ambulance, in promoting health. However, due to lack of research, and therefore, no statistics, it was not possible to convince the ministry of health of the efficiency of the bicycle ambulance. This research will strengthen the NMT advocacy campaign in broad terms, specifically the promotion of the bicycle ambulance. We intend to publish and disseminate the outcome and the information of the research to not only the ministry of health but to other national and International organisations involved in development issues and especially in health like WHO. The preliminary findings will be presented and shared at the VELOCITY in Munich, Germany in June 2007. At the local level this research will be shared with the different stakeholders involved in the two districts, which includes: the communities, the local councils, the district councils and the health workers.

A study to examine the role and impact on the health of disadvantaged groups of an appropriate, replicable community ambulance infrastructure (the uhuru).

Enock Zibengwa and a team from Riders for Health are working on this study.

Background

A randomised study to evaluate the effectiveness of Riders for Health’s community ambulance system; and its impact on outreach health programmes. The study will concentrate on the Community transport programme (the Uhuru), which focuses on maternal health and income generation. Maternal mortality due to inaccessibility of health services continues to be one of the major causes of deaths among women in rural Africa. Policy analysts observe that many African countries, such as Zimbabwe on attaining their independence, adopted health policies whose emphasis is on the provision of curative, urban-based services at the expense of preventive services that are appropriate for the majority of the people, particularly those in rural areas.

Riders for Health’s overall intervention strategies are based on the hypothesis that health and related social development for rural communities depend on the establishment of an appropriate, sustainable, cost effective and dynamic transportation infrastructure. If rural mobility is high, it is certain that general accessibility of health services and facilities will increase, and incidences of disease and maternal mortality will decrease. Riders’ experience with transport programming in Zimbabwe, and in other African countries, has confirmed the demand for and value of appropriate and well-managed transport for public health and preventive care. The research will assess Riders’ motorised mobility and health programmes using proven qualitative and quantitative research methods. Findings will be published and disseminated so as to share knowledge and practical experiences for formulation of policies that improve mobility and reduce vulnerability of rural Communities.

Overall and Specific Objectives

1. To highlight how an appropriate infrastructure for transport management has demonstrably improved primary, maternal and public health care of marginalised, disadvantaged or disenfranchised populations in rural communities.
2. To openly share mobility and health knowledge, approaches and techniques for the promotion of healthy, sustainable communities.
3. To demonstrate the impact of motorised mobility and health programmes on capacity building and the empowerment of women.

Methodology

Methodology considerations: The evaluation will employ both qualitative and quantitative methodologies within a participatory framework and make it possible for beneficiaries to learn from the experience.
Methodology: Generally multiple data collection systems and tools, targeting multiple sources of information will be utilised, in order to gain an objective picture of the situation. The proposed triangulation strategy will use diverse investigation methods to evaluate the programme, namely:
1. Participatory qualitative and formal quantitative/survey methods
2. Direct and indirect investigation methods (desk reviews and observations)
3. Primary and secondary data sources reviews
4. Focus group discussions

The evaluation will also provide case comparisons that is, contrasting case studies between communities that have benefited from Riders’ mobility programmes and those that have not.

Expected Outcomes of the Research

1. A demonstration of the way in which systemic change takes place once a sustained, replicable and cost-effective system is in place for enabling development at a community level.
2. A substantiated, in-depth analysis of Riders’ health and mobility programmes, showing that the Riders system is financially viable, can be measured and used as a budgeting tool, that it builds skills and capacity, and is easily replicated. This analysis can be used to sensitise the health and development sector on the importance of locally-managed, motorised mobility in primary health care at community level.
3. Heightened awareness of how 21st century solutions are an appropriate, efficient and cost-effective way of improving the lives and health of vulnerable groups. This awareness will help to influence the strategies and policies for motorised vehicle use of agencies that directly interface with rural communities – communities that are particularly vulnerable to ill-health, underdevelopment, economic insecurity, poverty, lack of empowerment of women and social exclusion.

Information Dissemination and Advocacy Strategy

Riders for Health has developed a wide-reaching system for disseminating information about the issue of appropriate transport for development. Dissemination at the regional and local level is carried out through established channels, including our International Academy of Vehicle Management in Harare, and regular communications with other international and in-country agencies and NGOs. The findings will also be disseminated through Riders for Health’s publications, which are circulated to partners and other stakeholders within the global health and development communities (for example, Riders for Health is a member of both the Schwab Foundation and Skoll Foundation networks of social entrepreneurs). We will also work actively to develop new ways of enabling relevant agencies to receive this information.