Effective Access to Care

Topic Overview

More than half of women in developing countries give birth at home, often far from heath centers and hospitals. There are far too few providers to serve the populations in these countries, but for many reason, it is not the lack of provider that keeps them from getting the care they need, but the lack of affordable transportation (cars, bicycles, ambulances, etc.) or the cost of the care itself. Cultural norms and beliefs may also impede a woman’s ability to seek care, especially during childbirth. The unpredictability of services at facilities that are understaffed and inefficient deters some women from seeking care at all. Women who do visit healthcare facilities often have no choice other than to walk. The average distance to a basic healthcare facility in rural Africa is eight kilometers (five miles), often on unpaved roads or pathways, and much farther to higher-level facilities that can provide emergency obstetric care. A woman who is hemorrhaging can bleed to death in two hours, usually long before she can be transferred to an appropriate health facility. Most healthcare facilities in rural areas do not have ambulances or other forms of transportation to bring patients to hospitals. Unreliable transportation can also mean that rural facilities struggle to maintain regular inventories of drugs and other medical supplies refer and transport patients to more specialized care, and attract and retain high quality staff.

Through interviews with experts, providers, and footage of women in need of care, this module examines some of the difficulties women face in accessing care.

Background Information

As noted above, women’s access to care can be constrained by barriers such as limited transportation, cost of care or transportation, and/or cultural barriers.

Transportation Barriers

Distance to facilities: Many women live at least eight kilometers (five miles) from a healthcare facility. These healthcare facilities are usually lower-level facilities that may have a skilled provider on staff; however, most do not have the basic medications, equipment, and supplies needed to save lives during an obstetric emergency.i Facilities that can support emergency care are often much farther away and often lack vehicles of their own to transfer patients. In Tanzania, for example, the average distance to a facility that can offer emergency care jumps to 31.7 kilometers. Because of the lack of transportation options, many women are forced to try to reach their nearest health center while in labor on foot—a gamble given that they could deliver or die from complications while en route.

Poor roads and transport systems: Those roads that do exist are often poorly maintained and hard to navigate. Many roads are not paved and cover difficult terrain. In some areas, during the rainy season, roads are impassible. There are also few public transportation systems that connect rural areas to the cities where most hospitals are found. Women have to rely on expensive taxis, truck drivers who may be passing through, or other unreliable forms of transportation to reach care.

Cost Barriers Transportation costs: When there are transportation options other than walking, the cost can be prohibitively high. In Tanzania, approximately 96.6% of the population lives on less than $2 a day.ii A roundtrip bus ticket to a hospital can cost $60,iii far out of reach for most of the population.

Hospital and medical costs: The cost of the care itself may make families decide not to bother seeking transport. In parts of Bangladesh, a complicated delivery can cost 90% of a family’s annual income,iv deterring many women from seeking care even when faced with an obstetric emergency.v

Cultural Barriers In communities where women’s rights and mobility are more limited, women may not be able to seek care outside the home without permission from their husbands or mothers-in-law. A woman may not participate in making the decisions about whether or not her family can pay for transportation to healthcare—if the family can even afford care at all. In addition, some cultures restrict the times of day when women can travel outside the home. In some areas, women cannot travel at night or it may be deemed “inappropriate” for a woman to travel by bus or on a motorcycle ambulance or to be seen outside the home, particularly if she is in labor. She may not be allowed to leave the home unless accompanied by a male relative or she may not be permitted to receive treatment from a male healthcare provider.

Human Resource Barriers The general shortage of healthcare workers can discourage people from going to healthcare facilities. Inadequate clinical staff levels may mean that even if a woman reaches a healthcare facility, there is no guarantee that there will be qualified staff to receive her and where there is staff, there will likely be exceptionally long wait times. Please see our module on the healthcare worker shortage for more information on this barrier.

Improving Access to Care

The challenge of improving access to care is that it depends on addressing the underlying weaknesses in infrastructure that impede so many development goals. Ultimately, developing countries need better transportation systems, communications and power systems so that women can access the care they need. Such improvements would also benefit those countries’ education systems, access to food and water, and their overall economic growth. Improved

infrastructure requires significant investments made over the long term; these investments must be given higher priority by the donor community. Nevertheless, in many countries, local communities, civil society organizations, and governments themselves are utilizing creative approaches to save lives. Some of these innovative approaches are listed below along with examples of where they are being implemented. 1) Locate health services in areas with unmet needs and/or bring health services to the

patient:

■ In Bangladesh, BRAC’s Manoshi Project locates healthcare services in the community and delivers care directly to the home by enabling community-based health providers to reach women and children living in urban slums: □ Midwives and other healthcare workers are based locally so that they can more

easily go to the homes of pregnant women to deliver care or information. □ Delivery centers staffed with midwives are set up close to the urban communities

to provide access to a hygienic, private birthing environment. □ Midwives attend most deliveries, but can also identify complications and handle

referrals for emergencies requiring a higher level of care.

■ In rural areas, healthcare workers are given bicycles, motorcycles, or boats to reach patients in outlying villages: □ In Senegal, the Ministry of Health has partnered with United Nations Population

Fund to create a program that trains rural community healthcare workers in reproductive health issues and outfits them with bicycles so they can travel from village to village. These workers are also trained to monitor the health of pregnant women and to refer them to health centers as required. Of course, it is still essential that the health centers are ready to receive the patients and deliver the required care.

□ Riders for Health provides low-cost motorcycles and maintenance for healthcare workers in seven African countries. The maintenance support keeps motorcycles running and enables healthcare workers to reliably visit remote villages.

■ Many countries, including Tanzania and Guatemala, have experimented with bringing pregnant women closer to care by creating maternity waiting homes. These homes are residential institutions located near a medical facility that provides essential and emergency obstetric care. Women with a risk factor or complication during their pregnancies are referred to these facilities before their delivery dates so they can be quickly transferred to the medical facility when labor begins.

2) Provide affordable, culturally appropriate transportation. Some communities have developed emergency transport services that work for their particular needs:

■ In countries such as Malawi, Zambia, Nepal, and Namibia, a bicycle or tricycle is modified to support a trailer that can carry pregnant women to a healthcare facility. Local volunteers drive the bicycle ambulances and are trained in maintenance and production of these trailers. Studies of pilot programs have shown that these bicycle ambulances save lives: a project evaluation in Zambia showed them to have saved 70 lives in a six-month period.vi The bicycles do have real limitations such as an inability to cover long distances, difficulty with poor roads or bad weather, and the lack of a way to bring along a family member.

■ In countries such as Malawi, Gambia, Ghana, Tanzania, Tibet, South Africa, and Bangladesh, specially designed covered sidecars or trailers with medical equipment are attached to motorcycles or tractors to transport women to health centers or from centers to hospitals. Most have at least two drivers per ambulance who are trained in maintenance and safe operation. Unlike bicycles, these vehicles are large enough to allow a family member to accompany the laboring woman to the hospital. Motorcycles are generally less expensive than larger vehicles and can access villages with poor roads, but are susceptible to weather, poor infrastructure, and lack of fuel.

■ In northern Nigeria, taxi drivers volunteer for training on how to spot warning signs of complications in a pregnant passenger, how to carry women in labor, and how to minimize delays. These drivers transfer women from their communities to health facilities. At the health facility, a staff member signs the driver’s logbook, which entitles the driver to “priority loading” at the next taxi park—effectively allowing the driver to jump the queue of other taxis waiting for passengers.

3) Use technology to bring healthcare closer to the community:

■ Some new programs are using new technologies and mobile phones to address transport issues in maternal health. For example, healthcare workers are using text messaging to support provide care to women in rural areas during their pregnancies. Cell phones are also being used to improve access to transportation during home deliveries in the event of a complication. One such program in Tanzania is experimenting with the use of cell phones to facilitate the electronic transfer of funds to taxi drivers when cash is not available.

The video module includes: ■ Interview and footage of Ali Hadar, Bengali widower, Bangladesh ■ Interview with Jeffrey Sachs, PhD, The Earth Institute, Columbia University, United

States ■ Footage of Janet, pregnant woman, Tanzania

■ Interview and footage of Rahel Maskiawa, midwife and healthcare worker, Tanzania ■ Interview with Dorcas Robinson, PhD, CARE, Tanzania ■ Footage of Petronila, pregnant woman, Guatemala ■ Interview and footage of Linda Valencia, MD, Planned Parenthood Federation,

Guatemala ■ Interview with Zury Rios, Congresswoman, Guatemala ■ Footage of Yasmeen Begum, BRAC midwife, Bangladesh ■ Footage of Chompa, pregnant woman, and her husband, Bangladesh ■ Interview with Kaosar Afsana, PhD, BRAC, Bangladesh

Discussion Guide

Opening Questions

■ What is your initial reaction to the video? ■ If you could ask anyone in the video a question, who would it be and what would

you ask? ■ Which segment resonated with you the most? Why?

Transport and Access Questions

■ How could mobile phones be used to reduce transportation barriers and improve care?

■ What are some of the limitations of the health dispensary in Tanzania? How can they be addressed?

■ What are the benefits of bringing healthcare workers into the community? What are the limitations? How can these be addressed?

■ Some countries have “maternity waiting homes” located near hospitals for women who are close to giving birth. Would these homes have helped any of the women in the segment?

■ What are some of the advantages and disadvantages of maternal waiting homes?

Social Questions ■ Do you think that Chompa went to the hospital? Why or why not? What could

Chompa’s husband have done to help get her to the hospital? ■ Did Chompa have a say in what was going to happen? Why or why not? ■ What are some of the challenges facing resource-strapped governments and how

might they be addressed?

Activities

1) Millennium Development Goals & Effective Access to Care

In 2000, the United Nations developed eight measurable goals to address poverty in the world; all 192 UN member states, including the United States, committed to reaching these by 2015. Goal 5 is to improve maternal health. Break the class into groups. Ask each group to create a list of the ways that transportation and access to healthcare are relevant to the other Millennium Development Goals (MDGs). Have the groups brainstorm possible actions that would address the MDGs and help increase access to healthcare in general and emergency obstetric care specifically.

■ Goal 1: Eradicate extreme poverty and hunger ■ Goal 2: Achieve universal primary education ■ Goal 3: Promote gender equality and empower women ■ Goal 4: Reduce child mortality ■ Goal 5: Improve maternal health o Target 5a: Reduce by three quarters the maternal mortality ratio o Target 5b: Achieve, by 2015, universal access to reproductive health

■ Goal 6: Combat HIV/AIDS, malaria and other diseases ■ Goal 7: Ensure environmental sustainability ■ Goal 8: Develop a global partnership for development

2) The Three Delays It is generally accepted that there are “three delays”vii in accessing emergency obstetric care:

■ The delay to seek care ■ The delay to reach proper medical services ■ The delay in accessing quality care at a healthcare facility

Break the class into groups. Ask each group to identify which delay occurred in each section. Do some of the women face multiple delays? Brainstorm ideas that could help women avoid each delay. i Dolea, C., et al., Increasing Access to Health Workers in Remote and Rural Areas Through Improved Retention. World Health Organization. February 2009. http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf Last Accessed 1/15/2011 ii United Nations Human Development Report. United Nations. 2009. Human and Income Poverty. Population living beneath $2 a day. http://hdrstats.undp.org/en/indicators/103.html Last Accessed 1/15/2011 iii Curnrow, R. Banking Revolution Saving Lives in Africa. 29 December 2010. CNN. http://articles.cnn.com/2010-12-29/world/mobile.banking.tanzania_1_mobile-phone-mobile-money-bank-account?_s=PM:WORLD Last Accessed 1/14/2011 iv Ibid. v Koenig, M. Maternal Health and Care-Seeking Behavior In Bangladesh: Findings from a National Survey. International Family Planning Perspective. 2007 (33:2). vi Simfukwe V. Barber C, Foster G. Evaluation Report on the 2008-2009 Bicycle Ambulance Pilot Project Implemented in Three Districts of Eastern Province, Zambia. Transaid. March 2009. http://www.transaid.org/projects/zambia,-bicycle-ambulance-project,-sept.-2008-%E2%80%93-mar.-2009 vii Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994;38(8):1091–110.