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Published on December 5th, 2008 | by admin

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Dial 911 and hope for the best

The lack of policy and planning concerning emergency medical vehicles is costing lives, writes Clarisse Cunha Linke

Government’s recent attempts to tidy up the management of its vehicle fleet are commendable and could save millions of dollars. But there is a little discussed issue around one GRN fleet that is costing Namibian taxpayers more than money. The lack of policy and procedures to regulate the distribution and use of emergency medical vehicles means that patients might die while waiting for an ambulance. Transport has a crucial role in increasing Namibian communities’ access to health services. A recent assessment on the impact of transport on access to health services for people living with HIV/AIDS in Ruacana, Outapi, Aussenkehr and Karasburg demonstrated that a lack of appropriate and affordable transport solutions hinders individual access to health facilities and movement of health workers. While the scope of the research was geographically limited, there is anecdotal evidence to suggest that the findings resonate with the situation in other regions. The assessment was conducted by the Bicycling Empowerment Network Namibia (BEN Namibia) in partnership with the International Community of Women Living With HIV/AIDS, and the AIDS Law Unit of the Legal Assistance Centre, from August to October 2007. The assessment showed that there is frustration across the board concerning the lack of transport to deliver healthcare, from patients in villages to national level health professionals. Transport in an emergency often depends solely on patients’ capacity to access cash. In rural areas, a common procedure is to phone for an ambulance and start making other arrangements because of the slim chance that it will actually turn up. It might cost up to N$400 for a patient to reach hospital by hiring a private vehicle. Families might sell assets or livestock, or borrow money from family members or friends if they need cash to cover fees in an emergency situation. Cash upfront District hospitals do have ambulances as part of their fleet, yet ambulance coverage is non-existent for most of the population. Outapi District Hospital, for example, has two ambulances but often one is broken, and the priority for their use is for referrals to Oshakati State Hospital. It might take two days for an ambulance to come to a health centre or clinic to collect a patient; a delay that at times cost lives. The existing vehicles’ constant maintenance problems, combined with use for staff needs or illegitimate purposes, mean that effectiveness of the already small fleet shrinks even further. In Karas the situation is no different. Transport in an emergency situation is also a burden to patients, and a private ride from Aussenkehr to Karasburg District Hospital might cost up to N$300. Some farms have private cars available for emergencies during working hours, nights and weekends, but only for their workers. HIV positive interviewees in Aussenkehr mentioned the extra trouble they face when borrowing money from family or friends to pay for transport, as stigma against people living with HIV/AIDS is stronger in southern Namibia than elsewhere. According to the Primary Health Care (PHC) Directorate, the Ministry of Health and Social Services has no clear policy defining the vehicle fleet required for different types of health facility. Referral and district hospitals always have ambulances. Health centres and clinics are part of district hospitals’ catchment areas and are allocated vehicles at the hospitals’ discretion. What is apparent from interviews with health service providers is that neither Karasburg nor Outapi district hospitals have sufficient vehicles or personnel to cover their own services, so facilities under their auspices are left without direct control over any form of transport. In a peculiar example of bureaucratic perversity, Primary Healthcare (PHC) Director, Maggie Nghatanga, explains that vehicle allocation, under the current structure is determined by available personnel in each health facility, therefore if there is no driver, there cannot be a vehicle. Clearly, without a specific policy outlining personnel, management systems and proper monitoring and evaluation procedures that lead to maintenance supervision and timely replacement of the fleet, service delivery will not reach all Namibians. While there is clear disappointment among health professionals about the transport available to deliver efficient health care, it seems that key institutions are not taking responsibility for finding solutions. The PHC Directorate claims that there is an insufficient budget to provide an adequate fleet for all types of health facilities, while one major international agency working in the health sector, UNAIDS, declares that transport is important to improve access to health services for people living with HIV/AIDS, but not part of their mandate. In the meantime, lack of appropriate transport in the health system has a devastating impact on emergency care.Two-wheeled solutions Looking at Namibia’s neighbours, though, it is impressive how initiatives exploring transport-related solutions to deal with access to health have mushroomed over the last years, varying from transport management systems for health facilities to delivery of alternative transport solutions, including bicycles and motorbikes. The bicycle ambulance is not intended to replace motorised ambulances, but to fill a gap where no services are provided. BEN Namibia’s work delivering more than 4,000 bicycles and 120 bicycle ambulances in the country to healthcare volunteers has demonstrated that there is an enormous demand from the grassroots level. Bicycle ambulances have also been distributed in Zambia, Tanzania, Uganda, and in Malawi. A study on the use of bicycle ambulances in Uganda showed a marked decline in infant and maternal mortality rates. In Malawi, motorbikes with sidecars placed at three remote rural health centres in Mangochi district reduced up to 76 per cent of the referral delay for obstetric emergencies compared to car ambulances in a pilot experience during 2001, a partnership involving e-Rangers and Riders for Health. According to a recently released report, the purchase price of a motorcycle ambulance was 19 times cheaper than for a car ambulance. Annual operating costs were almost 24 times cheaper than for a car ambulance. In Zimbabwe, a pilot project in Marowa village in 2003, also with a motorcycle, saw an increase in the incidence of home-based care visits by healthcare workers of 60 per cent. In Ghana, a partnership between the government and USAID worth US$270,000 distributed 128 motorbikes and 224 bicycles to address different transport needs that health facilities at district-level face. An assessment done by Ghana’s Community-based Health Planning and Services found that one nurse on a motorbike can outperform an entire sub-district health centre, increasing the volume of health service encounters by eight times. An adequate fleet for the health system, however, does not necessarily mean a large number of vehicles at each facility. After developing a fleet management programme together with UK development agency Transaid, the Department of Health in North West Province, South Africa, has seen a 55 percent reduction in fleet size, a 55 percent reduction in transport capital budget, a 35 per cent reduction in operational transport costs, and an 85 per cent transport availability. Namibia’s medical fleet problems are not unsolvable. They will require some investment, but merely asking donors to cough up for yet another batch of ambulances is not the long-term solution. Developing a policy based on the diverse transport needs of the country’s health facilities is the crucial first step. Without even a basic plan, dialling for an ambulance in much of the country will remain the exercise in futility that it is today. * The writer, Clarisse Cunha Linke, is the Organisational Development Director for Bicycling Empowerment Network Namibia


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