And So the Uganda Eranger Project Commenced
Introduction
Roger Neuberg is a Consultant Obstetrician and Gynaecologist. Through ALSO-UK (Advanced Life Support Obstetrics), he is heavily involved nationally and internationally in promoting training in life-saving skills for obstetric and neonatal emergencies both in hospitals and in the community.
In 2007, at the “Women Deliver” World Conference in London, he first saw the eRanger Motorbike Ambulance. He was so impressed with its potential that he resolved to make it both a Rotary club and Rotary District-wide project.
In 2011, at District 1070 Assembly as District International Service Chair, he launched his “Let’s Do Something Amazing!” project to provide a fleet of 20 eRanger Motorbike Ambulances for the 1 million people of Mbale District in Uganda. Mbale has a high incidence of maternal deaths particularly due to the mountainous nature of the terrain and poor road network which makes access to health centres difficult.
And so the “Uganda eRanger Project” commenced.
In October 2011, he joined a medical team from Partnerships Overseas Networking Trust (PONT) linked with the Welsh Ambulance Service and travelled to Mbale. He saw the eRanger in operation in Mbale and took part in the training of healthcare workers, student Medical Officers and midwives while working on the labour ward of the Mbale Regional Referral Hospital. He is very aware and familiar with every aspect of the project.
Since 2009 he has arranged for the presence of the eRanger in numerous UK District and National Rotary Conferences and Assemblies. During 2012, he gave 35 presentations on the project to Rotary clubs in District 1070 including one to Her Excellency Rotarian Joan Rwabyomere, Ugandan High Commissioner when she visited Leicester UK in 2012.
Such was the generosity of 43 of the 87 clubs in 1070, 3 other UK Rotary Clubs, private individuals and groups, that sufficient donations have been obtained to fund a fleet of 32 eRangers through a Global Matching Grant.
He has a very close working relationship with PONT, the Welsh Ambulance Service, the Ranger Production Company and with the Rotary Club of Mbale. This will be invaluable and essential during the implementation of the project.
He has liaised with the cooperating organizations in Mbale for the reception of the delivery and secure storage of the eRangers.
23 eRangers will be placed at emergency health facilities in the 3 districts of Mbale (Mbale, Manafwa and Bududa). 9 will be allocated to the 3 outlying districts of Lowero, Gulu and Tororo. PONT will have ownership of the eRangers which will be on permanent loan to the PONT-Mbale-CAP (Coalition Against Poverty).
[Between December 2010 – November 2013, 7 eRangers made 7,000 emergency runs in Mbale, Manafwa and Bududa. This averages out at 45 emergency call-outs per eRanger per month. The majority of these call-outs were for emergencies arising in pregnancy and labour. Many were life-saving. The effect of 32 more eRangers will be huge with a significant reduction in maternal deaths.]
Cooperating organisations
PONT is a twinned community link between Pontypridd in South Wales and Mbale District. PONT has established the Mbale -CAP as an integrated Primary Care system to help end poverty in the Mbale region. This is a coalition with Mbale / Manafwa / Bududa District Councils and their Directors of Health, Mbale Regional Referral Hospital and an American medical charity Kissito Healthcare International (KHI). A group of NGOs and the Rotary Club of Mbale are affiliated members.
The goal of PONT-Mbale-CAP is to establish a Village Health Team (VHT) in each community, comprising an Operational Level Health worker (OPL), Community Health Promoters (CHP) and Traditional Birth Referral Attendant (TBRA). The VHT will be integrated with local government health facilities and have access via mobile phone to the eRanger in order to reach skilled maternity and emergency health care. The Mbale-CAP will select those OPLS who will be trained as eRanger drivers.
A 4-week residential training course has been developed by PONT, the District Government Health Office and NGOs in Mbale. It is delivered by the NGOs with input from visiting PONT medical volunteer teams and leads to District Government Certification. On completion of training the health workers are equipped and enabled to provide Primary care at village level.
The trained VHT teams will continue to receive support, supervision and monitoring by the District Directors of Health in partnership with the NGOs responsible.
Regular update training including that provided by annual multidisciplinary teams visiting from the UK is a great encouragement, and is planned to continue for the foreseeable future. This methodology, developed in Mbale over the past 7 years, has shown over 90% retention of trained volunteers to date.
By their successful and cooperative nature in and with their communities, VHTs have become highly valued, bringing improved access to health information, advice and access to emergency care through the eRanger ambulance service, as well as mobilising people to help themselves. The community supports the volunteers through gifts in kind and help with their farming.
Additionally, the network provides rapid outflow of information from communities (eg cholera alerts) and a vehicle for rapid and effective dissemination into communities for government campaigns such as immunisation and health messages.
Since December 2010, PONT and the Mbale-CAP have gained experience in managing their growing fleet of eRangers (currently 7 vehicles).
In view of the furure dramatic expansion in the size of the eRanger fleet, PONT have invested in an eRanger ‘maintenance' bike with a large tool box as the side-car. This bike acts as support/repair vehicle to the motorbike ambulances should they breakdown in the community. Initially one mechanic in the PONT mechanical engineering workshop will be employed specifically for the maintenance of the eRanger fleet. Training will be provided at the workshop by one of the Ranger Production Company's roving mechanics, to be followed by in depth training in South Africa.
Progression of the project
Roger Neuberg will travel (at his own expense) to Mbale in April 2014 for the handover of the bikes to PONT and through the PONT-Mbale CAP to the recipient health facilities. Thereafter he will travel to Mbale annually to visit health facilities and meet with the cooperating organizations. He intends to visit the outreach Mbale-CAP projects in Luwero, Gulu and Tororo.
Data will be required on the numbers of Primary Care referrals and eRanger Motorbike Ambulance emergency transfers to health facilities.
The OPL eRanger Motorbike Ambulance driver will be trained on how to accurately keep a log to record data concerning all emergency ambulance runs. This will include journey statistics (driver name, callout, arrival and destination times) for vehicle monitoring. Basic clinical data for each patient to include the patient’s name, maternity, non-maternity, age, presenting problem and the outcome (if known), will provide an additional source of key data enabling sampling of local emergency trends and identification of unmet needs for remedial action.
These monthly collated returns will provide a cumulative analysis of eRanger activity.
Additional data will be obtained from the maternity registers at the health facilities, identifying all obstetric cases that were transferred by eRangers, the reasons for those referrals and the outcomes.
This data will be collated and shared with the District Directors of Health and the NGO coordinators from all 4 regions of Mbale/Luwero/Gulu/Tororo who will form the Ugandan Steering Committee, and with the UK Steering Committee linked to PONT. These two committees will meet 6 monthly to chart progress of the project in all 4 regions, and ensure reporting is taking place, with performance and clinical data analysis by region.
The University of Glamorgan Community to Community International Links academic unit in Wales will be invited to perform a project evaluation in 2016.
The District Directors of Health and NGO coordinators will oversee the day to day running of the projects to train Village Health Teams and eRanger OPL drivers and collate the information.
Roger Neuberg will be kept informed of the regional data analysis reports every 6 months from both the Ugandan and UK steering committees. He has undertaken to keep the UK donor Rotary clubs and non-Rotarian donors up to date with the impact that the eRangers are making. He will be requesting a breakdown on the number of emergency runs each individual bike has made over each 6 month period.
During his annual visits to Mbale he will personally check on call-out data from randomly chosen health facilities. He will make the necessary reports to Rotary International. After 2 years he intends to make an evaluation of the project. It is hoped that District 1070 Foundation will fund another Rotarian to act as a District Evaluator and travel with him to Mbale.
Conclusion
The ultimate goal is to reduce the maternal mortality rate in Mbale, Manafwa and Bududa to below 200 per 100,000 live births. A reduction in maternal deaths is expected in the outreach pilot regions of Luwero, Gulu and Tororo.
The Ugandan Government Health plan (HSSP III 2011-2015) highlights the need to develop Primary Health Care as the major strategy for delivery of health services in Uganda, recognising the importance of partnership with community development NGOs in addressing the funding gap.
The development of a Primary Care service through the Village Health Teams (VHTs) with trained volunteers equipped with mobile phones to call out the emergency motorbike ambulances and the supply of a fully operational, appropriately used and effective eRanger Motorbike Ambulance service, are essentially dependent upon each other.
At the close of the project to increase the number of VHTs in the 4 regions of Mbale, Luwero, Gulu and Tororo, the trained VHTs will continue to receive support, supervision and monitoring by the District Directors of Health with the NGOs responsible. The annual visits by the multidisciplinary medical teams from the UK are planned to continue for the foreseeable future.
The communities where the eRangers are based have great pride in "their bikes". The bikes are housed and looked after with meticulous care. Regular servicing and repairs by Ranger Production Company’s trained engineers will be essential in order to extend the duration of each bike's useful service for as long as possible. The long-term running costs of all of the eRangers will eventually come from the communities served by the eRangers.
The project must be seen as an investment in the future sustainable development of the entire community.
Strong collaborative partnerships have been built up by PONT, KHI and the Mbale-CAP with the government at local, regional and national levels. They have met with the Ugandan Ministers of Health on several occasions to keep them informed of the progress of the Mbale network, so they are keen to see if this model of cooperation and integrated primary care can be rolled out across Uganda. Scaling up to a larger number of districts will ultimately be carried out by the Ugandan Government.
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