Linking Rural Communities with Health Services: Assessing the Effectiveness of the Ambulance Services in Meeting the Needs of Rural Communities in West Africa

Linking Rural Communities with Health Services: Assessing the Effectiveness of the Ambulance Services in Meeting the Needs of Rural Communities in West Africa Final Report Prepared for the Africa Community Access Programme (AFCAP) By Transaid 15th April, 2013 This project was funded by the Africa Abstract: Community Access Programme (AFCAP) It is increasingly accepted in our understanding which promotes safe and sustainable of maternal healthcare in Africa that poor access to markets, healthcare, education, physical access is reducing the effectiveness of employment and social and political measures to reduce maternal mortality. This networks for rural communities in Africa. project developed an evaluation framework that combined transport measures with health condition assessment methods of the Vital Signs approach and the Glasgow Coma Score to Launched in June 2008 and managed by assess differences in patient condition when Crown Agents, the five year-long, UK being referred from local health centres to government (DFID) funded project, higher-level referral facilities. Surveys were supports research and knowledge sharing undertaken of 704 women from 40 between participating countries to communities across Katsina State, Northern enhance the uptake of low cost, proven Nigeria. It was found that whilst the majority solutions for rural access that maximise took 1-2 hours between being referred and the use of local resources. arriving at the referral facility many took up-to 7 hours. Whilst using the Glasgow Coma Score, the study found no statistical relationship between health condition and how a patient The programme is currently active in arrived at the referral facility or how long it Ethiopia, Kenya, Ghana, Malawi, took to arrive. However, using the Vital Signs Mozambique, Tanzania, Zambia, South approach, statistical associations were found Africa, Democratic Republic of Congo and between a number of vital signs and how South Sudan and is developing women arrived at the referral facility and how relationships with a number of other long it took to be referred. As a result, countries and regional organisations across improvements to how women travel to referral Africa. facility and the time referral takes can have positive impacts on the severity of patients This material has been funded by UKaid managed by referral facilities. Efforts by a range from the Department for International of countries across West Africa to establish Development, however the views widespread ambulance provision may be expressed do not necessarily reflect the effective in contributing to reducing maternal mortality. This study shows they may have a department’s or the managing agent’s positive impact on the skills, resources and official policies. equipment emergency obstetric care facilities needed to reduce maternal mortality. For further information visit https://www.afcap.org 2 | P a g e Table of Contents Executive Summary 1. Introduction 1.1. Problem description 1.2. Study Background 1.3. Differences from initial proposal 2. Literature Review 2.1. Causes of maternal mortality 2.2. Causes of neonatal mortality 2.3. Causes of maternal morbidity, especially fistula 2.4. Effectiveness of referral interventions 2.5. Effectiveness of transport solutions 2.6. Conclusions 3. Methodology 3.1. Study Area Description and Communities located 3.2. Survey Instrument design process 3.3. Data collection process 4. Data Analysis 4.1. Data cleaning, verification and analysis process 4.2. Descriptive statistics for each LGA and referral hospital surveyed 4.2.1. Descriptive statistics on access to referral facility 4.2.2. Descriptive statistics on patient condition on referral 4.3. Relationship between access and patient condition 5. Guidelines for Good Practice for the development and sustainable operation of African Ambulance Services tackling health MDGs in rural areas. 6. Dissemination Activities 7. Conclusion and future research needs 8. References APPENDIX 1 – Data Collection Protocol APPENDIX 2 - Bibliography of Impacts and Evaluation Methods APPENDIX 3 – Data analysis output APPENDIX 4 – CHEWs Trained APPENDIX 5 – Guidelines for the development and sustainable operation of Ambulance Services in Africa serving rural areas to tackle the health MDGs (separate document) 3 | P a g e Executive Summary It is clear from the limited, but growing, amount of academic literature that poor physical access is acknowledged as a significant factor in the limited number of women giving birth in health facilities in sub-Saharan Africa and in the significant number of rural women who die when giving birth through medical complications. In June 2011, the Africa Community Access Programme commissioned Transaid and its partners to undertake a study into the impact on maternal health of poor community access in West Africa. The study was commissioned to develop an evaluation framework to understand better the interaction between physical access and health outcomes. It was also designed to explore solutions that can be implemented to address physical access to maternal healthcare around National Ambulance Services and to develop knowledge tools to promote the sustainable management and scale up of such solutions. The study developed an evaluation framework that looked at the time taken in being referred from local health centres to higher level facilities and how women travelled when accessing the different levels of health care. It also looked at the health condition of women being referred along this ‘chain’ at the local health centre upon referral and at the referral facility upon arrival. It utilised two methods to assess patient condition, the Vital Signs approach and the Glasgow Coma Score. It also gathered information on the socio-economic background of the women surveyed and the previous medical and gynaecological experience. The study undertook fieldwork in Katsina State in Northern Nigeria. Women from 10 rural communities in each of 4 Local Government Areas who were referred with medical complications in childbirth were surveyed between February and March 2013. In total 704 women were surveyed. The study found that amongst the women surveyed for this study, there was on average a 1-2 hour gap between being referred by a health worker and reaching the appropriate referral facility. However, a significant number of women took between 4 and 7 hours to reach appropriate care. The majority of women reached their referral facility by motor vehicle or motorbike. Ambulance and the Emergency Transport Scheme contributed just over 10 per cent of referrals transferred. Travel on foot was a significant proportion of access to local health facilities but in accessing higher-level referral facilities it made up a small but, none the less, worrying level. The health condition of the women surveyed depended largely on how they were assessed. If the assessment used the Glasgow Coma Score, the women surveyed in this study largely arrived at referral facilities in good condition regardless of how they travelled or how long it took to be referred. However, using another valid medical assessment method, Vital Signs approach, over 43 per cent were assessed not to have normal vital signs or vital signs that are associated with being in a medically weak condition. The lack of an association of the experience of being referred with the Glasgow Coma Score might be because the Glasgow Coma Score is an aggregate score and not the direct health measurements as seen by practitioners, more readily represented by the Vital Signs approach. 4 | P a g e However, there was a significant relationship found between how long women took to arrive at the referral facility and their respiration, blood pressure and urine vital signs. There was also a significant relationship between the means of transport to the referral facility and their vital signs for respiration, neurological state, pulse, urine and temperature. Finally, there was a significant relationship between the means of transport to the initial health centre and their vital signs for neurological condition, blood pressure, pulse, urine and temperature. The project has shown that improving the means of access to referral facility may have a positive impact on the health condition of women in childbirth. The project draws upon the increasing experience being gathered across Africa in developing and managing national systems of Ambulance provision. To promote this transport solutions and its sustainable management, the project has developed a good-practice guide for the sustainable management of National Ambulance Services. The project has also set in place dissemination practices in order to translate this best –practice knowledge into use within professionals across West Africa and across the region. The project has shown that poor physical access does contribute to poor health condition of women when they arrive at the appropriate level of care to be treated in case of a maternal medical emergency. This worsened condition will require greater skill, more equipment and drugs and increased capability of the health system than would otherwise be the case when access is good. How women get to referral facilities does make a difference and so investment in ambulance provision, communications systems and community-based emergency response will make a difference to health outcomes for women giving birth and their new-born and the health systems that seek to deliver that outcome. 5 | P a g e 1. Introduction 1.1. Problem description Meeting the

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