From cost of treatment to lack of medicines, the barriers to accessing life-saving health care in rural Tanzania are well known. To help address these issues, the Government of Tanzania introduced a cadre of community health volunteers (CHVs) to provide essential health-care services in rural districts. Yet once trained, many CHVs lack the support they need to carry out their work, especially in remote areas; and referral systems from villages to health facilities are often inadequate, while emergency transport is scarce and costly. In response, the Health and Insurance Management Services Organization (HIMSO) has built on work initiated by its partner, the International Centre for Development and Research (CIDR) to improve health emergency transport and referrals between villages and health facilities. The project aims at improving emergency transport system (ETS) outreach, performance, reliability and sustainability in three districts in Mbeya Region and one district in Songwe Region.
The project is applying four innovations to the ETS spanning technology, product development, institutional management, and financial modelling:
Technological innovation: CHVs are trained to manage emergency cases by providing first aid, transmitting information to the ETS, and facilitating the referral of patients at the village level. The ETS Closed Users Group (CUG) enables CHVs to link to an information communication and emergency platform (ICEP) to alert a health facility (such as a dispensary or health centre). The health facility will then follow up on the case, determine the health services available, and facilitate the request and dispatch of emergency transport from the Community Health Fund Users Association (CHFuA), as well as real-time monitoring and follow-up – all via mobile phone.
Product innovation: The project employs private transporters to drive patients to the nearest health facility. It also markets the ETS product to non-CHFuA members and promotes village coverage so that pregnant women can access both transport and health facilities through financial contributions paid for by the villages.
Institutional management innovation: The project is piloting a public–private partnership coordinated by the CHFuA to help run and manage public ambulances.
Financial modelling innovation: The project has developed a co-financing model that leverages both district and private funding to run private and public ambulances.
To date, specific achievements include:
- 192 CHVs have been trained on first aid, the identification of health danger signs, and the evacuation process for emergency cases;
- The Closed Users Group has connected 147 CHVs, 63 health facility staff, four ambulance drivers, and three CHFuA coordinators;
- 203 private transport providers have been contracted to provide referral services;
- Four CHFuAs have been formed and registered at each district level to co-manage the public ambulances and memorandum of understandings have been signed for the co-management of the ETS;
- 1,031 patients have been transported from the village to nearby health facilities in an emergency, including 885 pregnant mothers and 36 newborn babies.
Draw from best practice: The ICEP for premium and claim handling was very ambitious. It was developed from scratch and took a long time. HIMSO may have benefited from examining what did and didn’t work for other tried and tested models and applying the lessons learned to its own innovation.
Transport needs to be appropriate to the patient: Some forms of transport are not always suitable for patients; for example, the rough terrain makes the use of motorbikes not ideal for heavily pregnant women. HIMSO has attempted to address this issue by (i) continuing to encourage women to go to health facilities in their early, rather than later, stages of labour; (ii) exploring how other forms of transport such as three-wheelers and pedicabs can be used to provide safer forms of transport; and (iii) identifying a car to use for serious cases where the use of motorbikes can risk patient safety.
Gender equity and social inclusion
As a consequence of some women feeling uncomfortable in disclosing their pregnancy to men, male CHVs are often informed by nurses within the health facility if pregnant women in the area are in need of their support. The project also found that because of safety concerns, women CHVs found it harder to conduct night transfers of emergency cases than their male counterparts.
Principles for digital development
Be data driven: The project developed the ICEP to monitor the time taken to transfer a patient from a village to a health facility and analyse how effective or efficient the process was, so it can be adapted accordingly.
Design with the user: The ETS Closed Users Group was initially based on text alerts; however, user feedback suggested that the CHVs preferred to call. In response, HIMSO introduced a claim form called a guarantee letter, which the CHVs use to record the time of an evacuation. The same form is used by the private transporters to record the distance covered and time taken for each transfer undertaken. The information is then used to calculate the cost-effectiveness and efficiency of the ETS model, as well as kilometres travelled, to work out suitable payments to private transporters.
HIMSO is working towards developing an economic model for scaling up its ETS approach beyond HDIF’s support. Accurate pricing will play a significant part in the sustainability of the approach as it will enable HIMSO to (i) collect premiums as per the risk taken; (ii) manage the ETS according to insurance principles; (iii) be in a better position to register the ETS as a micro insurance product with the Tanzania Insurance Regulatory Authority (TIRA); and (iv) better negotiate with potential partners using evidence on potential performance and risk.