Over the past couple of decades, a number of donors and charities have poured talent and treasure into programs to prevent and treat the diseases of poverty. Yet many people, especially in the remote reaches of Africa, can’t access those life-saving interventions. They are, unfortunately, separated from the laboratories, clinics and hospitals that offer such services by rugged terrain, not to mention the loss of a day’s labor and wages in the commute. Whatever measures developing countries have taken to address this disconnect—public transport, outreach, mobile care—are often compromised by poor infrastructure. Roads in the back country are often unusable or nonexistent, and the vehicles that ply them frequently break down and lie idle for want of spare parts and qualified mechanics.

Health systems, in other words, are only as good as the links between their facilities and the patients they are meant to serve. Riders for Health seeks to forge those links. Since launching its first nation-wide program in 1991 to connect public health service personnel to isolated settlements in Lesotho, the UK-based nongovernmental organization (NGO) has refined a health care transportation and fleet management system tailored to rough terrain that has improved access to health services for 12 million people in eight African nations. Vehicles, such as ambulances and, most of all, motorcycles managed by Rider’s staff carry patients and health care workers engaged in everything from malaria prevention to disease surveillance to the remotest reaches of the continent.

Aware of Riders’ capabilities, the Clinton Health Access Initiative (CHAI) approached Riders for help in 2008. CHAI was working with Lesotho’s Ministry of Health and Social Welfare to decentralize HIV treatment. Because HIV treatment requires sophisticated blood analysis—CD4+ T cell counts—they were interested in developing a transport system for the reliable delivery of samples and laboratory reports to and from rural areas.

A sample transport (ST) courier in Chadiza district collecting patient medical samples at a health center and packing them into a specially designed ST backpack. Photo: Riders for Health/Tom Oldham

“Having a system that links all levels of the health care hierarchy,” says Trevor Peter, Ph.D., Scientific Director of CHAI’s Laboratory Services Team in Gabarone, Botswana, “is essential to equity, to ensuring that everyone gets the same service.” In response, Riders created a specialized Sample Transport (ST) system for that purpose. By the end of 2009, Riders had expanded the ST system across Lesotho, and had already begun looking for other places to replicate the model.

It found a receptive audience in Zambia’s Ministry of Health (MoH) and in November, 2009, Riders launched—in partnership with the MoH and the Center for Infectious Disease Research in Zambia (CIDRZ)—a pilot ST program in Chadiza district of Eastern Province. Supported by a US$500,000 grant from the Adolf H. Lundin Charitable Foundation, the program focused on the transport of sputum, for TB analysis, and blood for HIV monitoring.

The Chadiza ST System

Chadiza district has 19 health centers that together serve roughly 8,500 patients every day.  Most of the health centers are rural facilities. The district also has one new hospital and three rudimentary laboratories linked to the mid-level, zonal health centers. Most of the diagnostic testing, however, is done at the main lab in Chadiza, though some sophisticated tests are referred to regional or national labs. The Riders’ program, which employs ten people, all Zambian and all trained to Riders specifications, serves 17 of 19 health centers. Its staff members manage, monitor and operate the ST system under the general direction of the provincial MoH.

A sample transport courier in Chadiza district meets the lab technician and lab assistant at the district lab and drops off patient medical samples he picked up that day. Photo: Riders for Health/Tom Oldham

Riders has fine-tuned an operational model—Transport Resource Management—to help service delivery vehicles survive the beatings meted out by the cruelest of African terrains. At its core is a stress on operator preparation and preventive vehicular maintenance. Couriers—in this case, motorcyclists—are professionally trained to ride in a manner that ensures their own safety, as well as that of the motorcycle and the precious samples they carry. They are also required to check their bikes every day in a sequence called PLANS, for petrol, lubricants, adjustments, nuts and bolts, and stop (brakes and tires), to nip potential disasters in the bud.

Finally, each month, a local technician employed by Riders and trained to its exacting standards gives each bike a thorough servicing where it is located. That not only ensures its flawless operation but saves time that would otherwise be spent ferrying the bike to and from a garage at some central location.

“Without these components,” says Kameko Nichols, Partnership Director at Riders, “vehicles will break down in three to six months in these rural areas—and we’ve seen it happen within a week.” The importance of avoiding that can’t be overstated. “When you have a system for sample transport, it needs to be up and running all the time,” says Nichols. “It’s very important that you don’t miss even a single day of scheduled services because the day you’re not there, and the samples spoil, it’s very likely that you’ll lose those patients [to follow up]. If they return two weeks later looking for their results and learn they have to provide samples again, it’s very likely they’ll lose confidence in the health system.”

Thus, Riders worked closely with the MoH to recruit couriers and train them. The requirements weren’t stringent. Candidates had to have a basic education, so that they would be able to contribute to data collection and log entries at laboratories. That didn’t pose any problems, says Mr. Lackson Daka, Ministry of Health Clinical Care Officer in Chadiza district, because there’s no shortage of Zambians with secondary school education, and much unemployment.

Consultations with local leaders quickly established that the communities in Chadiza would prefer to have local staff employed in that role—which was in line with Riders’ policies of stressing local employment. “This is also valuable because local people know the environment in which they are operating very well,” says Daka. “They know the customs and values of the people here. Someone coming from far away would take some time to learn these things.”

Net Effects

Riders’ and the MoH’s efforts have not been in vain. Before the program started, on average, roughly 64 percent of the health facilities served by Riders’ couriers sent samples to the central lab in Chadiza every week. Two of them managed to do so every couple of weeks, and one outlier sent them in only once a month. All of them dealt constantly with transport problems and personnel shortages related to this task. The health care workers would often have to take the time to grab whatever transportation was available and ferry the samples to the lab themselves, picking up the reports on their next visit.

A sample transport courier in Chadiza district travels to a rural health center to pick up patient medical samples and drop off results. Photo: Riders for Health/Tom Oldham

One, who worked in a facility with only one other care provider, would ride his bicycle four hours each way over dirt roads to deliver samples and return with reports. Today, samples are delivered like clockwork at least once every week, and sometimes more often. “Workers no longer have to go to the laboratory to deliver specimens or collect the results,” says Daka, “so they now have more time to see their patients.”

The turnaround time has improved as well. “Since we started working with Riders,” recalls Dr. Kennedy Malama, Ministry of Health Provincial Medical Officer for Eastern Province, “we have cut the time taken for results to reach the health facilities in this particular district from two weeks to ten days or less.” This is important because delays in report delivery delay the initiation of treatment—which isn’t just bad for the patients. It also puts their families and communities at risk if they happen to have communicable diseases, such as TB.

“We have also noticed,” says Malama, “that the quality of the specimens coming to the lab has improved. The rate of specimen rejection has been reduced.” Prior to Riders’ intervention, a large number of samples were routinely rejected by lab personnel because they had deteriorated so much that they were unusable. This was largely due to the mishandling of samples, which were often exposed to light, vibration and heat on their perilous journey from health center to laboratory. They were sometimes even bundled into plastic bags and carried in ordinary backpacks. This often meant that patients who had taken the time and trouble to appear at the clinic and returned weeks later for their diagnoses would be forced to provide blood and sputum samples again.

The Riders couriers are not only trained in appropriate sample handling but equipped with motorcycle top-boxes and specially designed backpack carriers as well. This has reduced the sample rejection rate significantly. Taken together, the changes instituted by the ST system have contributed to a 150 percent increase in the delivery of samples and results, and a 254 percent growth in laboratory testing volumes. The uptick in the numbers may have something to do with better monitoring and data collection, but the health centers have no doubt that more patients are now appearing for essential tests.

Further, the increased reliability of sample and report delivery has meant that the health centers can now arrange follow-up appointments and patients turn up because they have reason to believe the visit will be worth the time. Health center personnel say there has been a 14 percent increase in patient attendance, and attribute the growth to greater confidence in the district’s health system due to the direct and indirect effects of the ST program.

Sustaining the Gains

There are, of course, limits to the ST system’s reach. For one thing, its impact is modulated by the quality of the laboratories and health centers it serves. Though the MoH has taken significant measures to improve services at both types of facilities, they simply lack sufficient resources. Some tests, such as dry blood spot analysis for early infant diagnosis of HIV, can’t be done in the province. The nearest instrumentation for this test is only available at CIDRZ’s facility in the capital city, Lusaka, and has to be sent there by courier mail. Both the laboratories and health centers also have to cope with frequent shortages of reagents and consumables, and instruments are often in serious need of maintenance or repair.

This has been compounded by the growth in patient and laboratory volumes. “That can put a lot of pressure on the lab,” says Constance Chibiliti, Program Manager at Riders in Zambia. “It may not be performing to capacity because it doesn’t have the required machinery, or the machinery might have broken down. That does affect our turnaround time. What we’ve tried to do at Riders for Health is identify some of the primary health facilities that can run samples, so as not to overwhelm the main hub.” In particular, approached by Riders, the MoH has trained some of the technicians in zonal health centers to run some samples, she says, reducing the pressure on the main laboratory to a degree. It has also reinforced the microscopy skills of some of the technicians to speed sample processing.

But other, structural problems remain. For one, a shortage of qualified medical services personnel seems intractable. “We can move the samples from the health center to the central laboratory,” says Malama, “but the fact that we do not have an adequate number of staff to process all the samples that are brought in can lower the impact of that effort.”

The reluctance of skilled technicians to work in remote areas, far from the urban centers of Zambia, has only compounded this problem. Riders has done what it can to help. Its trained couriers, for example, help with data entry at the laboratories and have improved log-keeping. That has allowed laboratory personnel to focus more on the tests.

More subtly, the growth in sample volume and better monitoring of such changes allows the provincial MoH to advocate for more resources. And it has, in fact, obtained funding to hire some people and obtain new instrumentation by demonstrating its efficiencies and quantifying the need. “When you get one part of the health system working,” observes Nichols, “you can start targeting other aspects that aren’t working as well. We’ve really seen the lab system improve significantly since we started.” Again, however, much work lies ahead in building the professional capacity of laboratories.

The bigger question, perhaps, regards the sustainability of the ST system. Riders has already expanded to another province, but donors are still picking up the tab and likely to be doing so for some time. “All partners move on eventually,” observes Peter, “and this can’t be something that exists for a few years and then disappears.” If that happens, the gains of public confidence in the health system would quickly be reversed.

Yet, as Malama observes, the MoH just doesn’t have the resources to fund an expanded transportation system for the rest of Eastern province, let alone all the other 70 districts in the country. The government has been increasing allocations to the MoH, he says, so he’s optimistic about the system’s long-term prospects. But first, more partners and funding will be needed if other provinces seek to replicate Chadiza’s successes.

By Unmesh Kher