TECHNICAL BRIEF: ADDRESSING TRANSPORT BARRIERS TO
MATERNAL AND CHILD HEALTH CARE SERVICES
The objective of this technical brief is to assist Department of Health (DoH) officials at national,
provincial and district levels to conceptualise, plan and budget for ways to redress the critical
problem of transport as a barrier to accessing maternal and child health services in South Africa. While
DoH policies outline responsibility for transport for referred patients between primary, secondary and
tertiary centres, there is no clear indication of responsibility for patients accessing primary health care
centres. It is suggested that DoH work together with the Department of Transport and the Department
of Rural Development on strategies to address transport issues (Rural Health Advocacy Project, 2013).
Based on a literature review of low income settings, this technical brief provides a menu of possible
direct and indirect, as well as short and long term interventions. It points out strengths and drawbacks
that decision-makers need to take into account, and provides a reference list where more information
can be found.
The World Health Organization (WHO) estimates that every day, approximately 800 women die from
preventable causes related to pregnancy and childbirth. In South Africa, statistics show that there
were 1,500 maternal deaths in 2013 (WHO, 2014). It is only by identifying and addressing the major
causes of maternal and child mortality, that action can be taken to improve maternal and child health,
and therefore achieve Millennium Development Goal 5, reducing maternal mortality.
It is estimated that 75% of maternal deaths could be prevented through timely access to essential
childbirth-related care (Babinard and Roberts, 2006). Three major delays have been identified as
contributing to a high incidence of maternal mortality; these include a delay in reaching a health
facility for treatment, delay in receiving treatment and delay in deciding to seek care. Among these
three, a lack of transport and emergency ambulance services can further exacerbate any emergency,
especially in cases of complicated pregnancies (UNFPA, 2011). Transport services affect access to both
preventative and emergency childbirth care, playing a key role in the survival of women and their
newborns, as complications in birth may rapidly become life-threatening.
In low income countries, particularly rural areas, considerable time is spent by women and their
families in waiting for transportation and travelling to health facilities. Adding to this is poor roads,
too few vehicles and high transportation costs, all of which are major causes of delay in decisions to
seek and reach emergency obstetric and postnatal care (Babinard and Roberts, 2006).
In South Africa there is limited access to clinics and health care services for those living in outlying
areas, where there are neither government health services nor regular mobile clinics. Long travel
distances and high travel costs have been identified as barriers to South Africans accessing healthcare
(Harris et al., 2011). With this in mind, it is crucial to address these transport barriers by implementing
approaches that will help South Africans, in particular women, to access maternal health care services.
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It should be noted that barriers to transport are diverse and complex, with some being more systemic
than others. Transport barriers can be tackled directly by providing transport to the poor and
marginalised or indirectly by providing mobile clinics or waiting homes; and interventions can be short
or long term. With this in mind, three approaches to enable women to access healthcare services have
been identified, these include: public/private partnerships and transportation programmes;
specialised health transport (i.e., ambulances); and transport funds or transport vouchers.
The main benefit of all three approaches is that they have shown to reduce maternal and infant
mortality by enabling women to better access health facilities in a timely manner, especially in an
emergency. Furthermore, these approaches help create partnerships, as well as build capacity and
community awareness about maternal health issues. On the other hand, these approaches require
commitment from various stakeholders, capacity building for drivers and funding associated with high
running costs.
1. PUBLIC/PRIVATE PARTNERSHIPS AND TRANSPORTATION PROGRAMMES
Public/private partnerships and transportation programmes aim to improve the availability of
emergency transport and therefore address barriers to access. These programmes focus on training
and encouraging local taxi drivers to transport women to health centres, so that they can access the
required healthcare services. Examples have been identified in Ghana (UNFPA, 2011) and in Nigeria
(Transaid, 2009). These programmes have proven to be highly effective in low resource and
developing countries with low uptake of healthcare services (Theophilus, 2013).
Public/private partnerships and transportation programmes are examples of ways to improve the
availability of emergency transport for women needing to access health facilities. These programmes
build partnership and capacity among taxi drivers, but if not well publicised and monitored they can
have little impact in getting women to health facilities.
Taking this into consideration, the following issues should be considered when implementing such
programmes:

Accountability, commitment and supervision: Transportation programmes that use voucher
systems and schemes should be protected, monitored and reinforced because they serve as
an accountability tool for tracking referrals and benefits for drivers (UNFPA, 2011). All
committees involved in the set-up of such initiatives or partnerships need to continue
reinforcing their commitment, and orient new stakeholders and staff on the benefits of such
programmes (UNFPA, 2011). Also, effective supervision should be set up to ensure that drivers
are providing a quality service (Theophilus, 2013).

Indicators: Transportation programmes need to determine clear and attributable indicators
to better support the effectiveness and impact of the initiative (UNFPA, 2011).

Training: Health facility staff members need to be continually trained and sensitised on how
to prioritise taxi drivers, how to consistently provide vouchers and how to positively interact
with taxi drivers (UNFPA, 2011). Taxi drivers need to be trained on basic first aid response,
how to handle expectant mothers and emergency child birth, safe driving practices, etc. In
order to reduce costs, training using peer groups should be implemented (Theophilus, 2013).

Partnering with government: Public-private partnerships should be set up with government
(i.e., Department of Transport and the Department of Health), as this will improve healthcare
utilisation and increase uptake of healthcare services (Theophilus, 2013).
2. SPECIALISED HEALTH TRANSPORT (AMBULANCES)
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Specialised health transport, such as ambulances are various forms of locally appropriate transport.
In Somalia donkey cart ambulances are the most effective way of transporting women to the
nearest health facility (CARMMA, 2013), while in Zambia bicycle ambulances (Health Partners
International, 2013), in Malawi motorcycle ambulances (Hofman et al., 2008) and in South Africa
car ambulances (Schoon, 2013) have also proven to be very effective. These forms of transport are
designed to help women in isolated areas who have poor access to health services or who are unable
to afford transport services to reach their nearest health facility to obtain maternal health services.
There are many benefits of having specialised health transport available to assist women in an
emergency to access health facilities without delay. However, these forms of transport are also costly
and appropriate training is required for the drivers, in order to ensure that women are able to reach
the health facility safely.
In order to ensure that specialised health transport is successfully implement the following needs to
be considered:

Training: It is essential that there is adequate operator training, safety training, management
training and maintenance training prior to the introduction of any of the various modes of
specialised health transport (Transaid, 2010).

Affordability: In resource-poor countries motorcycle ambulances at rural health centres are a
useful means of referral for emergency obstetric care, and a relatively cheap option for the
health sector (Hofman et al., 2008).

Dedicated vehicles for maternity transfers: Health authorities should prioritise inter-hospital
transport vehicles within their budgets to ensure access of the pregnant population to
appropriate care and where feasible, to assign dedicated vehicles to maternity transfers
(Schoon, 2013).
3. TRANSPORT FUND OR TRANSPORT VOUCHER
A Transport Fund or Transport Voucher is a scheme where women are given financial support (cash
or a voucher) to assist them with transport to the nearest health facility in order to receive maternal
healthcare services. In many instances this allows them to use local transport to and from the health
facility for antenatal, delivery and postnatal care. Several initiatives have been implemented in
Bangladesh (Laurel et al., 2010; Ahmed & Khan, 2011), India (De Costa, et al., 2009), Nepal (UNICEF,
2013), Sierra Leone (Amnesty International, 2009), Uganda (Pariyo et al., 2011) and South Africa
(Durden, 2014).
Implementing a transport fund or transport voucher scheme has shown to have increased community
awareness about maternal health and provide economic benefits to transport providers, along with
increasing women’s to access health facilities. However, these schemes are dependent on external
funding and are a short-term measure to assist poor women, and not a solution to maternal mortality
in low-income settings.
In order to ensure sustainability of a transport fund or transport voucher programme, the following
suggestions are made:

Capacity and Cost: Two important things to consider in setting up an initiative such as a
transport fund or transport voucher is the capacity to run the scheme and the cost of running
the scheme. Proper running of the scheme requires that there is a clear system for paying the
providers, this payment needs to be done regularly and frequently (Pariyo et al., 2011).
TECHNICAL BRIEF: TRANSPORT FUND
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
Community Mobilisation Fund: Because government may have difficulties in meeting the
financial requirements and donors get fatigued over time, there is a need to mobilise the
community to contribute to the running of such a programme. One option could include the
creation of community mobilisation fund perhaps through community insurance schemes.
Families could then be encouraged to make periodic contributions that would cater for the
transport needs of the mother and the newborn. This insurance scheme would then liaise with
local transport providers and discuss pricing and service arrangements (Pariyo et al., 2011).

Partnership: Implementing a transport fund or transport voucher in collaboration with the
district heath team, organising regular meetings with stakeholders at district level to discuss
implementation and how to address challenges, and discussing new ways to sustain the fund
can also be beneficial (Pariyo et al., 2011).

Community involvement: Those identifying people in need must be embedded in the
community and have a clear idea of the context and the community needs (Durden, 2014)

Fund management: There should be direct, hands-on management of the fund, anti-fraud
measures must be put in place, strong support and follow-up processes for clients must be
instituted, and good record-keeping and data gathering processes should be adhered to
(Durden, 2014).

Short-term assistance: The fund should be seen as once-off or short-term assistance for
people in need, until more sustainable support from government services can be secured
(Durden, 2014).
ALTERNATIVES TO TRANSPORT PROGRAMMES

Mobile clinics: Enabling more mobile clinics to travel to outlying areas can be useful in
addressing some of the transport barriers faced by women (Durden, 2014).

Building clinics: Building more clinics to service areas where there are large spread-out
populations can be beneficial (Durden, 2014).

Maternity waiting homes: If the number of emergency vehicles cannot be increased
nationally, then other interventions, such as the establishment of maternity waiting homes,
should continue (Schoon, 2013; Durden, 2014).

Work-site clinics: Encouraging and supporting employers hosting work-site clinics (Durden,
2014).

Free government-funded modes of transport: Improving free government-funded modes of
transport to government services, and enhancing the availability of ambulances (Durden,
2014).

Job creation and income-generating opportunities: Creating jobs and income-generating
opportunities, so that women are able to earn money so they can afford public transport
themselves (Durden, 2014).
Taking into account the consideration the above mentioned experiences and considerations has the
potential to provide greater access to women over the longer-term to healthcare services. Without
either short or long term measures to improve access to maternal and child health, health risks to
women who are pregnant or caring for babies will increase. The effects on women with HIV are
exacerbated as they are at greater risk of falling ill or dying due to late treatment, and have the
potential to pass on the virus to their unborn child. This in turn impacts on the health of their children
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and the wider community. Investing in improved access to healthcare at this earlier stage by
addressing barriers to transport also has the potential to reduce the overall financial and human
resource burden on the South Africa health system.
REFERENCES
Ahmed, S. and Khan, M. 2011. “A maternal health voucher scheme: what have we learned from the
demand-side financing scheme in Bangladesh?” Health Policy and Planning 26: 25-32.
Amnesty International. 2009. “Out of Reach: The cost of maternal health in Sierra Leone.” Retrieved
September 8, 2014, from http://www.amnestyusa.org/sites/default/files/pdfs/outofreach.pdf.
Babinard, Julie and Roberts, Peter. 2006. “Maternal and Child Mortality Development Goals: What
Can the Transport Sector Do?” Retrieved September 8, 2014, from
https://www.ssatp.org/sites/ssatp/files/pdfs/Topics/gender/tp12_maternal_health%5b1%5d.pdf.
CARMMA. 2013. “Has Somalia’s Health System found a Breakthrough to Address High Maternal
Mortality Rates using the Somali Donkey?” Retrieved September 11, 2014, from
http://www.carmma.org/fr/update/has-somalia%E2%80%99s-health-system-found-breakthroughaddress-high-maternal-mortality-rates-using.
De Costa, A., Patil, R., Kushwah, S. S., and Diwan, V. K. 2009. “Financial incentives to influence maternal
mortality in a low-income setting: making available ‘money to transport’ – experiences from
Amarpatan, India. Global Health Action DOI:10.3402/gha.v2i0.1866.
Durden, E. 2014. “A Narrative Report on the KZN Red Cross Transport Fund”. Durban, South Africa.
Health Partners International (HPI). 2013. Linking communities to maternal health care via an
Emergency Transport System. Retrieved September 12, 2014, from http://www.healthpartnersint.co.uk/our_projects/documents/MAMaZPolicyBrief-ETS_000.pdf.
Hofman, J., Dzimadzi, C., Lungu, K., Ratsma, E. and Hussein, J. 2008. “Motorcycle ambulances for
referral of obstetric emergencies in rural Malawi: Do they reduce delay and what do they cost?”
International Journal of Gynecology and Obstetrics 102: 191-197.
Laurel, H., Nguyen, H., Sloan, N., Miner, S., Magvanjav, O. et al. 2010. “Economic Evaluation of
Demand-Side Financing (DSF) for Maternal Health in Bangladesh.” Retrieved September 9, 2014,
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Pariyo, G., Mayora, C., Okui, O., Ssengooba, F., Peters, D. et al. 2011. “Exploring new health markets:
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Theophilus, I. 2013. “Promoting Emergency Transport Scheme in Safe Delivery Service: A case study
of Gombe State, Nigeria.” PPT presentation presented at the 2013 Global Maternal Health
Conference: Improving Quality of Care, Arusha, Tanzania.
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20Nigeria%20ETS.pdf.
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Collaboration with Ghana Private Roads and Transport Unions (GPRTU).” Retrieved September 10,
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