ADDRESSING
TRANSPORT
BARRIERS:
APPROACHES TO
ACCESSING
MATERNAL AND
CHILD HEALTH
SERVICES
A Secondary
Literature Review
Josianne Roma-Reardon
CONTENTS
ACKNOWLEDGEMENTS ........................................................................................................................ 3
INTRODUCTION .................................................................................................................................... 4
ADDRESSING TRANSPORT BARRIERS: APPROACHES ........................................................................... 4
ADDRESSING TRANSPORT BARRIERS: STRENGTHS AND WEAKNESSES ............................................... 8
RECOMMENDATIONS......................................................................................................................... 10
REFERENCES ....................................................................................................................................... 11
ANNEXURE ......................................................................................................................................... 13
ABBREVIATIONS
CARMMA
Campaign on Accelerated Reduction of Maternal, Newborn and Child Mortality in Africa
DSF
Demand-Side Financing Program
EOC
Emergency Obstetric Care
ETS
Emergency Transport Scheme
EU
European Union
GPRTU
Ghana Private Roads and Transport Unions
HPI
Health Partners International
HSA
Health Surveillance Assistant
MAMaZ
Mobilising Access to Maternal Health Services in Zambia
MDG
Millennium Development Goal
NDoH
South African National Department of Health
NGO
nongovernmental organisation
NURTW
National Union of Road Transport Workers
RCH
Reproductive and Child Health
RMCH
Strengthening Primary Health Care in South Africa Programme
SFH
Society for Family Health
UNICEF
United Nations Children’s Fund
UNFPA
United Nations Population Fund
USD
United States Dollar
WHO
World Health Organization
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 2
ACKNOWLEDGEMENTS
This report has been developed in support of the Reducing Maternal and Child Mortality through
Strengthening Primary Health Care in South Africa Programme (RMCH). The RMCH programme is
implemented by GRM Futures Group in partnership with Health Systems Trust, Save the Children South Africa
and Social Development Direct, with funding from the UK Government. RMCH is committed to helping reduce
the high number of avoidable maternal and child deaths in South Africa by strengthening the primary health
care system. The programme provides technical assistance to the South African National Department of
Health (NDoH) and the Districts to improve the quality of, and access to, reproductive, maternal and child
health services for women and children living in poorer, underserved areas in South Africa.
Disclaimer
This material has been published by the RMCH Programme with funding from UK aid from the UK
Government. The views expressed do not necessarily reflect the UK Government’s official policies. All
reasonable precautions have been taken to verify the information contained in this publication.
RMCH Programme
GRM International | Futures Group Europe
2nd Floor
Turnberry House
100 Bunhill Row
London, EC1Y 8ND
United Kingdom
Website: www.rmchsa.org; www.futuresgroup.com
South African Red Cross Society
221 Festival Street
Hatfield
Pretoria
0699
South Africa
SARCS KwaZulu-Natal
201 Kenneth Kaunda Road,
Durban North
4001
South Africa
Website: www.redcross.org.za
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 3
INTRODUCTION
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, as well as long queues for patients at government facilities, and an overall sense that patients
are disempowered have been identified as barriers to South Africans accessing health care (Harris et al.,
2011). With this in mind, it is crucial to address the transport barriers faced by women and implement
approaches that can help them better access maternal health care services.
It is estimated that 75% of maternal deaths could be prevented through timely access to essential childbirthrelated 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 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).
This report presents a summary of findings from a secondary literature review on approaches to address the
transport barriers that seek to enable women, particularly vulnerable ones, to access clinics and hospitals for
maternal and child care. The findings presented are based on peer reviewed academic literature and grey
literature, and the scan was not restricted to South Africa, but looked at experiences of other countries as
well, including from Africa and Asia. Three main approaches, including public/private partnerships and
transportation programmes, specialised health transport, and transport funds or transport vouchers are
described, as well as their strengths and weaknesses. The report also presents recommendations on how
best to develop approaches to address transport barriers faced by women and children in accessing maternal
and child care.
ADDRESSING TRANSPORT BARRIERS: APPROACHES
This literature draws on various development projects from across 11 countries that are implemented by
government or civil society organisations. In all instances except one, the projects rely on an external inflow
of resources from a donor or government budget to fund the transport service. The one exception is a
community based saving scheme where members mobilise resources. We also know anecdotally, that other
responses to accessing health care that deal with the transport issue exist outside of formalised development
projects (hence not documented) and involve the private sector, for example the provision of an onsite clinic
by farmers or factory owners. Furthermore, what is not covered here, as they are typically not documented,
are the community’s own responses to transport issues, including the loan and use of wheelbarrows and or
ox charts in rural Zimbabwe to transport pregnant women, and assistance with transport by neighbours and
other community members as part of organic systems of self- help and mutual assistance.
The three main approaches identified in the literature to address the transport barriers that seek to enable
women and children access to clinics and hospitals for maternal and child care, include: (1) public/private
partnerships and transportation programmes (in Ghana and Nigeria); (2) specialised health transport
including donkey cart ambulances (in Somalia), bicycle ambulances (in Zambia), motorcycle ambulances (in
Malawi), and car ambulances (in South Africa); and (3) transport funds or transport vouchers, where women
are given financial support (cash or voucher) to assist them with transport to receive maternal healthcare
services (in Bangladesh, India, Nepal, Sierra Leone and Uganda).
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 4
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
accessing facilities. 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 (i.e. Collaboration with Ghana Private Roads and Transport Unions Project) and
in Nigeria (i.e. Emergency Transport Scheme). These programmes have proven to be highly effective in low resource and developing countries with low
uptake of healthcare services (Theophilus, 2013).
Country
GHANA
Programme
Collaboration with
Ghana Private Roads
and Transport Unions
(GPRTU) Project
Funding
EU,
Government of
Ghana and
UNFPA
NIGERIA
Emergency Transport
Scheme (ETS)
Society for
Family Health
Nigeria (SFH),
Population
Services
International
and Transaid UK
Description
The project aims to improve the number of referrals of emergency obstetric
cases by incentivising taxi drivers to transport pregnant women to the closest
health facilities, which is done in collaboration with the Ghana Transport
Unions (who represent Ghana’s private taxi system). The project is based upon
a simple voucher reimbursement system where drivers provide transport in
exchange for a voucher or a fee paid by the family. Evidence of the voucher
allows drivers to access additional benefits ‘pre-determined’ by their local
transport union chapter. These benefits include drivers being given priority for
other transport jobs or skipping the queue at the taxi rank.
The project focuses on training and encouraging local taxi drivers to transport
pregnant women to health centres. This is in collaboration with members of the
National Union of Road Transport Workers (NURTW). Drivers are rewarded for
volunteering their services through a benefit known as ‘priority loading’. Once a
driver has proven that he has transported a pregnant woman (by presenting his
log book complete with the signature of a health facility in-charge) the driver is
granted permission to park his vehicle at the front of the loading queue,
potentially saving himself many hours of waiting for passengers.
Reference
UNFPA (2011)
Transaid
(2009)
2. SPECIALISED HEALTH TRANSPORT (AMBULANCES)
Specialised health transport, such as ambulances are various forms of locally appropriate transport. In some areas donkey cart ambulances (e.g. Somalia
and Kenya) are the most effective way of transporting women to the nearest health facility, while in other areas bicycle ambulances (e.g. Zambia),
motorcycle ambulances (e.g. Malawi) and car ambulances (e.g. South Africa) 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.
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 5
2.1 Donkey Cart Ambulances
Country
SOMALIA
Programme
not identified
Funding
not identified
Description
Reference
Donkey-driven carts provide rapid transport of expectant and sick mothers to CARMMA
the nearest health facility.
(2013)
Funding
UKaid
Description
The aim of the programme was to test a community engagement approach,
aimed to stimulate demand for maternal and newborn healthcare services
among poor communities living in rural areas. Locally appropriate transport was
introduced, including 123 bicycle ambulances. Riders were trained in
maintenance and usage of the vehicle, its safe-keeping, what to do in an
emergency, how to handle pregnant women, record-keeping, how to relate to
facility staff, and how to ensure that the patient receives immediate treatment.
Funding
Ranger
Production
Company and
Riders for
Health
(Zimbabwean
NGO)
Description
Reference
The objective of this study was to assess whether motorcycle ambulances placed Hofman et al.
at rural health centres are more effective than car ambulances in reducing delay (2008)
for obstetric emergencies. Three motorcycle ambulances were stationed at
three remote rural health centres. At each health centre a Health Surveillance
Assistant (HSA) was selected as the rider - HSAs are government-paid community
health workers. The three riders were trained on how to ride the motorcycle
ambulance, on simple maintenance and on data recording in logbooks.
Funding
Department of
Health – Free
State
Description
Reference
In response to organised ambulance services having been identified as integral Schoon (2013)
to the success of national programmes aimed at reducing maternal mortality,
the Free State Department of Health decided to provide 48 ambulances for interfacility transport, among which 18 were dedicated to maternity care.
2.2 Bicycle Ambulances
Country
ZAMBIA
Programme
Mobilising Access to
Maternal Health
Services in Zambia
(MAMaZ) Programme
Reference
Health
Partners
International
(HPI) (2013)
2.3 Motorcycle Ambulances
Country
MALAWI
Programme
Safe Motherhood
Project (in southern
region of Malawi)
2.4 Car Ambulances
Country
SOUTH
AFRICA
(Free
State)
Programme
Dedicated Obstetric
Inter-facility Transport
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 6
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 South Asia (in Bangladesh, India and Nepal) and in Africa
(in Sierra Leone and Uganda).
Country
BANGLADESH
Programme
Maternal Health
Voucher Scheme part
of Demand-Side
Financing (DSF)
Program
Reproductive and
Child Health (RCH)
Program – RCH II
(launched in 2005)
Funding
Government of
Bangladesh
NEPAL
The Aama Programme
Government of
Nepal
SIERRA
LEONE
Community-based
savings and loan
scheme
Communitybased
UGANDA
Informal transport
markets in facilitating
access to maternal
healthcare services
Makarere
University,
Uganda
INDIA
Government of
India
Description
Poor pregnant women receive vouchers which entitle them to free maternal
health services, transport subsidies, cash incentive for delivery with a qualified
provider (either at home or at a designated facility), and a gift box. Providers (i.e.,
health care facilities) receive incentives to distribute vouchers and to provide
services covered by the vouchers.
The project was an experiment to see if making ready funds easily available (and
accessible) for transportation in an emergency would help reduce maternal deaths
among vulnerable groups in a low, rural and high maternal mortality setting. Up to
Rupees 900 (USD $20) per emergency referral case was paid for transportation in
emergency to pregnant mothers, and up to Rupees 100 (USD $2.30) was paid to
the accompanying Emergency Obstetric Care (EOC) facilitator traveling with the
emergency referral case.
This programme provides transport incentives to women who come for
institutional delivery. The woman receives this incentive only at the time of
discharge from the health facility. The fund can be useful for pregnant woman who
have difficulties finding money for transport in an emergency.
Community-based savings and loan schemes have been set up to provide funding
for emergencies, including pregnancy-related emergencies in Koinadugu district,
Sierra Leone. Community members contribute small amounts throughout the year
for example (USD $0.16) a week – and the fund is then available for the members
to draw on for emergencies, including pregnancy-related emergencies.
Transport vouchers that facilitate women to access free transport for maternal
health services (antenatal, delivery care and postnatal), and a service voucher that
also facilitates access to these maternal health services. This package is offered to
all pregnant women resident in the study area.
Reference
Laurel et al.
(2010) /
Ahmed and
Khan (2011)
De Costa et al.
(2009)
UNICEF (2013)
Amnesty
International
(2009)
Pariyo et al.
(2011)
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 7
ADDRESSING TRANSPORT BARRIERS: STRENGTHS AND WEAKNESSES
The strengths and weaknesses of each of the three main approaches to address transport barriers are presented. Please see Annexure for strengths and
weaknesses of each individual example.
Approach
Examples
Strengths
Weaknesses
1. Public/private partnerships and transportation programmes
Aim: These
programmes focus
on training and
encouraging local
taxi drivers to
transport women to
health centres in an
emergency, so that
they can access the
required maternal
healthcare services.
Ghana (UNPFA,
2011)
Nigeria (Transaid,
2009)
 Decrease in maternal and infant mortality.
 Increase in women’s access to emergency
obstetric services and medical equipment.
 Builds partnerships between transport unions
and community.
 Builds capacity among taxi drivers as they
receive training to enable them to safely
transport women in emergency situations.
 Inspires transport unions and its workers to
feel a great sense of commitment towards
addressing maternal health issues.
 Potential to attract government support,
encouraging replication.
 If programme is not well publicised can lead to
inadequate support, lack of recognition and poor
attitude towards taxi drivers (from health facility staff
or police officers).
 Poor return of voucher to taxi drivers, preventing
them from receiving reimbursement and other
privileges.
 Insufficient or inadequate recognition of taxi driver’s
efforts.
 Poor data collection among taxi drivers with low
literacy levels.
 High costs associated to train all taxi drivers.
 Difficulty in ensuring quality due to lack of supervision
of taxi drivers.
2. Specialised health transport (ambulances)
Aim: Various forms
of locally
appropriate and
specialised
transport (i.e.,
donkey cart
ambulances, bicycle
ambulances,
motorcycle
ambulances and car
Donkey Cart
Ambulance in
Somalia (CARMMA,
2013)
Bicycle Ambulance
in Zambia (HPI,
2013)
 Decrease in maternal and infant mortality.
 Women (pregnant and newly delivered) are
able to access health facility without delay.
 Locally appropriate forms of transport
(depending on the terrain and resources).
 Low cost implications (purchase and
operating) with donkey cart, bicycle and
motorcycle ambulances.
 Transport providers (or drivers) need to be trained in
first aid response, on how to handle a pregnant
woman, on emergency child birth, etc.
 Costs associated to maintenance.
 Seasonal factors, such as the weather (i.e. rain).
 The conditions of roads.
 Breakdown and punctures.
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 8
ambulances) used to
effectively transport
women in isolated
areas to health
facilities, so that
they can access
maternal health
services.
Motorcycle
Ambulance in
Malawi (Hofman et
al., 2008)
Car Ambulances in
South Africa
(Schoon, 2013)
 When available at health facility can depart
with little delay and can reduce delay in
transferring women from rural centres to
hospitals (quick dispatch).
 Community involvement in protecting
programme from misuse.
 Community involvement in recruiting and
training riders to ensure availability of
transport, and mechanics to perform
maintenance.
 Maternity vehicles being utilised for transporting
patients other than pregnant women in need of
emergency services.
 Need for discussion between midwives and
emergency services personnel to better explain the
benefits of this form of transport (i.e. transport
strategy).
3. Transport funds or transport vouchers
Aim: Women are
given financial
support (cash or
voucher) to assist
them with transport
to the nearest clinic
or hospital in order
to receive maternal
healthcare services.
Bangladesh (Laurel  Decrease in maternal and infant mortality.
et al., 2011 and
 Increase in utilisation of maternal health
Ahmed et al., 2011)
services (antenatal, delivery, postnatal and
check-ups).
India (De Costa et
 Reduction in transport cost barrier faced by
al., 2009)
pregnant women.
 Encourages pregnant women to access
Nepal (UNICEF,
health facilities.
2013)
 Increase in community’s awareness of
maternal health.
Sierra Leone
 Community-based schemes create sense of
(Amnesty
community ownership.
International,
 Volunteers imbedded in community add
2009)
advantage in identifying women in need.
 Economic benefit felt by transport providers,
Uganda (Pariyo et
their families and the community.
al., 2011)
 Provides a reliable, safe and relatively
comfortable journey to/from health facility.
South Africa
 Can be easily replicated with allocation of
(Durden, 2014)
substantial funds and close connection to the
community.
 Delays in timely disbursement of funds to
beneficiaries.
 Difficulty or errors in targeting appropriate
beneficiaries.
 Providing funds is a short-term measure to assist poor
women and not a solution to maternal mortality in
low-income settings.
 Sustainability, as this scheme requires rigid
administration and sufficient funding.
 High cost of running this scheme (administration,
overheads, etc.).
 Dependency on external funding source (i.e.,
government, donors, NGOs or community).
 Potential for fraud or forgery.
 Changes in external conditions (i.e., fuel hikes,
weather, etc.)
 Limited to specific client group in urgent need.
 Requires an awareness campaign to inform
community of the scheme.
 May be difficult to replicate on a wider scale in larger
communities.
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 9
RECOMMENDATIONS
Recommendations to develop approaches to address transport barriers faced by women in accessing
clinics and hospitals are as follows:
1. Public/private partnership and transportation programmes

Accountability: 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).

Commitment: All committees involved in the set-up of such initiatives need to continually
reinforce their commitment, and orient new stakeholders (UNFPA, 2011).

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 on how to prioritise drivers
and consistently provide vouchers, as well as positively interact with drivers (UNFPA, 2011).

Supervision: Effective supervision should be set up to ensure that drivers are providing a quality
service (Theophilus, 2013).

Partnering with government: Public-private partnerships should be set up with government to
improve healthcare utilisation and increase uptake of healthcare services (Theophilus, 2013).
2. Specialised health transport (ambulances)

Training: Adequate operator training, safety training and management training prior to the
introduction of any of the modes of specialised health transport are required (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).

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

Capacity and Cost: Capacity to run the scheme is very important, as well as ensuring proper
running costs, and a clear system for paying the providers regularly (Pariyo et al., 2011).

Sustainability: The creation of a community mobilisation fund, through community insurance
schemes, where families could be encouraged to make periodic contributions that would cater for
the transport needs of the mother and the newborn (Pariyo et al., 2011).

Ownership: A transport fund should be implemented in collaboration with the district heath team
and stakeholders to discuss implementation and challenges (Pariyo et al., 2011).
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 10
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, J. and Roberts, P. 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.
Health Partners International. 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,
fromhttp://reliefweb.int/sites/reliefweb.int/files/resources/Bangladesh%20DSF%20evaluation_FINA
L_Feb%202010.pdf.
Pariyo, G., Mayora, C., Okui, O., Ssengooba, F., Peters, D. et al. 2011. “Exploring new health markets:
experiences from informal providers of transport for maternal health services in Eastern Uganda.” BMC
International Health and Human Rights 11(Suppl 1): S10.
Republic of South Africa. 2014. “North West to spend R84m to improve ambulance response time.”
2013. Retrieved September 13, 2014, from http://www.sanews.gov.za/south-africa/n-west-spendr84m-improve-ambulance-response-time.
Schoon, M. G. 2013. Impact of inter-facility transport on maternal mortality in the Free State Province.
South African Medical Journal 103(8): 534-537.
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.
Transaid. 2010. “Assessing Access to Health Services for Rural Communities.” Retrieved September 21,
2014, from
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 11
http://www.transaid.org/images/resources/20%20Transaid%20Technical%20Case%20Study%20%20Assessing%20Access%20to%20Health%20Services%20for%20Rural%20Communities.pdf.
Transaid. 2009. “Northern Nigeria Emergency Transport Scheme” Retrieved September 11, 2014, from
http://www.amddprogram.org/sites/default/files/Transaid_Technical%20Case%20Study_Northern%
20Nigeria%20ETS.pdf.
Transaid. 2008. “Zambia Bicycle Ambulance Project” Retrieved September 9, 2014, from
http://www.amddprogram.org/sites/default/files/Transaid_Technical%20Case%20Study_Zambia%20
Bicycle%20Ambulances.pdf.
UNFPA. 2011. “Innovative Approaches to Referrals of Emergency Obstetric Cases – Working in
Collaboration with Ghana Private Roads and Transport Unions (GPRTU).” Retrieved September 10,
2014, from http://ghana.unfpa.org/assets/user/file/TRANSPORT_UNION.pdf.
UNICEF. 2013. “Innovative Approaches to Maternal and Newborn Health: Compendium of Case
Studies.” Retrieved September 8, 2014, from
http://www.unicef.org/health/files/Innovative_Approaches_MNH_CaseStudies-2013.pdf.
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 12
ANNEXURE
Approaches to address transport barriers: strengths and weaknesses of individual examples.
1. PUBLIC/PRIVATE PARTNERSHIPS AND TRANSPORTATION PROGRAMMES
Country: GHANA
Programme: Collaboration with Ghana Private Roads and Transport Unions (GPRTU) Project
Funding: EU, Government of Ghana and UNFPA
Reference: UNFPA (2011)
Strengths:
 Helps link emergency obstetric cases to skilled attendants.
 Increases women’s access to appropriate medical equipment.
 Better utilises emergency obstetric and newborn services.
 Inspires transport unions and its workers to feel a great sense of commitment to reducing
maternal and infant mortality.
 3,285 referrals of women in need of emergency obstetric services (since 2006).
 Reduction in maternal deaths: 135 deaths in 2009 compared to 160 in 2008.
 Decline in infant mortality from 3.6 to 3.0 across five years of the project – this decline may
be attributable to the efforts of drivers who have helped reduce delays in access to health
services.
Weaknesses:
 Since project inception driver’s support for the initiative has reduced, this is corroborated
by a reduction in the number of clients.
 Instances where drivers do not receive the voucher claim forms because health facility staff
may be pre-occupied with handling emergency cases, therefore preventing them from
receiving reimbursement and other privileges/rewards from the union.
 Taxi drivers report insufficient or inadequate recognition of their efforts.
 Due to inadequate knowledge about the project there have been reports of instances of
poor attitudes exhibited by health facility staff towards taxi drivers.
 Instances of uncooperative and harassing police who do not have adequate knowledge of
the project and therefore don’t allow the speedy conveyance of pregnant women.
Country: NIGERIA
Programme: Emergency Transport Scheme (ETS)
Funding: Society for Family Health Nigeria (SFH), Population Services International and Transaid UK
Reference: Transaid (2009)
Strengths:
 Builds capacity among taxi drivers as they receive training on safe driving practices, danger
signs in pregnancy and delivery, lifting of women with complications and vehicle
management.
 Over 2,274 women have received timely medical help (since 2012).
 Scheme has attracted support from the government, which may encourage replication of
the system in other jurisdictions.
Weaknesses:
 Data collection can be a challenge due to the low literacy levels of the volunteer drivers.
 High cost implications to train all drivers.
 Difficulty in ensuring effective supervision of drivers to ensure a quality service is provided.
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 13
2. SPECIALISED HEALTH TRANSPORT (AMBULANCES)
Donkey Cart Ambulances
Country: SOMALIA
Programme: not identified
Funding: not identified
Reference: CARMMA (2013)
Strengths:
 The availability and use of donkeys is widespread as they have been part of Somalia’s history
for thousands of years.
 Among the Somalis, donkeys do not belong to any clan, can be ridden by both males and
females, are easy to maintain and are readily available throughout the season.
 Special reflective ear tags and reflective plates have been developed, which enable the
donkeys and carts to be seen at night.
Weaknesses:
 There is a problem of irresponsible under-age donkey-carts drivers.
 Little or no information on how many of the owners in each region have been trained in
basic first aid response, handling of expectant mothers, emergency child birth, how to load
carts properly, how to balance the load better, and how to prevent harness wounds on the
donkeys.
Bicycle Ambulances
Country: ZAMBIA
Programme: Mobilising Access to Maternal Health Services in Zambia (MAMaZ) Programme
Funding: UKaid
Reference: Health Partners International (2013)
Strengths:
 Pregnant women and newly delivered mothers were able to access a health facility without
delay.
 Cost of bicycle ambulances was relatively modest – 3,400 Zambian Kwacha (or USD $770).
 Communities took stewardship of the programme and protected it from misuse.
 Communities had recruited and trained additional riders to improve availability of transport,
and recruited mechanics to perform maintenance.
Weaknesses:
 Costs associated with maintenance.
 Seasonal factors such as weather (rain), the condition of roads and breakdown or punctures.
Motorcycle Ambulances
Country: MALAWI
Programme/Study: Safe Motherhood Project (in southern region of Malawi)
Funding: Ranger Production Company and Riders for Health (Zimbabwean NGO)
Reference: Hofman, Dzimadzi, Lungu, Ratsma and Hussein (2008)
Strengths:
 Cost of purchasing a motorcycle ambulance is less than for a car ambulance.
 Operating costs for a motorcycle ambulance was USD $508, while for a car ambulance this
was USD $12,139.
 As observed from the logbooks, motorcycle ambulances are less likely than car ambulances
to be misused for non-health-related purposes.
 Motorcycle ambulances at health centres are always on site and can depart with little delay.
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 14

Motorcycle ambulances reduce delay in referring women with obstetric complications from
remote rural health centres to the district hospital.
Weaknesses:
 Costs associated with maintenance.
 Seasonal factors such as weather, the condition of roads and breakdown or punctures.
Car Ambulances
Country: SOUTH AFRICA (Free State)
Programme: Dedicated Obstetric Inter-facility Transport
Funding: Department of Health – Free State
Reference: Schoon (2013)
Strengths:
 Maternal mortality decreased from 279/100 000 live births (in 2011) to 152/100 000 live
births (in 2012).
 The mean dispatch interval decreased from 32.01 to 22.47 minutes.
 The number of vehicles dispatched within 1 hour increased from 84.2% to 90.7%.
 Effective and prompt inter-facility transport of patients with pregnancy complications to an
appropriate facility resulted in a reduction of maternal mortality.
Weaknesses:
 Changing the strong views of the emergency service staff that any patient outside a health
centre required to be awarded a higher priority for transport.
 In some areas emergency services managers utilised the dedicated ‘maternity’ vehicles to
fill gaps within their services.
 Need for extensive discussion between midwives and emergency services personnel to
increase the promotion and uptake if this new transport strategy.
3. TRANSPORT FUND OR TRANSPORT VOUCHER
Country: BANGLADESH
Programme: Maternal Health Voucher Scheme part of Demand-Side Financing (DSF) Program
Funding: Government of Bangladesh
References: Laurel, Nguyen, Sloan, Miner, Magvanjav et al. (2010) / Ahmed and Khan (2011)
Strengths:
 Increase in utilisation of maternal health services.
 71% of women in DSF sub-districts received a voucher booklet.
 Average cost per voucher distributed is estimated to be USD $41 – this covers maternal
health services, transport subsidies, cash incentive and gift box.
Weaknesses:
 Delays in the disbursement of funds both from the central level to the sub-districts, and
from the sub-districts to the beneficiary or provider.
 The Government of Bangladesh’s standard financial regulation that unused monies be
returned to the Treasury at the end of the fiscal year presents an additional and serious
disruption to voucher programme operations.
 Few private and NGO facilities are part of the DSF programme.
 Fund and vouchers were not available on a timely basis.
 Errors in targeting beneficiaries.
 Not enough vouchers supplied to the local DSF committee for distribution.
 Women did not receive delivery-related cash incentives on time.
 Limited option of healthcare providers, public providers were the only designated providers.
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 15
Country: INDIA
Programme: Reproductive and Child Health (RCH) Program – RCH II (launched in 2005)
Funding: Government of India
Reference: De Costa, Patil, Kushwah and Diwan (2009)
Strengths:
 The project intervention of promoting ANC, training providers, and providing financial
support for transportation seemed to have lowered the maternal mortality in the study
block significantly, in comparison to the previous year or the neighbouring block the same
year.
 Most deaths averted were in the post-partum period and deaths that occurred at home
(nine of 12) died in hospital or en route. It is possible that the project averted those postpartum deaths as a result of making transportation funds available.
Weaknesses:
 Poor uptake of project funds (even though it was well publicised, had support from local
leaders and money was easily available). Perhaps this is because the money was given to
women who in some way were ‘socially better paced’ than the women who were targeted
by the project or due to the low status of women in a patriarchal study setting, which would
imply that maternal health is not perceived as an important priority in the community.
 Providing transport funds for emergency is a short-term measure to assist poor mothers in
the immediate situation.
Country: NEPAL
Programme: The Aama Programme
Funding: Government of Nepal
Reference: UNICEF (2013)
Strengths:
 Encourages women to access health facilities.
 Decrease in transport cost barriers faced by women.
Weaknesses:
 Funding must be provided by government – may not be sustainable in the long-term.
 Some women may not be aware of the transport incentive.
 Women only receive the incentive at the time of discharge from health facility.
Country: SIERRA LEONE
Programme: Community-based savings and loan scheme
Funding: Community-based
Reference: Amnesty International (2009)
Strengths:
 Approximately three quarters of the residents are members of the scheme.
 Creates sense of community ownership.
 The scheme is community-based.
Weaknesses:
 No clear description of the process of drawing on the funds or who gets priority.
 Fund depends solely on generosity of community members - no guarantee that funds will
be continually contributed by members.
Country: UGANDA
Programme/Study: Informal transport markets in facilitating access to maternal healthcare services
Funding/Researchers: Makarere University, Uganda
Reference: Pariyo, Mayora, Okui, Ssengooba, Peters et al. (2011)
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 16
Strengths:
 Increased utilisation of maternal care services.
 Increased attendance at first, second, third and fourth visits for ANC, as well as an increase
in institutional deliveries and PNC.
 Increased community awareness about maternal health, with the transporters contracted
by the project playing a leading role in mobilising expectant mothers to attend services.
 Economic benefits felt by the transport providers, their families and community generally,
as the payment which the transporters received for the services offered was their main
source of income (for the majority).
Weaknesses:
 Costs of running the voucher programme, which include payments made to the transporters
and project administrator, printing the vouchers, identification cards and contracts, as well
as other overhead costs.
 Method of payment and verification of vouchers, since payments had to be made in cash
(transporters did not have bank accounts) a strict administrative process was required
which involved auditing and verifying voucher claims to avoid duplication or forgery.
 Difficulty in obtaining operating licenses, as many transporters did not have the required
legal documentation (which can be an expensive process).
 Changes in external conditions, such as a hike in fuel prices or weather conditions (rain).
 Delays encountered at the health facilities, as many transporters would prefer to wait with
the mother at the unit and then take them back home – however due to a high turn up of
mothers and a shortage in health workers, transporters had to wait long periods for the
mothers to be attended to.
ADDRESSING TRANSPORT BARRIERS: APPROACHES TO ACCESSING MATERNAL AND CHILD HEALTH SERVICES 17