Written

A Team of Researchers Explores Health Care Delivery in Africa

Can well-managed fleets of vehicles increase health worker productivity?
Riders for Health deploys vehicle fleets to support and strengthen health care networks in developing countries. (Photo by Davis Albohm)

Zambia is one of the least densely populated nations in Africa, with rural villages separated from one another by hundreds of miles of treacherous roads and dirt paths. For several months in the winter, some of those roads simply disappear as torrential rains inundate the surrounding floodplains. This wreaks havoc on any attempt to provide health care to isolated populations, and makes reliable transportation a matter of life and death — not just in emergency situations but also in terms of outreach programs aimed at disease prevention. Enter Riders for Health, a UK-based social enterprise that uses vehicle fleets comprised mostly of motorcycles to support and strengthen health care networks in developing countries.

The organization has been active in sub-Saharan Africa since the late 1980s. With client partners such as health ministries, NGOs, and community organizations, Riders has grown to offer a range of services — from planning budgets for health-related transport to sourcing vehicles and spare parts to inventory to fuel management to the collection of patient diagnostic samples. It now manages some 1,400 motorcycles and vehicles across 7 African countries, and operates a sophisticated hub-and-spoke system in which skilled technicians regularly travel to service vehicles in communities where health workers are based, thereby facilitating the mobilization of health resources to rural areas.

The organization's basic hypothesis is that efficiently managed vehicle fleets, operated and maintained by well-trained riders and mechanics, increase health worker productivity — the number of outreach visits workers are able to make — and health equity; that is, how well rural communities are served relative to populations in closer proximity to health centers. But, until fairly recently, that has never been rigorously tested. So in 2009, with a $1.83 million grant from the Bill & Melinda Gates Foundation, Stanford Graduate School of Business' Global Supply Chain Management Forum launched a five-year study to assess the role of transport in bridging the gap — the so-called "last mile" — between remote communities in the Southern Province of Zambia, where public transportation is infrequent at best, and the provision of health care. (The foundation subsequently increased the grant to $2.27 million.) The results of the study, scheduled for release next year, are likely to provide the impetus for health ministries to think creatively about resource allocation. "It will be a very, very big eye opener for everyone," predicts George Muwowo, program manager on Stanford's Zambia team.

Stanford GSB Partnership

The collaboration dates back to 2006 when Stanford GSB's Hau Lee, Thoma Professor of Operations, Information and Technology, attended a logistics conference in Chicago. He was one of just six people in the audience for a presentation by Riders' husband-and-wife cofounders, Barry and Andrea Coleman. In Riders, Lee saw a learning opportunity with a purpose beyond being "socially responsible," as he puts it, or "a good citizen." Discerning not only the scalable potential of the Riders model to save lives, he also intuited a valuable lesson for future managers at global companies expanding into emerging markets: that innovative solutions can make a big difference in challenging, resource-poor environments.

Six months later, Lee emailed Andrea to propose a case study on Riders and then began teaching the case in his core classes covering supply chain management in operations. "To my wonderful satisfaction," he recalls, "the students did not think of this as non-essential or non-relevant. But, in fact, many of them felt this is how the private sector can contribute to social causes and increase the well-being of developing economies."

The Riders case study took on a life of its own as other MBA programs began incorporating it into their curricula. The study of supply chain as a means of overcoming the last-mile challenge in economies lacking broad-based infrastructure emerged as a compelling new research agenda.

The Gates Foundation has committed $12.5 million to Riders for Health including the "sub-grant" to Stanford GSB. The original grant proposal aimed to expand Riders' geographic footprint and increase the number of vehicles and motorcycles it managed on behalf of its partners. Riders also proposed a research component, but the foundation suggested going beyond internally monitoring the impact of its programs. Additional money was in the offing if a plan could be prepared quickly and the right outside experts came on board.

Hearing about the opportunity from the Colemans, Lee envisioned a study that would examine not just logistics and the efficacy of Riders' approach, but also an entire system of health-care delivery. He teamed up with Lesley Sept, a PhD in public health who, at the time, directed the Forum's Socially and Environmentally Responsible Supply Chains Program. Their combined expertise made Stanford GSB an ideal partner for Riders and the Gates Foundation, which shared an interest in augmenting health supply chains through the dissemination of best practices.

Research Process

Just to set the stage to begin collecting data in Zambia took two-and-a-half years and required much negotiating and relationship-building with the country's health ministry. The study covers four randomly selected control districts and five (originally four, one of which was divided in two) experimental districts. Before any intervention by Riders for Health, researchers in the field spent five months collecting baseline data on the status quo.

The Ministry of Health's existing fleet and modus operandi remained in place in the control districts, while two Riders models — Transport Resource Management (TRM) and Transport Asset Management (TAM) — were introduced into the experimental districts. Under TRM, Riders takes over management (including maintenance, training, and fueling) of fleets already owned and deployed by the Ministry of Health. Motorcycles and other vehicles in the TAM program are procured, owned, and managed by Riders.

In March 2012, Riders deployed 76 motorcycles and 4 SUVs into the experimental districts and mobilized 76 Environmental Health Technologists (EHTs). Starting out several mornings a week from hub health centers in their respective districts, the EHTs visit outreach posts to engage local populations in disease-prevention education and immunization. They also monitor the growth of infants and children, and test bacteria levels in water and food supplies.

Stanford GSB employs a team of seven data-collection officers who, in addition to conducting phone surveys, regularly visit health centers in their assigned districts to interview EHTs and managers of vehicle fleets at the district level. The data collectors have handheld scanners for copying monthly "tally sheets" of services performed at the centers and on outreach. Back at Stanford, researchers download the tallies and compile them. A more complete picture of health services delivery emerges, says Stanford GSB project manager Davis Albohm, when the tally data is combined with findings from the interview surveys of EHTs and tracking information obtained from global-positioning receivers attached to a subset of motorcycles and other vehicles.

Real-time tracking data from the GPS program is fed to Stanford GSB researchers, who are working in partnership with Geographic Information Systems (GIS) experts at Stanford's Branner Earth Sciences Library. The GIS maps they create chart the routes and distances traveled by the health technologists. Population density overlays are applied to create color-coded "heat maps" depicting what Kala Mehta, epidemiologist and lead research consultant on the evaluation study, calls "health-outreach coverage."

By linking this data with demographic health information surveys undertaken by Zambia's Ministry of Health, an interdisciplinary team, including Eran Bendavid, an infectious diseases physician and assistant professor at Stanford School of Medicine, can draw correlations between EHT productivity, outreach coverage, and health outcomes broken down to the village level.

Laura Hubbard, associate director of Stanford's Center for African Studies, is one of four anthropologists doing qualitative research for the Riders study. Among them, Jess Auerbach, a doctoral candidate at the center, is focused on the human and technical aspects of transport allocation and staffing at Zambia's Ministry of Health, gleaning insight into supply-chain sourcing and the trickle-down effects of transport decisions made at the top.

In an email, Auerbach recounts how one driver, at the end of a 12-hour shift in the Mazabuka district, received a call from hospital staff to pick up a patient at a remote clinic. Auerbach went along to observe.

"First we had to collect a nurse from her home," she wrote, "get fuel authorization [and] fetch a mattress from the hospital. Then we drove 90 kilometers in a Land Cruiser-turned ambulance over sometimes all-but-non-existent roads." At the clinic, an adolescent mother who had just given birth was collected with her infant and taken to the hospital by placing the mattress behind the front seats and hanging up an intravenous drip with wire. Usually that journey takes several hours by ox cart, followed by at least two more hours in one of the open-topped trucks that serve public transport needs in the region. In this case, it took just two-and-a-half hours.

Takeaways

Experiencing the adverse conditions firsthand has provided a deep appreciation and respect for those who deliver health care in Zambia.
Jess Auerbach, doctoral candidate at Stanford's Center for African Studies

For Auerbach and the rest of the Stanford team, experiencing the adverse conditions firsthand has provided a deep appreciation and respect for those who deliver health care in Zambia — and driven home the idea that logistics and transport can have a big impact in underdeveloped settings, just as they do in developed economies.

The study has broader implications for promoting economic development in places like Zambia, says Sonali Rammohan, associate director of the Forum. Indeed, understanding supply-chain dynamics can help companies and other ventures obtain agricultural commodities and other inputs, as well as finished goods such as textiles and artisanal crafts, from rural communities. There are also potentially valuable lessons for retail and other sectors looking to overcome last-mile distribution challenges. "Hopefully," she says, "with what we learn, we can influence how multinationals and others practice," in terms of sourcing and delivering goods and services.

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