International Development CommitteeWritten evidence submitted by Riders for Health
1. Despite the focus the Millennium Development Goals have brought to serious issues of development since 2000, great opportunities have been missed because of a failure to invest in the key infrastructure that would underpin sustainable, lasting development.
2. Riders for Health asks that the Committee recommend that post-2015:
There must be a focus on improving appropriate transport infrastructure to address equitable access to health care, education and services to rural areas—colloquially known as “the last mile”.
Resources are committed to the effective management of the vehicles used in development—especially in health-care delivery—so that they function normally irrespective of terrain and distance from capital cities. This will also provide local employment and saleable, transferrable skills as well as local management-level capacity.
Social enterprise is recognised as being able to engage in provision of services and expertise to developing governments in public-private partnerships and should be promoted.
The agenda is focused on development partners working together, and with local communities, to get better results.
There is a commitment to investing in transport infrastructure that does not necessarily require road building.
Introduction to Riders for Health
3. Riders for Health is a non-profit social enterprise that has more than 20 years’ experience working to strengthen access to health care in rural communities in Africa.
4. Riders for Health works in partnership with ministries of health, international NGOs and smaller, community based organisations to manage two- and four-wheeled vehicles to allow partners to expand the reach of their work and increase their reliability. Riders for Health puts in place technicians and simple, low-cost workshops into areas where no existing vehicle maintenance structure exists, so that vehicles can be serviced regularly to prevent the breakdowns that disrupt services and waste money and assets.
5. Riders for Health works in eight countries across sub-Saharan Africa, and its work is improving access to health care for over 12 million people. In 2009 it received funding from the Bill & Melinda Gates Foundation to expand its work and, as part of this, is funding a new programme in Southern Province, Zambia, where a groundbreaking study is being carried out by the Stanford University Global Supply Chain Management Forum. The aim of this control-based study is to establish, in evidential terms, the precise impact on health systems of having a complete fleet of perfectly-functioning vehicles. In 2012 Riders for Health was part of the Department for International Development’s Aid Match programme.
6. The lessons we have learned through 20 years of working in this sector may well be relevant to other sectors and other locations, but our focus in this evidence will be in the area of our own expertise in supporting primary and outreach health care delivery. It will of course be the judgement of the committee whether any wider lessons can be learned.
Failure to make Sufficient Progress on Health Goals
7. In many countries throughout sub-Saharan Africa, the Millennium Development Goals (MDGs) relating to health are far behind targets. Health interventions are falling short of their intended impact and, as a result, significant resources are wasted while people are needlessly dying each year.
8. One reason for this shortfall is the gap in health care reaching non-urban populations. According to the World Health Organization (WHO), between 40 and 60% of people in developing countries live more than eight kilometres away from a health facility. Lack of reliable transportation constrains the performance of health delivery organisations and therefore the uptake of health interventions. This affects everything from basic preventive measures to advanced health technologies.
9. Lack of reliable transport and its impact on reaching rural communities is a particular problem in sub-Saharan Africa. The transport unit of the World Bank reported that transport problems have been identified as part of the reason for limited progress toward achieving MDGs 4 and 5—aimed at improving child and maternal health respectively.
10. As the need for transport for effective health care delivery has been recognised, huge investments in purchasing vehicles have been made over the years. However, there is an overwhelming tendency for vehicles to break down in Africa after a very short proportion of their intended mechanical life. This is due to a widespread misunderstanding of the precise needs and nature of vehicles in hostile conditions and harsh terrain. Large amounts of money are frequently spent on over-specified vehicles in the misguided belief that vehicles with big “tough-looking” shells will last longer. Underlying the problem is the fact that the dealer-based servicing networks that enable vehicles to work normally over long lives in the developed world are entirely missing from rural Africa. The vital servicing function has to be provided in some other way.
11. Governments and development agencies routinely overlook the fact that keeping vehicles running costs money and often under-budget for on-going maintenance. This is exacerbated by lack of training in technical skills and the supply-chain-management that is relevant to consumables for vehicles servicing. There is also often a shortage of expertise available to ensure that the vehicles will run predictably once they are introduced into an environment with difficult terrain and very little vehicle maintenance infrastructure. Once the vehicles travel out of capital cities, availability of replacement parts becomes a challenge and it is not uncommon to see a vehicle intended for health care delivery immobilised—perhaps forever —for lack of an inexpensive replacement part.
Riders for Health asks that the Committee recommend that whatever agenda is set, post-2015, there must be a focus on improving appropriate transport to increase access to health care in rural communities.
12. Letting health delivery vehicles fail is almost a criminal act of negligence. Millions of dollars have already been invested in these vehicles, to simply buy replacements when they break down draws resources from other areas of budgets, but the alternative of having no transport means health care simply not reaching the most remote places.
13. Improving health care in the long term should involve strengthening health systems. A strong health system should be able to focus on every area of health care. A single outreach clinic set in a village serving mothers and their families from the local area, can provide vaccinations for children, provide ante- and post-natal care, can monitor levels of malnutrition and disease burden.
14. A health worker with a well-maintained motorcycle can see five times more people, and spend twice as long in communities. A dedicated courier system for blood samples can cut testing times from months to days, improving disease monitoring and treatment, and last mile logistics can make sure clinics always have the drugs they need and people are not left without the treatment they need.
15. When millions of dollars are spent training health workers each year it means they are equipped with the skills to carry out the work that communities and people at risk of preventable diseases desperately need. However, without reliable transport these skilled health workers are put in the demoralising position of knowing they can’t fully provide the service that is needed due to having to spend so much time walking or sharing unreliable transport. By reducing the time they spend walking to villages their productivity is directly improved and as a result health workers are more likely to want to work in rural areas and staff retention rated for the ministry of health will be better.
16. One of Riders for Health’s programmes—in The Gambia—has provided data which shows that:
32% of health centres are scheduling more outreach clinics meaning they reach more communities, more often with maternal and child health services, immunisations and other life-saving treatment.
No outreach clinic is cancelled due to transport or fuel constraints, whereas before 32% of cancelled outreach clinics were because of this.
8% more referrals from health centres to hospitals are made by ambulance.
Outreach health workers spend four days each week doing outreach work, compared to just two days before. This means they can visit three times more villages each week.
Health workers can increase the frequency of visits to villages and increase the number of new villages reached—this is especially important when considering equity of health service availability and coverage.
Riders asks the Committee to recommend that post-2015 social enterprises are engaged in providing their expertise to developing governments in public-private partnerships.
17. As transport management is not a core competency of a MoH or other health care providers, Riders believes that those organisations should outsource this crucial service along the model of public-private partnerships (PPPs).
18. While public private partnerships are an important model, Riders for Health would not recommend relying on the private, for-profit sector. Governments, especially those with limited experience and capacity, face a fundamental problem in that they lack the specialised technical knowledge to be “intelligent” purchasers of private sector services, which creates the potential for corruption and the buying-in of poor service at a high cost.
19. Riders for Health believes that social entrepreneurs are the optimum partners for developing governments, because they have social rather than financial outcomes at heart and must be transparent and accountable themselves. Riders’ social entrepreneurial values, and their managed system, enable them to provide non-inflated, cost-effective transport management services for their partners with whom they share the commitment to achieving positive health outcomes.
20. The development of specific competencies and expertise in development are rare. Seeing the widespread and complex challenges in the developing world, many agencies tend to take too a broad an approach and address a variety of issues without developing specialist knowledge in any one area.
21. Vehicle management is not a core competence for health-focused development agencies and the ministries with whom they work. Therefore they often misunderstand or critically underestimate the funding needed to run a vehicle for its natural lifespan and do not have the necessary immediate funding or the appropriate techniques required. Humanitarian fleets deteriorate prematurely because the vehicles are not maintained and are allowed to run until they breakdown, at which point the unpredicted repairs prove too costly or cannot be carried out because the necessary expertise, tools or supply-chain are not in place. The upshot of this dangerous combination is that precious resources are wasted and health care goals are not reached.
22. It is Riders’ belief that all organisations have a responsibility to identify both their core competency and their “core incompetence”, and focus their efforts accordingly. For example, the agencies with which Riders works have a core competency in health—such as the development of new drugs or the design of appropriate sanitation systems. Where they do not (and, in Riders’ opinion, should not) have a core competence in areas such as vehicle maintenance. Riders firmly believes that the management of these areas should be outsourced to a specialist agency.
23. A small number of NGOs have been set up to address the challenge of reliable transport for development, but their focus has tended to be on strengthening the performance of the for-profit sector or on addressing broad development themes such as road safety or the lack of metalled roads. They do not support the direct employment of local people or work in partnership with health providers. Other commercial organisations which run large vehicle fleets in challenging conditions tend to work purely in the area of disaster relief rather than in sustainable development. As such, the vehicles are not managed properly and are not made part of the necessary infrastructure for the long-term development of the area affected.
24. In the case of Riders for Health, we have always retained a single focus on the issue of transportation. This has enabled Riders to develop a core competency in the management of vehicles in harsh conditions, to create depth and breadth of expertise—from specific technical knowledge, to accurate costing mechanisms, data management and management disciplines—and ensure that they consistently achieve high standards in all areas of their work.
25. To ensure sustainability Riders charges a non-profit fee for its fleet management services. This is calculated on a “per kilometre” basis and is designed to encompass every aspect of fleet management (insurance, fuel, servicing, parts). Riders’ programme in The Gambia is now financially self-sustaining and the MoH takes full responsibility for service payment. Such enterprise not only ensures the longevity of the programme, but also opens up new opportunities for financing health system strengthening.
26. Riders for Health’s objective is always that the local ministry of health should pay for the vehicles they use. It is unsustainable and undesirable for any NGO, foundation or bi-lateral donor to pay for transport in the long term, moreover, that relationship would reinforce issues around donor dependency. In cases where Riders for Health’s work has been established and has provided its benefit to the health system, ministries of health are more than willing to take on budgeting for this service, not least because it puts the sustainability of this vital service in their hands and not in the hands of donors or NGOs.
27. In 2009, Riders leveraged an investment of $3.5 million to implement their first managed vehicle leasing programme in the Gambia, in the form of a loan over five years from Guaranty Trust (GT) Bank (underwritten by the Skoll Foundation for Social Entrepreneurship). This enabled Riders to purchase a fleet of 90 motorcycles for outreach health workers, and four-wheeled vehicles including 14 trekking vehicles, 36 ambulances and 12 “pool” vehicles. The Gambian government, together with the Global Fund to Fight Against HIV/AIDS, Tuberculosis and Malaria (GFATM), are meeting the running costs for the vehicles.
28. Riders’ programme in The Gambia demonstrates a uniquely balanced and replicable model for public-private partnership that gets health care on the road regularly and reliably. As such, it has shown itself to be more appropriate for development (particularly for government ministries) than any other private sector service.
29. Riders for Health believe that every major global health initiative must include managed transportation as an integral part of its work and of a country’s health system. This will see managed transportation systems in operation at scale throughout sub-Saharan Africa. It will mean that outsourcing by governments will become more commonplace—a vital step that directly facilitates sustainable change.
Riders asks the Committee to recommend that the post-2015 agenda is focused on development partners working together, and with local communities to achieve better results.
30. One of the problems with splitting the Millennium Development Goals into separate themes has been that it has encouraged actors to focus on just one area, at the expense of others, and has discouraged the overall strengthening of health systems. One organisations may say, “we will put in a programme to improve ante-natal care”, while another focuses their funding on reducing child mortality. They may both spend money on putting place some infrastructure for the project (or then again, they may not), whereas if they cooperated, they could reduce costs and share the benefits of the improved infrastructure.
31. Riders for Health is currently taking part in a study being carried out by Stanford University Global Supply Chain Management Forum, which is being funded as part of a grant from the Bill & Melinda Gates Foundation, that will look at the impact on health systems of mobilisation of health workers.
32. There also needs to be a commitment to working in partnership with local people. All of the programmes Riders for Health run are managed by local people. Where possible it is crucial that local staff are trained with the skilled needed, so these skills stay in county. Riders for Health are proud that many of their apprentice technicians have the ambition of using their skills to set up their own businesses. It is only by giving people the skills to match their entrepreneurial drive that will help stimulate economic growth.
33. Training and skills building shouldn’t only be the reserve of specialist programmes, every programme that is established should think about how its implementation will help to increase the skills of local people.
Riders asks the Committee to recommend that post-2015 there is a commitment to investing in transport and infrastructure building that is not solely focused on building roads.
34. Investment in improving transport infrastructure cannot be left to organisations who are wholly reliable on donations for their funding. This can never be sustainable. At the same time market conditions for many of the key infrastructure projects will put off potential investment. But this should not exclude introducing business principals to improving services.
35. One of the biggest challenges needs to be on making sure that funders are more open to funding transport costs as well as building enthusiasm for funding running costs.
36. Riders for Health have come across numerous funders who will refuse to fund transport projects. This is undoubtedly down to the fact that millions of dollars can be spent on vehicles, yet there is a feeling that they are likely to just breakdown in the African environment within a short space of time. Yet, if the money was invested into providing ongoing running costs, then the appropriate vehicles should last for many years, and should never break down.
37. There is even more reluctance to invest in ongoing running costs of programmes than there is to make the initial purchase. This is a problem faced by many in development, there is far more attraction to saying you have been able to launch a brand new project, than simply being able to say you have kept a well functioning project running. This provides perverse incentives to constantly start new projects, when what may be more effective is less investment in keeping an existing initiative running.
September 2012