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Transport and Communication Systems in Health Services

Article  in  Tropical Doctor · August 1977

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Tropical Doctor, July I977 TRANSPORT AND COMMUNICATION SYSTEMS IN HEALTH SERVICES
Community Medicine
Transport and
communication systems
in health services
Oscar Gish, BA MPhil
Godfrey Walker*, MSc (Social Medicine), MB,
BS, DCH, DRCOG
Institute of Development Studies,
University of Sussex
TROPICAL DOCTOR, 1977, 7,119-122
During the past few years greater interest has been
shown in ways in which the effectiveness of basic
health services might be increased. One of the major
areas of difficulty in most developing countries is poor
communication systems between health headquarters
(regional and district) and more peripheral u.nits.
Rural clinics and dispensaries are often relatively
isolated. Owing to difficulties in communications the
staff of these units are frequently forced to accept a
chronic shortage of even basic medical supplies. For
similar reasons referral systems are often virtually
non-existent. Local communities understandably
question the worth of care that is dispensed from such
isolated and ill-equipped facilities.
HEALTH SERVICE FUNCTIONS IN WHICH TRANSPORT CAN
BE USED
The movement of health workers and patients is of
great importance within any health service. It enables
the coverage of the system to be effectively extended.
In developing countries the movement of health
workers is likely to be relatively more important than
that of patients. This is because travel is u.sually
severely limited for the majority of people owing to
the general absence of modern transport systems and
their inability to pay for it.
At the local level (clinic, health post or dispensary),
it is important that the staff are able to travel to
neighbouring communities (up to a dista~ce of, say,
15 miles away), for predictable health care IS~U~S such
as the holding of under-five and ante-natal clinics and
also for home visiting of patients, e.g. the follow-up
"Present appointment: Senior Registrar, Department of
Community Health, London School of Hygiene. and
Tropical Medicine and the North East Thames Regional
Health Authority.
I 119
of tuberculosis patients who have lapsed from treat-
ment. For such visiting greater use should be made of
cheap and relatively unsophisticated transport.
Where animals, e.g. horses and donkeys, are available
they should be used. If they are not available or not
acceptable then more use should be made of bicycles
or light motorcycles. It is unfortunate that th~re
exists a tendency to concentrate upon more expensive
forms of transport to the relative neglect of cheaper
means. In part this has been encouraged by the
provision of quite "large numbers of various types of
modern transport" by UNICEF over the past 25
years, although this is now changing (WHOjUNICEF
1974·)
A. The following characteristics are common to most
Third World countries;
I. a large proportion of the causes of mortality and
morbidity are potentially preventable by existing
health service technology;
2. approximately 70% of the population are either
less than 15 years of age, or females in the child-
bearing age group of 1 5-44 years;
3. government health expenditures of approximately
£1 per capita; .
4. approximately one physician per 10,000 populatIon
and one non-physician primary health worker per
4,000 population.
B. The main health service functions in which
mechanical transport has been used are;
I. the supportive visiting of peripheral basic care
units;
2. the ambulance-evacuation of patients;
3. vertical health programmes;
4. delivering primary patient care;
5. scheduled visits not necessarily including direct
patient care;
6. specialist clinical rounds on a scheduled basis.
Given A and B above, the health service activities with
the highest cost-benefit ratio in which mechanical
transport can be used is supportive visiting to rural
primary care units.
SUPPORTIVE VISITING OF PERIPHERAL BASIC CARE UNITS
Visits by relatively highly trained, but scarce health
personnel are likely to be highly beneficial to the
effectiveness of care dispensed from units staffed by
more basically trained workers. The most important
factor being the establishment of continuing and
regular contact between health personnel leading to
the development of rapport and confidence so
120 I TRANSPORT AND COMMUNICATION SYSTEMS IN HEALTH SERVICES
essential in the effective functioning of a dispersed
health care network. The optimal frequency of such
supportive and educative visits would appear to be at
about fortnightly intervals with each visit lasting
approximately four hours. During these visits several
tasks are usually performed:
I. referral clinics can be conducted where patients
already screened by permanent staff are seen;
2. on-going (especiallypreventive) health programmes
can be discussed and problems clarified;
3. supplies, both medical and general, can be
delivered;
4. where indicated pathological specimens, e.g.
sputum in suspected cases of tuberculosis, and
blood for Hb and WR and Kahn, can be collected -
the results being returned at the subsequent visit;
5. where required more general areas of community
concern can be discussed with local representa-
tives, e.g. development officers, teachers, tribal
authorities or elected bodies; and
6. those patients requiring the more sophisticated
facilities of a hospital can be transported there on
the return journey.
AMBULANCE-EVACUATION OF PATIENTS
Transport solely for ambulance purposes is difficult
to justify in developing countries. While such use of
transport is often the most immediately appealing, it
is expensive and dependent upon good communica-
tion systems. Examples of light aircraft having been
successfully used for ambulance services in general
are only to be found in high income countries. In
most developing countries these services have "had
to cope with many financial and technical difficulties"
(WHO/UNICEF 1974, p. 17). The cost-per-emer-
gency flight is usually high. For the service operated
by the African Medical and Research Foundation
(AMRF) in Nairobi it was over £100 during 1973,
and for the Royal Australian Flying Doctor Service
about £250. However, the disparity in health
expenditure for these two countries is very great-
Kenya spent just over £1 per capita in 1973 while
Australia spent almost £60 in 1971.
VERTICAL HEALTH PROGRAMMES
Vertical health programmes have been great users of
transport. However, over the past decade it has been
increasingly realized that such programmes are likely
to be more effective and efficient in the use of scarce
resources if integrated into comprehensive primary
care syterns (Soper 1969).
PRIMARY PATIENT CARE
The delivery of primary care from land vehicles or
Tropical Doctor, July I977
aircraft is far less cost-effective than the provision of
care from fixed clinics. A recent study in Botswana
(Gish and Walker 1976) has compared the cost-
effectiveness of mobile land and air clinics with that
of fixed clinics. The fixed clinics were found to be
about 14 times more cost-effective than the air
delivered service and eight times more than the
land transport based. This was in great part due to
the larger proportion of patients seen at fixed clinics
whom it was considered could be treated effectively,
and that the costs of transport were higher than
equivalent annual capital costs for fixed facilities.
SCHEDULED VISITS NOT NECESSARILY INCLUDING DIRECT
PATIENT CARE
The regular delivery of supplies to peripheral health
units is extremely important for their effective
functioning. Usually these deliveries can be inte-
grated into supportive visiting schedules, although
occasionally when particularly bulky or heavy objects
require transporting then special visits by large
vehicles are necessary.
SPECIALIST CLINICAL ROUNDS
Specialist clinical rounds from regional or national
hospitals to relatively isolated hospitals are likely to
be important, once again, mainly in an educative and
supportive capacity. However, of total health service
transport requirements this capacity is likely to be a
relatively minor one.
CHOICE OF VEHICLES
In many developing countries funds devoted to
health service transport is small. If optimal use of
this money is to be made then it is important that the
proposed type of mechanical transport is critically
matched to desired health service function. This will
probably mean that ideal matching to cover all
eventualities will not be possible.
For the majority of supportive visiting light (three
quarter to one ton) pick-ups or vans are adequate. In
particular those with front-wheel-drive are often
more manoeuvrable, especially in sandy or muddy
conditions. While the "go-anywhere" reputation of
four-wheel-drive vehicles (e.g. Ford F250 4 X 4,
Leyland Land-Rover or Toyota Land-Cruiser) is
well deserved, their cost is two to three times that of
light pick-ups or vans. The Land-Rover type of
vehicle can only be justified exceptionally, e.g. for
visiting health units in very sandy or marshy areas, or
where several days are spent away from the base.
Purpose-built vehicles are rarely justifiable mainly
due to their high cost (about twice that of the equivalent
basic model), but also to their inappropriateness. Any
Tropical Doctor, July I977 TRANSPORT AND COMMUNICATION SYSTEMS IN HEALTH SERVICES
necessary minor adaptations are best made locally
where they can be carried out in consultation with
those who will be using the vehicle. The potential for
the use of light aircraft in health services would seem
to be very limited. This is mainly because of their
initial high capital cost (approximately £31,000 for a
single-engined aircraft, e.g. Cessna-zoo, or over 15
times that of a one ton pick-up), their need for
sophisticated base and maintenance facilities and
(usually) a pilot taking a relatively high salary. The
aircraft's main advantage is its speed. Greatest use
can be made of this attribute by utilizing aircraft to
visit (in a supportive capacity) permanently staffed
facilities at a great distance from the regional health
headquarters. In these cases speed of travel is
important in keeping travelling time down to a
reasonable proportion of total work time. In the
Botswana situation simple criteria were developed,
within local resource constraints, to identify those
clinics which justify visiting by aircraft (Gish and
Walker 1976). The criteria were: those clinics that
are located by virtue of distance or difficult terrain at
such travelling time from regional health headquarters
by road that;
I. more than one day is required for the visit to one
clinic;
2. that a total stay of more than four nights from the
base is involved in anyone trip (it is agreed
among people making such trips in Botswana
that stays of four nights away from their base in
one stretch, or in one I4-day period is an upper
acceptable limit on a regular basis).
Wood (1970 and 1971) in advocating the more
widespread use of light aircraft, has emphasized that
they are only slightly more expensive to operate on a
per mile basis than are four-wheel-drive vehicles.
However, the major issue with regard to the use of
aircraft in the delivery of health services is to assure
that this use is restricted to planned cost-effective
activities. In the context of the great majority of
developing countries this will rule out the use of the
aircraft for emergency services, and virtually restrict
its use to a supportive relationship to fixed units which
could not otherwise be as effectively reached by land
vehicles. This means that there is an absolute need to
integrate the aircraft into the ongoing health delivery
system. It also means that the use of the aircraft must
always be planned so as to avoid its diversion to
emergency purposes. If the work of the aircraft is not
tightly scheduled it is virtually inevitable for it to be
called upon when emergencies do arise. Unless every
effort is made to guard against the use of aircraft for
emergencies it is also likely that the very availability
of the aircraft will draw it into such work, an in-
I 121
creasing proportion of which is unlikely to be strict
("red") medical emergencies.
RADIO COMMUNICATIONS
Radio-communication systems connecting peripheral
and often isolated primary care facilities with district
or regional health headquarters have been used in
many countries, often in association with flying
health services. While the effectiveness of such systems
is difficult to quantify and thus evaluate there is
agreement that benefits are likely to be found in the
following areas of health care:
I. an increase in the morale of the staff at peripheral
units resulting from a decrease in their sense of
isolation;
2. the improvement of individual patient care by
enabling ready access to advice and, where
indicated, transport to evacuate patients;
3. the further education of clinic staff through
regular contact with more highly trained health
personnel;
4. the co-ordination and implementation of com-
munity preventive health campaigns;
5. the more efficient management of administrative
tasks, e.g. the supply of drugs, dressings and
vaccines, the communication oflaboratory reports,
etc.
Health personnel working in units equipped with
radio-communication systems stress the importance
of routine call-up times (usually once or twice a day)
when the advice of a doctor or other senior health
worker stationed at the base is available. They also
stress the paramount importance of an adequate
maintenance service for the radio equipment. It is
with regard to inadequate servicing that most
problems have arisen in the operation of radio-
communication systems. Although most services
have been operated as supportive networks to flying
doctor services this is by no means a necessity.
There are several manufacturers of appropriate
radio equipment. The most important issues in the
choice between different brands are local availability,
the provision of adequate servicing facilities, and
standardization with other local (particularly govern-
ment) systems. The cost of different transceivers
varies depending upon technical specifications.
Generally adequate units costing around £800 are
obtainable from the following, mostly United
Kingdom, sources:
(i) Aero Electronics (AEL) Ltd., Gatwick House,
Horley, Surrey, England, RH6 95U. The
transceivers manufactured by AEL are priced
around £400 and have been used extensively in
Africa, especially by missions.
122 I TRANSPORT AND COMMUNICATION SYSTEMS IN HEALTH SERVICES
(ii) Pye Telecommunications Ltd, Newmarket
Road, Cambridge, England, CBS 8PD.
(iii) Racal Communications Ltd., Western Road,
Bracknell, Berkshire, England, RGI2 IRG.
(iv) Redifon Telecommunications Ltd., Broomhill
Road, London, England, SWI8 4JQ.
(v) Stoner Communications Inc., 8751 Industrial
Lane, Cucamonga, California 9173°, USA.
Each unit requires in addition to a transceiver an
aerial costing about £100 and, ideally, a small
generator costing around £150 to power the trans-
ceiver (although a 12 volt DC battery can be used).
This total capital cost of £1,050 is equivalent to an
annual amount of £170, including a ten year, 10%
discount rate. Annual maintenance and running costs
are usually not more than £75 per unit. This total
annual cost of about £240 would be equivalent (in
the case of Botswana) to an increase of less than 4%
in an average clinic's total annual costs. The increase
in effective care dispensed from such clinics is judged
to be appreciably greater than the proportionate
increase in costs.
CONCLUSIONS
The use of all mechanical transport in health services
must be viewed critically. This is even more im-
portant with the recent massive increase in fuel
prices. Given the resources available and the health
needs of populations in most developing countries,
the use of health service transport with the highest
benefit-per-unit-cost is likely to be that involved in
the supportive (not policing) visiting of permanently
staffed basic care units. For the majority of this
visiting small vans or pick-ups are adequate. Where
Occasional Correspondence
SICKLE CELL DISEASE IN PREGNANCY
Dr Duflo disagrees:
The article about "Sickle cell disease in pregnancy"
by K. A. Harrison (Tropical Doctor, 1976, 6, 74-80)
is quite interesting. However, I disagree with some
therapeutic procedures advocated by the author.
I. Pyrimethamine (p. 77) is best avoided during preg-
nancy. This drug enhances folate deficiency (usual
during pregnancy in the tropics) and probably causes
fetus malformation.
2. Tetrac cyclines (p. 48) should be avoided during
pregnancy: high dosages cause maternal acute hepatic
steatosis and even small dosages give a yellow colour
to the teeth of the baby.
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Tropical Doctor, July I977
several nights have to be spent away from the health
base larger Land-Rover type vehicles or lorries might
be necessary. The use oflight aircraft can usually only
be justified to serve permanently staffed units at a
great travel time from a health base. If aircraft are to
be used in this capacity then their use must be tightly
scheduled to guard against their diversion to activities
with a lower cost-benefit ratio.
Radio-communication systems connecting isolated
peripheral health units with regional or district health
headquarters are likely to appreciably increase the
overall effectiveness ofsuch units.
ACKNOWLEDGEMENTS
We thank the Botswana government, and the UK Ministry
of Overseas Development which assisted the authors in
1975 during their work as consultants to the Government
of Botswana on the development of mobile health services.
REFERENCES
Gish, 0., and Walker, G. J. A. (1976). Mobile Health
Services: a Study in Cost-effectiveness. London: Greenfield.
(In press.)
Soper, F. L. (1969). The Relation of the Mass Campaigns for
the Prevention of a Specific Disease to the General Health
Services. WHO/PHA/Mass Campaigns/5.
Wood, A. M. "The Use of Modern Forms of Transport in
Community Medicine", in Health and Disease in Africa:
East African Medical Research Council Conference, Nairobi,
I970. Ed. Gould, G. C. Kampala: East African Literature
Bureau.
Wood, A. M. "Communication with Rural Areas by Radio,
Light Aircraft and Mobile Land Units". J. roy. Coll. Surg.
Edinb., 16,202.
WHO/UNICEF (1974). Joint Study on Alternative Ap-
proaches to Meeting Basic Health Needs of Populations in
Developing Countries. JC/UNICEF-WHO/75.2.
3. Heparinization (pp. 78-79), advocated by the
author, is a rather hazardous procedure in many
tropical hospitals with poor laboratory facilities. The
dangers of overdose during pregnancy are well
known. Moreover, the efficiency of heparin during
vaso-occlusive crisis is not established.
4. Blood transfusions (pp. 77-79) during the last
trimester of the pregnancy are obviously difficult
under tropical conditions. However, they are probably
less dangerous and more useful than heparin.
EDWARD DUFLO
BP I679
Medecin de L' H8pital du Point G
Bamako, Mali