Riders For Health

For the exclusive use of S. Sarvaiya, 2024.
CASE: GS-58
DATE: 11/26/07
RIDERS FOR HEALTH:

HEALTH CARE DISTRIBUTION SOLUTIONS IN SUB-
SAHARAN AFRICA
Transportation in Africa needs to be made a high-profile issue so people can realize its
importance, address it, and allow it to disappear again.
—Andrea Coleman, co-founder of Riders for Health
INTRODUCTION
In 1996, Andrea and Barry Coleman launched Riders for Health, a United Kingdom-based
nonprofit dedicated to the improvement of transportation systems for health workers in Africa.
The nonprofit’s main program, Transportation Resource Management, involved a maintenance
and training program for motorcycles and other vehicles used by health workers to deliver
medical care in remote African communities. Although dedicated to an unglamorous area of
health care, the program was incredibly successful and one of the few examples of a practical
solution to the world’s most intractable health care problems. Nevertheless, by 2007, the
organization was at a critical decision point. It had tapped its established, external funding
sources almost to maximum levels but still required significant capital to expand. The
organization had to decide what strategies, both financial and operational, to implement in order
to achieve the much larger scale it needed to spread the benefits of its program across wider
sections of Africa’s afflicted population.
HEALTH CARE IN AFRICA
In 2007, Africa was the poorest continent in the world, with the standard of living in Sub-
Saharan Africa significantly below that of almost every other part of the world. Average per
capita gross national income (GNI) amounted to just $746 in Sub-Saharan Africa compared with
$1,600 in East Asia, $4,000 in Latin America, $32,000 in the European Union, and $43,600 in
Brian Tayan prepared this case under the supervision of Professor Hau L. Lee as the basis for class discussion rather
than to illustrate either effective or ineffective handling of an administrative situation.
Copyright © 2007 by the Board of Trustees of the Leland Stanford Junior University. All rights reserved. To order
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This document is authorized for use only by Sahil Sarvaiya in Strategic Operations Immersion Spring 2024 taught by JAMES HINTLIAN, Cornell University from Jan 2024 to Jul 2024.
Riders for Health, GS-58 p. 2
the United States. Africa’s most populous nation, Nigeria, had per capital GNI of only $650,
meaning that its 130 million citizens lived on less than $2 per day.1
Along with poor economic conditions, Africans had a much lower life expectancy. For example,
average life expectancy for men and women was 49 years versus 77 in the U.S. In Malawi, a
country with particularly poor health conditions, a child had a 12.5 percent chance of dying
before the age of five, compared to 0.8 percent in the U.S. Mothers in labor also faced high risk,
with the mortality rate of mothers in childbirth at 1.8 percent in Malawi versus 0.014 percent in
the U.S.2
Among infectious diseases, HIV/AIDS, malaria, measles, pneumonia, tuberculosis, and

dehydrating diarrhea (caused by cholera, dysentery, typhoid, and rotavirus) were the most
deadly. In Sub-Saharan Africa, 25 million adults and children were living with HIV/AIDS,
representing 6 percent of the population. Swaziland, Botswana, Lesotho, Zimbabwe, Namibia,
and South Africa were among the hardest hit, with infection rates of 19-33 percent.3 Each year,
2 million Africans died from AIDS. In addition, 1 million Africans died each year from malaria
and 0.4 million from tuberculosis (see Exhibit 1 for causes of death in Africa).
Because of the extremely poor health care conditions in Africa, national and international figures
have labeled the situation a global crisis. Former British Prime Minister Tony Blair called
reversing poverty and disease in Africa “the fundamental moral challenge of our generation.”4
Bill Gates, founder of Microsoft and co-chair of the Bill and Melinda Gates Foundation,
described the situation by stating, “If you believe that every life has equal value, it’s revolting to
learn that some lives are seen as worth saving and others are not.”5
International Aid
Several international aid groups, nongovernmental organizations, governments, and nonprofits

accelerated efforts to increase the amount of resources dedicated to addressing the humanitarian
crisis in Africa. The best known on a worldwide basis was the Global Fund. Founded in 2002,
the Global Fund was a Swiss-based nonprofit organization whose mission was to make
significant progress in decreasing the number of deaths from AIDS, tuberculosis, and malaria in
the developing world. Grants by the Global Fund averaged $1 billion per year and were
collected from the pledges of 50 countries around the world, with the United States as the largest
donor providing approximately 33 percent of total funds. Over half of Global Fund grants were
1
2007 figures based on 2005 data, reported in U.S. dollars and based on the Atlas method. Source: World Bank,
“GNI per capita 2005,” http://web.worldbank.org (June 14, 2007).
2
WHOSIS (WHO Statistical Information System), “World Health Statistics 2007,” http://www.who.int/whosis/
whostat2007/en/index.html (June 14, 2007).
3
UNAIDS, “Report on the Global AIDS Epidemic 2006,” http://www.unaids.org/en/HIV_data/2006GlobalReport/
default.asp (June 14, 2007).
4
“Promises, What Promises?” The New York Times, May 22, 2006.
5
Harvard University Commencement, July 7, 2007, http://www.gatesfoundation.org/MediaCenter/Speeches/Co-
ChairSpeeches/BillgSpeeches/BGSpeechHarvard-070607.htm (June 14, 2007).
allocated to Sub-Saharan Africa, with grant money sent directly to the ministry of health in each
nation to support local programs.6
The United States government allocated money through the President’s Emergency Plan for
AIDS Relief (PEPFAR) in addition to providing funds to the Global Fund. First proposed in
2003 by George W. Bush in the State of the Union address to Congress, PEPFAR pledged to
allocate $15 billion over five years to fight AIDS in Africa and the Caribbean. It was the largest
source of funding for AIDS treatment in Africa, with funds granted to 15 “focus” countries.
Unlike the Global Fund, which provided funds to African governments and health ministries,
PEPFAR provided funds directly to clinical programs.7
Founded in 2000, the Bill and Melinda Gates Foundation focused on global health as one of the
three main beneficiaries of its roughly $33 billion endowment. The two priorities of the global
health initiative were to increase access to existing therapies and tools to fight diseases, and to
expand research in the development of effective and affordable health solutions. The Gates
Foundation operated on a partnership model that relied on third-party organizations and groups
to implement solutions.
In addition to funding organizations, several groups provided on-the-ground services to improve

health care conditions in Africa and increase public awareness. Médecins Sans Frontières (MSF,
known in English as Doctors Without Borders) employed over 3,000 doctors, nurses and other
health care workers to provide medical resources and training in developing nations. UNAIDS,
established by the United Nations in 1994, advocated for accelerated global action on
HIV/AIDS. Catholic Relief Services provided aid in emergency situations and developed
sustainable health programs in local communities. Many prominent politicians and high profile
individuals also dedicated their time to mobilizing and coordinating international aid efforts.
Though recognizing the challenges, many felt optimism that tangible progress could be made.
Bono, lead singer of the rock band U2 and Time co-Person of the Year in 2005 for African aid
efforts, explained the common objective by stating, “My generation wants to be the generation
that ended extreme poverty.”8
Healthcare Solutions
Several affordable health care solutions were available to improve the conditions of those who
suffered. Although there was no vaccine to cure or prevent HIV/AIDS in 2007, antiretroviral
medicines had been developed that could slow its progress and spread. Because the HIV virus
was prone to mutation and eventual resistance to drugs, HIV/AIDS treatment typically consisted
of three drugs used in combination, in what was called a drug cocktail. Drug cocktails could be
created through either generic medicines or more potent next-generation medicines, often under
patent protection. HIV/AIDS patients had to remain on a drug therapy regimen for life, which
6
“The Global Fund to Fight AIDS, Tuberculosis, and Malaria,” AVERT, 2006, http://www.avert.org/global-
fund.htm (October 19, 2006).
7
“President’s Emergency Plan for AIDS Relief (PEPFAR),” AVERT, 2006, http://www.avert.org/pepfar.htm
(October 19, 2006). Total PEPFAR pledges included money given to the Global Fund.
8
James Traub, “The Statesman,” The New York Times, September 18, 2005.
required recurrent monitoring by local health workers. Through continuous drug access,
HIV/AIDS could be treated as a manageable, though still life-threatening, chronic condition.
Due to pressure from the activist community, pharmaceutical companies often made their patent-
protected drugs available for distribution in Africa at a significantly lower price than that in
developed markets. For example, Gilead Sciences sold the advanced antiretroviral drug Viread
(tenofovir disoproxil fumarate) at its cost of production, which came to $17 for a 30-day supply.
The same 30-day supply cost $360 in the United States. By comparison, generic d4T, an older
generation AIDS treatment, was sold in Africa at a cost of $5 for a 30-day supply.
Malaria and tuberculosis had both been widely eliminated in the developed world. Although no
vaccine had been developed for malaria, preventative drugs were available to reduce the risk of
developing the disease, which was transmitted by mosquitoes. However, because anti-malarial
drugs had to be taken continuously, they were not a cost-effective solution in most Sub-Saharan
countries. Also, individuals often developed resistance to anti-malarial drugs over time. Most
organizations favored the distribution of inexpensive bed nets which protected families from
malaria-infected mosquitoes at night. Such bed nets typically cost $5. Tuberculosis, which was
caused by bacterial infection, could usually be cured with antibiotics that cost $16.
Commercial drugs also existed for several other common diseases, including measles, Hepatitis
B, and rotavirus. International aid was used to procure these drugs and other medical supplies.
It was also used to expand local health clinics and develop education programs to improve
treatment and prevention.
Obstacles to Providing Health Care
Despite the increase in financial resources and dedicated efforts of humanitarian organizations to
improve health care in Sub-Saharan Africa, conditions had changed little in recent years. The
number of people living with HIV/AIDS remained similar to what it had been years before; for
the most part, new infection rates were the same as they had been in the late 1990s. Even though
health organizations had made efforts to expand the availability of antiretroviral medicines, such
drugs were reaching only 28 percent of the patients who needed them.9
Experts pointed to the significant difficulties in overcoming infrastructure and other logistical
obstacles. First, there was a severe shortage of health care workers to support the continent’s
population. Africa was estimated to have 2.3 health care workers per 1,000 population,
compared to 4.3 in south-east Asia, 18.9 in Europe, and 24.8 in the Americas. To some extent
this shortage was due to the difficulty of recruiting and training qualified workers in hard-to-
reach locations and for low wages. However, qualified health workers were also difficult to
retain and often quit their positions because they found it difficult to fulfill their duties without
the necessary supplies, support, and access to patients. Africa’s health workforce was under-
represented by nurses and support staff, placing additional strain on skilled doctors to perform
9
Sharon LaFraniere, “New AIDS Cases in Africa Outpace Treatment Gains,” The New York Times, June 6, 2007.
routine procedures like vaccinations as well as administrative work. These shortages were
exacerbated by the fact that a greater percentage of the population required medical attention.10
Second, the continent had a severely underdeveloped physical infrastructure system. For
example, most African nations lacked a modern sewage collection and treatment system. These
systems, implemented in developed nations in the second half of the nineteenth century, had
been directly responsible for the elimination of water-transmitted diseases such as cholera. By
comparison, their absence in Africa contributed to the prevalence of several diseases.
The continent also lacked an integrated road, transportation and logistics network. For example,
Zimbabwe had a total area of 390,000 square kilometers but an estimated road system of only
18,300 kilometers.11 Although major African cities were connected by paved roads, much of the
population lived in remote communities that were accessible only by single-lane sand or dirt
paths. According to the United Nations, 62 percent of Africans lived in rural communities
compared with 19 percent in North America and 28 percent in Europe.12 In many African
countries, only 20-30 percent of the rural population lived within 2 kilometers of a road.13
Furthermore, there was limited existing infrastructure, such as postal services or railroads,
reaching into these communities. As a result, health workers could not easily reach the vast
population living in remote locations. People requiring medical attention had to devise their own
ways to travel to the closest health clinic. Without motor transportation, they were often forced
to walk or rely on a relative to push them in a wheelbarrow. Tragically, those who lived five
miles or more from a health clinic and were sick, malnourished, or pregnant had significantly
lower survival rates than those who lived closer to a clinic.
Third, cultural barriers sometimes disrupted access to medical treatment. For example, drugs
and vaccines that were imported into African countries were received by the ministry of health or
customs office. In some cases, local officials expected foreign organizations to pay bribes or
facilitating payments to accelerate processing of paperwork; failure to make such payments
could delay access. As another example, disease or infection often carried a social stigma, with a
patient being shunned by his or her community. As a result, an individual who suspected s/he
might be sick often chose to put off seeking medical attention until the condition became
impossible to ignore. Such a practice not only led to higher risk for the patient but also increased
infection rates for those nearby.
New methods were needed to overcome these obstacles. The most effective solutions would be
those that allowed for increased physical presence or outreach by health workers into the
community itself. Although viable solutions would draw the financial support of international
organizations, in the long term workable solutions would have to become economically self-
sustainable.
10
The World Health Organization, “The World Health Report 2006,” http://www.who.int/whr/2006/en/ (June 14,
2007).
11
Africa South of the Sahara, 2001, (London: Europa Publications, 2000).
12
United Nations, World Population Prospects: The 2006 Revision Population Database, http://esa.un.org/unpp/
p2k0data.asp (June 14, 2007).
13
The World Bank, Africa Development Indicators, 2006, (Washington, DC: 2006), Table 7.2: Transportation.
RIDERS FOR HEALTH
In 2007, Andrea and Barry Coleman were co-chief executive officers at the United Kingdom-
based nonprofit Riders for Health, an organization dedicated to the design and management of
motorcycle training and maintenance programs in Sub-Saharan Africa. Barry—who had an
academic background in philosophy, law, and theology—led the operations team at Riders and
formulated the strategy for how the organization would develop over time. Andrea—who had a
practical background in motorcycle racing and motorcycle team management—served as the
entrepreneurial and creative spirit of the organization, spearheading the fundraising while also
working closely with Barry on operations. The husband and wife team fell almost
unintentionally into the nonprofit world, led by their strong ideals and a belief that their practical
knowledge of vehicle maintenance and management could have a substantial positive impact on
health care solutions in Africa. Both have affable and engaging personalities, joking that they
were “blue collar philanthropists.”14
The story of Riders dates back to 1986 when Andrea Coleman and United States Grand Prix
motorcycle racer Randy Mamola decided to raise money for Save the Children, a United
Kingdom-based nonprofit dedicated to helping children in developing nations that suffer from
poverty and disease. At the time, Andrea worked in motorcycle team management in the U.K.
Barry worked as a feature writer for the Guardian and also covered motorcycle racing for the
newspaper on the weekends.
Mamola and Barry Coleman were subsequently invited by Save the Children to observe how the
funds they raised were used to immunize children in Somalia. During a visit to a remote
community, the health officials accompanying them mentioned that immunization in such
locations was rare because insufficient motor transportation made access difficult for health
workers. The two noticed several motorcycles left by the side of the road that, according to
locals, were no longer operable. Upon inspection, they were shocked to discover that many of
the bikes were considered irreparably damaged with odometer readings of only 800 kilometers
(500 miles). Health officials explained that the motorcycles broke down prematurely due to
dusty and hot conditions. Mamola and Coleman, however, realized that the locals simply had
not been trained in basic motorcycle maintenance; many of the bikes were rendered out of
commission due to problems that were inexpensive to prevent or repair, such as dust in the
carburetor, failure to replace an oil or air filter, or a broken clutch or brake cable.
Shortly thereafter, Coleman was engaged as a consultant by Save the Children and the World
Health Organization to assess its fleet of 86 motorcycles in Gambia. Coleman discovered that
only 12 of the bikes were still in operation, with the remainder no longer in use due to similar
problems witnessed in Somalia; the 12 in use remained operable because they were regularly
maintained by a driver with basic knowledge of mechanics. When Coleman was informed that
UNICEF had donated another fleet of 83 motorcycles to the NGOs, his advice was: “Line them
up on the quayside and push them in the river.” Without parts or training, they would end up
being more of a liability than a productive asset, costing much-needed resources while failing to
deliver the expected benefits.
14
All quotations from Barry and Andrea Coleman from interviews with the case writer on June 26 and July 12,
2007.
Based on his findings, Coleman designed and developed a motorcycle training and maintenance
outreach program to ensure that African organizations could utilize vehicles over their estimated
useful lives through cost-effective measures. The program, which began as a consulting project
for Gambia, was later replicated in Uganda and Lesotho. Then, full-scale nationwide programs
were launched with the ministries of health in Zimbabwe, Nigeria and Gambia. The program
was also adapted to include four-wheel vehicles, such as Land Rovers.
While Barry focused on the development of the Riders programs, Andrea worked to set up the
entity that became Riders for Health, registering the organization as a nonprofit in the United
Kingdom and putting in place the necessary administrative, legal and funding platforms. The
Colemans believed that the effectiveness of their programs could be maximized if executed
through an organization that focused on building scalable, replicable, and financially self-
sustaining practices. Riders’ customers were primarily ministries of health, but also included in-
country nongovernmental organizations and other relief organizations such as Catholic Relief
Services and UNICEF. The principle beneficiaries of Riders’ work were ultimately health
workers and the patients who critically required care.
Transport Resource Management
The Riders for Health solution for motorcycle fleet maintenance was called Transport Resource
Management (TRM), a program that was designed to work within the tough conditions and
limited resources of many Sub-Saharan African countries. As Andrea Coleman explained:
How do you run and manage a fleet when there is no infrastructure to speak of,
when there are no roads, no dealerships, no system for delivering parts, no
services, no training and knowledge of maintenance practices? We knew that we
had to find a solution and that it would not be a first world solution. It had to be a
developing world solution to a developing world problem.
TRM was designed as a last-mile delivery solution demonstrating that a logistical solution could
be found even in the absence of existing infrastructure. TRM was designed with three
fundamental principles in mind. First was the principle of preventative maintenance. Through
routine inspection and the regular replacement of basic parts, significant damage could often be
avoided. Because health workers relied on their motorcycles to reach patients in critical need of
care, keeping a motorcycle operational directly impacted their ability to save lives. Preventative
maintenance provided the best assurance that a motorcycle would not break down while in use.
Second, TRM was based on the principle that local individuals from each African nation should
be responsible for the ongoing management of the program. Administrative and technical staff
in the country’s offices were African. Riders believed that such a practice would lead to the
accumulation of a knowledge base about technical and business management that over time
would benefit the local economy. Riders also recognized that African technicians would have
more credibility with African health workers and patients. Technicians enrolled in a six-week
training course led by Riders in which they learned basic motorcycle maintenance skills and
training techniques. Upon completion of the course, they were responsible for teaching health
workers the basic skills of routine motorcycle inspection and for performing intermediate-level
services on an ongoing basis. Over time, the technicians increased their knowledge base by
pursuing more advanced lessons from Riders’ instructors.
Third, the TRM system was designed to be scalable. Riders wanted to ensure that the basic
operating tenets that supported a single fleet of motorcycles in a country would continue to work
as more customers were added to the program. Restructuring the flow of parts and allocation of
administrative and technical staff once a program was put in place could cause costly
disruptions.
Motorcycles in the TRM

There were various reasons why motorcycles were effective transportation vehicles in sub-
Saharan Africa, the most important being their ability to access terrain that was inaccessible by
four-wheel vehicles. They were cheaper to purchase and operate (a health organization could
purchase six motorcycles for the cost of one four-wheel vehicle). Motorcycles also required
fewer and less complicated tools to maintain, and they had lower carbon emissions per kilometer
than a four-wheel vehicle. Finally, they were less subject to abuse. Because four-wheel vehicles
like a Land Cruiser were status symbols, corrupt officials would “borrow” them for personal
purposes, diverting them from their much-needed public mission.
The motorcycle fleets traditionally owned by African health organizations consisted of a variety
of makes and models, many of which were inappropriate for the terrain and conditions of Africa.
In order to reduce the cost and complication of TRM, Riders emphasized the importance of
standardizing vehicle fleets wherever possible. The bikes most commonly recommended by
Riders were agricultural specification bikes, including the Honda XL125, Honda CTX200,
Honda CT110, and the Yamaha AG200. Agricultural specification bikes were rugged and low
tech, making them well-suited for riding conditions in Africa. They had high mud guards above
the front and rear wheels, hand guards on the handlebars, and a fully enclosed chain for greater
protection against debris and pebbles kicked up by the tires. The turn indicators were mounted
on rubber for better insulation against shock. The smaller one- and two-stroke engines had
greater power output, and could be started by kick-start which was less prone to failure.
Most health ministries and nongovernmental organizations had their own fleet of motorcycles,
although Riders advised on the acquisition of new bikes when requested. The health ministries,
which did not have significant capital or discretionary budgets, often received motorcycles as
donations from foreign governments and large foreign agencies. Better endowed organizations,
such as UNICEF, generally purchased their own motorcycles. Agricultural specification bikes
cost approximately $2,000 each.
Although organizations were excited to receive motorcycles as donations, Riders warned them to
prepare for the additional costs that were required to maintain the bikes over their useful lives
and advised that they delay acceptance if they were unprepared to fund these costs. According to
Barry Coleman, “A free gift isn’t much of a gift if it comes with associated costs. It can have
negative value for the unprepared recipient.”
Maintenance Practices
Riders designed a rigorous maintenance program for its customer’s motorcycle fleets, which they
were expected to follow closely. Health workers were trained to do routine pre-ride checks
every day to ensure their bikes were fit for operation. The checklist included inspection of the
tires, oil level, coolant level, the chain, brakes, and lights. They also made certain that nuts and
bolts were tight and performed a visual check, looking for signs of damage, excessive dirt or
dust, and pebbles lodged in the engine, chain or tires.
Once per month, a Riders-trained technician performed maintenance on the bike and changed
parts that were at highest risk from daily wear and tear. Small-dollar parts were replaced before
their full useful lives had run out, according to a strict replacement schedule designed for rough
riding conditions. Unexpected damage, such as a broken chain or clogged air filter while on the
road, could cause significantly more expensive damage to the bike frame or engine, not to
mention the risk to the rider and inability to reach patients. Replacement-part maintenance was
performed on an outreach basis, meaning that technicians went out into the field to service the
motorcycles in the locations in which they were used. Physical inspection of the bikes allowed
the technician to plan the parts and service that would be required on the next visit. It also
allowed the technician to provide refresher training and riding instructions for health workers.
By having both the health worker and trained technician follow conservative, routine practices,
Riders aimed to keep vehicles fully operational between scheduled services. By adhering to
Riders’ guidelines, an organization could extend the useful life of its motorcycles from
approximately 20,000 kilometers (12,400 miles) to 80,000 kilometers (49,700 miles).
Operations Management
Operations management was another critical aspect of Riders’ TRM program. TRM was run on
a hub-and-spokes model within each country. The largest Riders office was usually centered in
the country’s capital, which served as the bridge to the developed world. The national office was
typically staffed 60 percent with technicians and 40 percent with office administrators. Spare
parts were imported into the national office and then redistributed to smaller regional offices.
Regional offices tended to have higher levels of technical staff (80 percent), leveraging as much
as possible the administrative support of the national office. Regional offices, in turn, supported
the health workers who were widely distributed among remote communities (see Exhibit 2 for a
map of Riders’ operations in Zimbabwe).
Because spare parts were expensive, Riders taught careful inventory management practices. By
maintaining service records on each motorcycle and gathering feedback from technicians in the
field, Riders’ logisticians had advance knowledge of what parts would be required and could
appropriately time inventory replenishment. The national office tended to have the highest level
of spare parts inventory. Riders provided similar expertise on the management of fuel supplies.
They also made sure that all health workers were equipped with the proper protective gear, riding
suits, and helmets.
Riders charged a fixed cost per kilometer to operate TRM. The annual fee, which was designed
to cover operating and local administrative expenses on a breakeven basis, was generally in the
range of $0.17 to $0.19 per kilometer. This fee covered everything from setting up the local
office, to replacement parts, petroleum, protective gear, training, and logistics management. The
fixed fee structure allowed the organizations that Riders served to more reliably plan their budget
and keep track of the territory that health workers covered.
Funding Riders for Health

Although the TRM program operated on a breakeven basis within each country, the United
Kingdom office required donated funds to support central administrative work. In addition, the
expansion of TRM into new countries and any significant scaling up of the program within a
country also required the infusion of fresh capital that was not recaptured through the per
kilometer fee. The Colemans believed that amortizing those costs in the TRM fee would make
the program prohibitively expensive for the organizations it supported, as well as run counter to
their ultimate nonprofit mission of improving the delivery of health care in Africa (see Exhibit 3
for Riders’ financial results).
As a result, Riders continued to raise money through MotoGP (the motorcycling equivalent of
Formula One) to support its central office and program expansion. Money was raised through
hosted events in which Riders made professional motorcycle racers available to interact with
fans, who were charged an entrance fee, and through the auction of celebrity clothing and
memorabilia. Professional racers were accepting of the events because they were proud of a
humanitarian effort that grew directly out of their sport and believed it helped to raise the image
of racing.
In addition, Riders was beginning to find acceptance raising money from nonprofit foundations.
In Riders’ early days, foundations had found the connection between motorcycle maintenance
and delivering health care too far removed, unproven, and difficult to understand. The nonprofit
community preferred to fund the direct costs of supporting health workers and supplying
medicines and supplies; they were not as enthusiastic about funding infrastructure costs that they
viewed as having only an indirect impact. As Andrea Coleman explained, “People see a picture
of someone changing an oil filter and they say, ‘why would I want to pay for this?’” The
nonprofit community was not accustomed to thinking in terms of the costs of decreased health
worker mobility or the impact that failed motorcycles had on addressing disease. With time,
however, as other international aid efforts failed to gain traction, nonprofits began to appreciate
the importance of infrastructure and logistics. Riders found that its ability to quantify both the
cost and the impact of its efforts led to better acceptance by foundations and other grant-making
bodies. For example, by the end of 2007, Riders had reached an agreement to launch a new
program in Lesotho, with initial seed funding from the Elton John AIDS Foundation. It was the
first national program whose initial funding was predominantly provided by a nonprofit
foundation, rather than hosted events in association with MotoGP.
Impact of Transport Resource Management
Riders demonstrated through TRM that roads and a developed-world transportation system were
not a necessary requirement for delivering health solutions. Simply by extending the operational
life of a motorcycle fleet, it was able to help the health organizations that it served reach
significantly more patients and do so in a manner that created financial savings. For example, in
Zimbabwe, the Department of Health estimated that its budget for managing its motorcycle and
vehicle fleet saved £319,400 in 2004 due to reduced motorcycle repurchase costs. The country,
which also applied TRM techniques to its fleet of vehicles, saved an additional £504,700 from
reduced vehicle repurchases that year. Taking into account the increased number of patients that
health workers were able to visit, it was able to realize a 62 percent reduction in annual
motorcycle fleet maintenance costs per thousand patients reached (£25 per thousand patients
reached under TRM, down from £67 per thousand on an unmanaged basis). The Gambia
Department of Health realized similar results in 2004: annual savings of £27,300 on motorcycle
repurchase costs, £141,600 on vehicle repurchase costs, and a 24 percent reduction in annual
fleet maintenance costs per patient treated per month by nurses on an outreach basis (£3.3 to £2.5
per patient per month).
Cost savings were derived largely from the fact that health workers were able to reach more
patients and therefore achieve better leverage from their resources. For example, Riders’
experience in Zimbabwe indicated that a health worker using a motorcycle was able to reach
approximately five times as many people as one who travelled on foot. More importantly, health
workers in Riders’ TRM were better able to make repeat visits to patients, ensuring better long-
term care. In Zimbabwe, a health worker using a motorcycle was able to visit two villages of
500 people every day, which translated into 20,000 patient visits per month. The same health
worker on foot could not possibly provide care on this scale. In a geographical region where
villages were 10 kilometers apart, the health worker might travel a total of 40 kilometers. At a
cost per kilometer of $0.17, this mileage translated to $6.80 per day or $136 per month.
Distributed over 20,000 patient visits, this cost equaled 0.68 cents per patient visit.
With greater mobility, Riders’ health workers were able to diagnose and treat more patients with
illnesses. Health organizations were also able to utilize savings on fleet replacement costs to
increase the number of health workers employed.
Case Study: Binga Program

The impact of TRM was exemplified by a program that Riders operated in the Binga region of
Zimbabwe. Located in the northwest region of the country, Binga was one of the poorest
districts in Zimbabwe. In 2002, Riders established a TRM program in Binga, training and
equipping the 16 health workers responsible for patients in the area.
As a result of the TRM program, Riders’ equipped health workers were able to make more visits
to local communities and increase education on methods to slow the spread of diseases, such as
HIV/AIDS, malaria, and cholera. They distributed mosquito nets and provided instruction on
use. They also provided prenatal care as well as education on reproduction and birthing.
Riders conducted a study in partnership with local public health officials and academics from the
University of Southampton to measure the impact of TRM in the Binga District.15 In the study, a
comparison was made between Binga and the Gokwe, a neighboring region to the southeast
where no change was made in motorcycle usage and maintenance. Results showed that
increased mobility dramatically increased the presence of health workers in local communities.
Only 22 percent of those surveyed in Gokwe reported weekly visits by health workers, versus 49
percent in Binga. Conversely, 68 percent of people surveyed in Gokwe said that health workers
visited their community less often than monthly, compared to only 13 percent in Binga.
Comparisons were also made between malarial deaths in each district in 2001 and 2002.
Whereas Gokwe exhibited a 44 percent increase in malarial deaths year-over-year, Binga
reported a 21 percent decrease. Although not a scientifically controlled study, the results
15
Results were later verified by business consultancy OC&C in a due diligence report for Riders for Health.
provided strong support for the Riders’ TRM solution and indicated that it was consistent with
improved health outcomes (see Exhibit 4 for results from the Binga-Gokwe study).
GOING FORWARD
In 2007, Riders for Health was at a crossroads. The organization had demonstrated that its TRM
program was both a financially and medically sensible solution for health organizations in the
poorest regions of Africa. Sixteen years after the launch of the first program, Riders had national
programs in Gambia, Nigeria and Zimbabwe, with local programs in Kenya and Tanzania. The
organization had grown to support 900 health workers in these countries by equipping each one
with a regularly maintained vehicle. Importantly, Riders had achieved these results from a
standing start of almost no capital. Growth had come entirely through fundraising among the
motorcycle racing community, sponsored events, foundation support, and fees earned on the
program. Riders had received numerous awards for its achievements. It was honored as a Tech
Museum Laureate in 2006, short-listed in the International Aid and Development category at the
United Kingdom Charity Awards in 2005, and was winner of the Global Health Council Award
for Best Practices in Global Health in 2005. In addition, Barry and Andrea Coleman were jointly
named Ernst & Young (U.K.) Social Entrepreneurs of the Year in 2006. Riders for Health was
also featured in the Emmy-winning documentary “Rx for Survival,” which aired on PBS.
Riders had expanded into other business areas as well. It had developed a program called the
International Academy of Vehicle Management (IAVM), which offered training courses on the
techniques of transportation maintenance to individuals in positions of responsibility throughout
the developing world. Services included short courses on maintenance and operations
management to major consulting projects for organizations who wanted to implement Riders’
practices. Through IAVM, Riders believed it could further spread the practice of vehicle
management across Africa by increasing local expertise.
Also, Riders had developed a new transportation solution known as the Uhuru. The Uhuru was a
motorcycle with a side-car attachment that a health worker could use to transport patients (see
Exhibit 5). The surface of the side-car attachment resembled a stretcher, with additional
padding for comfort and straps so that the patient could be tightly secured during transport. The
vehicle attachment allowed workers to more safely drive gravely ill patients and pregnant
women to a nearby clinic, an alternative that was dramatically more conducive to their health
than walking or being transported by wheel barrow. The Uhuru was designed to provide
functionality in addition to patient transportation. For example, when not in operation, the power
take-off at the back wheel could be connected to a water pump, with enough power to pump
water at a rate of over 100 liters per minute. The water pump allowed local communities to more
efficiently irrigate agricultural fields by no longer having to carry water in pails. Also, the uhuru
came with a detachable rear trailer which could also be used to transport water or fuel. The
Uhuru had generated intense interest by many as a practical solution for emergency situations.
However, Riders decided that the mass manufacturing of such devices was beyond the range of
its core business.
Also, the Colemans recognized certain risks in the operations of TRM, the most prominent of
which was that Riders could not control the disposal of vehicles. The organizations that Riders
supported were inclined to keep vehicles in operation until they were irreparably broken down.
Such a mentality arose from conditions that demanded the maximization of scarce resources. As
a result, these organizations did not have a mentality of optimizing the residual value. However,
Riders’ fee structure—a fixed fee per kilometer per vehicle—masked the fact that the true cost of
maintaining a motorcycle was not linear, depreciating in a straight line each year. Even though
Riders added up and averaged the total costs expected over the lifetime of the bike, the first years
were generally less expensive and later years significantly more expensive. Attempting to keep
bikes in service beyond Riders’ recommended useful life would lead to a spike in costs that
Riders would have to absorb under a fixed-fee price schedule, or would lead to a gradual
escalation in the fixed-fee price.
Increasing Sustainability and Impact
All in all, Riders for Health had proven very practical in developing solutions for the devastating
health situation in Africa, and the Colemans were proud of the work that their team and affiliates
had done. The work of Riders had highlighted the fact that, despite the lack of an integrated
transportation system in Africa, health services could still be delivered to remote locations in a
cost effective manner, and the provision of reliable motorcycle and motor vehicle transportation
could act as a catalyst to improve health conditions on the continent. The Colemans recognized,
however, that Riders’ current programs supported only a very small percentage of the estimated
200,000 total vehicles used by health workers in Africa. They knew that they had a proven
solution with TRM, and wanted to increase its future impact by leveraging its knowledge base
and programs. Such an expansion would literally improve the health of millions of individuals.
The Colemans also knew that they could not rely solely on the charity of the motorcycle
community to fuel a significant increase in the size of the organization. The development of a
new country program would cost almost £150,000 in set-up costs, and the expansion of an
existing program anywhere from £15,000 to £40,000. Although the professional racing
community was highly supportive of Riders’ mission, there was not enough money available
through sponsored events to fund several more national programs. Riders would have to find
entrepreneurial ways to generate funds, increase scale, and improve economic sustainability.
The organization had a few options. First, it could find a way to access larger capital pools.
Second, it could expand its existing activities—operations management and logistics services—
and apply them to new markets. Third, it could introduce new financial models for its existing
activities. An example would be introducing a leasing program in which Riders would purchase
vehicles outright and charge them out at a higher per-kilometer fee to include depreciation.
Fourth, it could expand the ancillary businesses that it had entered or develop other related
transportation businesses in Africa. This might include leveraging its existing infrastructure to
deliver other goods or services in the countries where it was established.
Exhibit 1
Causes of Death in Africa (Estimates for 2002)
United States,
(in thousands) Africa Canada, and Cuba
Population 672,238 333,580
Total Deaths 10,664 2,720
1. Communicable diseases, maternal and

perinatal conditions and nutritional 7,671 167
deficiencies
Infectious and parasitic diseases* 5,625 69
Tuberculosis 348 1
STIs excluding HIV 93 0
HIV/AIDS 2,095 14
Diarrheal diseases 707 2
Childhood diseases 527 0
Meningitis 20 1
Hepatitis B 20 1
Hepatitis C 8 5
Malaria 1,136 0
Tropical diseases 56 0
Intestinal nematode infections 3 0
Respiratory infections 1,118 72
Maternal conditions 231 1
Perinatal conditions 554 17
Nutritional deficiencies 143 8
2. Noncommunicable conditions** 2,252 2,380
3. Injuries** 741 173
* Zero denotes less than one thousand.

** Noncommunicable conditions consist primarily of cancer, diabetes, neuropsychiatric disorders,
cardiovascular diseases, and respiratory diseases. Injuries include unintentional accidents, suicide,
violence and war.
Source: World Health Organization, “World Health Report 2004,” http://www.who.int/whr/2004/en/

(June 14, 2007).
Exhibit 2
Riders for Health: Operations in Zimbabwe
Source: Riders for Health.
Exhibit 3
Riders for Health: Statement of Activities (2005)
Fundraising
Nigeria Gambia Zimbabwe UK Total
(£ in thousands) branches
Income
Operational income £ 650 £ 450 £ 804 £ 60 £ - £ 1,964
Events 267 75 342
Grant funding
Restricted 43 - 43
Unrestricted 8 - 8
Donations
Restricted 22 - 22
Unrestricted 205 180 385
Sale of goods 37 - 37
Other 14 - 14
Total Income £ 650 £ 450 £ 804 £ 656 £ 255 £ 2,815
Expenditures
Cost of providing services £ 273 £ 95 £ 92 £ 32 £ - £ 492
Salaries 295 188 250 518 - 1,251
Fundraising costs 110 70 180
Overheads 74 50 130 98 - 352
Other 5 25 30 27 - 87
Total expenditure £ 647 £ 358 £ 502 £ 785 £ 70 £ 2,365
Adjustments (80) (300) (380)
Surplus (deficit) £ 3 £ 12 £ 2 (£ 129) £ 185 £ 73
Number of Vehicles 400 205 630
Employees 35 154 41 14
Notes: Surplus in Gambia consisted of vehicle replacement funds, held in trust for Department of State for Health.
Surplus in Zimbabwe represented monies owed to Riders for TRM denominated in Zimbabwe dollars but expected
to be worthless upon repayment due to hyperinflation.
Source: Riders for Health. Copyright © Riders for Health. All rights reserved. Reprinted by permission of Riders
for Health.
Exhibit 4
Riders for Health: Binga Program, Zimbabwe (2001 – 2002)
Percent of population indicating increased visits (2001 -

2002)
100%
8%
Gokwe Binga
Percent change in malarial deaths
44%
-21%
Gokwe Binga
Frequency of health worker visits
3%
5%
Never / do not
13%
remember
Less than monthly

35%
68%
Monthly
5% 49%
Weekly
22%
Gokwe Binga
Note: Gokwe region reported no change in motorcycle usage and maintenance. Binga implemented Riders for
Health TRM in 2002.
Source: Riders for Health, OC&C
Exhibit 5
Riders for Health: The Uhuru
The Uhuru is a multi-purpose vehicle; a revolutionary take on the traditional motorcycle and sidecar. Cost-effective,
lightweight, and extremely sturdy, it has been designed to carry a stretcher and a pop-up seat for women in imminent
labor. It also has a power take-off at the back wheel which, when connected to a pump, can pump over 100 liters of
water a minute. With its trailer attached, the Uhuru can also be used to carry freight.
Vehicle: An agricultural-specification 200cc motorcycle. Fitted with off-road tires and special equipment it’s a ‘go
anywhere’ vehicle. This is fitted to a purpose-built sidecar chassis, which is designed to complement the motorcycle
and is manufactured in Africa using local materials and skills.
Equipment: 20 liter water/petrol can; hand winch; large battery; emergency lighting; cargo carrying area; lockable
equipment storage locker; soft seat and removable stretcher system for ambulance duty complete with rain
protection for patients; tow bar.
Trailer option: Purpose-built in Africa from the same materials as the sidecar, this is a simple box trailer to
increase the carrying capacity of the vehicle. It has an optional tow arm to allow it to be towed by the sidecar, solo
motorcycle or push-bike, or it can be pushed by hand. The large wheels, together with its light but strong
construction, give it the ability to operate off-road. It can carry up to eight jerry cans (160 liters of water or fuel).
Power pack: Self-aligning v-drive power rollers complete with water pump and auxiliary power take-off. This has
been designed to transfer the power from the back wheel of the bike to drive equipment including a water pump
delivering over 100 liters per minute. To give continuous operation the motorcycle is fitted with a cooling fan
system and hand throttle. Giving easy and safe operation in the field, it extends the uses of the Uhuru.
Source: Riders for Health, “The Uhuru, In Detail,” http://www.riders.org/en/html/uhuru_detail.php (July 14, 2007).

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RIDERS FOR HEALTH:

HEALTH CARE IN AFRICA

Among infectious diseases, HIV/AIDS, malaria, measles, pneumonia, tuberculosis, and

Several international aid groups, nongovernmental organizations, governments, and nonprofits

In addition to funding organizations, several groups provided on-the-ground services to improve

Obstacles to Providing Health Care

Transport Resource Management

Motorcycles in the TRM

Funding Riders for Health

Impact of Transport Resource Management

Case Study: Binga Program

Increasing Sustainability and Impact

Population 672,238 333,580

Total Deaths 10,664 2,720

1. Communicable diseases, maternal and

2. Noncommunicable conditions** 2,252 2,380

3. Injuries** 741 173

* Zero denotes less than one thousand.

Source: World Health Organization, “World Health Report 2004,” http://www.who.int/whr/2004/en/

Source: Riders for Health.

Adjustments (80) (300) (380)

Surplus (deficit) £ 3 £ 12 £ 2 (£ 129) £ 185 £ 73

Number of Vehicles 400 205 630

Percent of population indicating increased visits (2001 -

Percent change in malarial deaths

Frequency of health worker visits

Less than monthly

Source: Riders for Health, OC&C

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