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Background: Although a number of intermediate transport initiatives have been used in some developing countries, available evidence reveals a dearth of local knowledge on the effect of these rural informal transport mechanisms on access to maternal health care services, the cost of implementing such schemes and their scalability. This paper, attempts to provide insights into the functioning of the informal transport markets in facilitating access to maternal health care. It also demonstrates the role that higher institutions of learning can play in designing projects that can increase the utilization of maternal health services. Objectives. To explore the use of intermediate transport mechanisms to improve access to maternal health services, with emphasis on the benefits and unintended consequences of the transport scheme, as well as challenges in the implementation of the scheme. Methods. This paper is based on the pilot phase to inform a quasi experimental study aimed at increasing access to maternal health services using demand and supply side incentives. The data collection for this paper included qualitative and quantitative methods that included focus group interviews, review of project documents and facility level data. Results: There was a marked increase in attendance of antenatal, and delivery care services, with the contracted transporters playing a leading role in mobilizing mothers to attend services. The project also had economic spill-over effects to the transport providers, their families and community generally. However, some challenges were faced including difficulty in setting prices for paying transporters, and poor enforcement of existing traffic regulations. Conclusions and implications. The findings indicate that locally existing resources such as motorcycle riders, also known as boda boda can be used innovatively to reduce challenges caused by geographical inaccessibility and a poor transport network with resultant increases in the utilization of maternal health services. However, care must be taken to mobilize the resources needed and to ensure that there is enforcement of laws that will ensure the safety of clients and the transport providers themselves. © 2011 Pariyo et al; licensee BioMed Central Ltd.
The pilot was conducted in Kamuli, one of the two districts of Eastern Uganda where the quasi experimental study is being implemented. The two districts were selected out of a total of four districts in the eastern region that had at least 3 health sub districts (HSD). They were selected because they were more comparable in terms of their capacity to offer maternal health services. Kamuli has an estimated population of 680,500, with 35.9% of the population below the poverty line and 34% of pregnant women delivering in health facilities. Pallisa, which is the second district, has an estimated population of 480,000, 35.9% of its population live below the poverty line and 44% of women delivering in health facilities. In each district one of the three health sub-districts was randomly selected as an intervention HSD and one of the remaining two, which most closely reflected demographic composition and availability of health services infrastructure (both public and private), selected as a control HSD. In Kamuli, Budiope HSD with 14 health facilities is the intervention and Buzaaya HSD with 11 health facilities is the control. A HSD is based on a health administrative area with population ranging from 30,000 to 100,000 and up to 10 health facilities. The intervention package comprises of a transport voucher that facilitates women to access free transport for maternal health services (Antenatal care, delivery care and postnatal care) and a service voucher that also facilitates access to these maternal health services. This package is given to all pregnant women (irrespective of the trimester of the pregnancy), resident in the study area during the study period. The study also has a health systems strengthening component that is being conducted in both the intervention and control districts. This component comprises of training of health workers, supportive supervision and distribution of basic supplies and equipment in facilities in the intervention and control arms. The study was piloted in Kamuli district between December 2009 and March, 2010. During this period voucher booklets were given out to over 12,000 mothers. Thereafter the distribution of vouchers was stopped. All the women who had received vouchers during the pilot period (December 2009 to March 2010) continued to receive the services that the voucher entitled them to; use of local transport to a health facility and access to services with no extra demands by providers (such as provision of gloves). Between April and May 2010 the pilot study results were reviewed and used to inform the design and implementation of a wider intervention planned to run until June 2011. The voucher booklets were distributed at antenatal care (ANC) clinics. Each voucher booklet distributed during the pilot contained twelve transport vouchers for movement to and from the facility for antenatal, delivery and post natal care. It also contained seven service vouchers for antenatal, delivery and post natal care. The transport voucher entitled a pregnant woman to use locally available transport (motor cycle, bicycle) to the health facility for ANC, delivery and postnatal care services. However, the number of vouchers used per woman depended on her gestation period at enrollment (determines how many ANC sessions she can attend) as well as her choice of delivery place and whether or not she attended PNC. Women who were referred from a lower level facility to a higher level facility e.g., for a caesarean section or other complications, received a special voucher for transport that allowed them to use a motorized vehicle (public taxi or ambulance). When a mother wanted to come to the clinic she had to contact any transport provider of choice either by phone or by word of mouth (within their reach). Sometimes the transporters made the initiative and went out to look for the mothers themselves. After transporting a client, the transporter received a transport voucher from the client. The transporter retained this voucher and redeemed it for cash from the study coordinator. Payments were made to the transporters every two to five weeks at the stages where they registered. Setting up the transport scheme was a long tedious process that required several visits to the field to identify the transporters, their registration, organizing them into groups, and selecting leadership to work with. There were 3 main stages, which included a) mapping of the transport providers, b) sensitization of providers about the transport scheme, and c) identification of transporters and signing of contracts. A mapping of the study area was done to locate the different stages that existed, identify the chairmen for the stages and local prices charged to the nearest health facility. The prices ranged from 2,000 to 10,000 Ug sh (USD $0.90 to 4.50) for motor cycles, and from 500 to 1,000 Ug sh (USD $0.22 to 4.5) for bicycles. Determining the rate at which the transporters should be paid was challenging to the project. The commercial fee that is charged usually fluctuates depending on the distance travelled, the time of day or night as well as the terrain of the place. Recognizing that it would be difficult to determine precise distances travelled and to confirm the time of travel, the study team decided to set a flat price of 5,000 Ug Shs (approximately USD $2.27) for each trip to or from a health facility using a motor cycle or 2,000 Ug. Sh (USD $0.90) for each bicycle ride to or from a health facility. After agreeing on the fares with the transporters, the study team met with the transporters and told them about the study purposes and its mode of operation. Those who were willing to participate were then registered, and their photographs and identification details were obtained so that they could be given identity cards. Each transporter signed a contract with the study team to operate under specified and agreed conditions, but also taking into account the laws governing transportation services in the country. They were also solely responsible for the safety of the clients whom they transported. Contracts were signed with a total of 592 transporters, of whom 211(35.6%) used bicycles, 379 (64%) motorcycles and 2 (0.33%) cars. All the transporters were young to middle aged males. There were no females, because cycle transport was seen to be an exclusively male occupation. The transport business was the main source of livelihood for the majority of the transporters, although earnings were generally low because of the low volume of clients. The findings reported in this paper are from a combination of methods including a review of project documents, focus group discussions and analysis of facility level data. Four focus group discussions were conducted with transporters who consisted of motorcycle riders in Kamuli district. The two car owners who had been registered initially had stopped participating in the study, so they were not included. The majority of bicycle riders also dropped out because mothers preferred to use motorcycles; consequently it was difficult to get sufficient bicycle riders for a focus group discussion, so the discussions were eventually limited only to the motorcycle transporters. The focus group discussions comprised of 6-8 motorcycle transporters who were selected with the help of the stage chair person (Leader of the transporters in a specific location). Thematic analysis was applied to the focus group discussions, minutes of project meetings and reports. Facility level data was reviewed to obtain statistics on the utilization of antenatal, delivery care services. They have been presented as graphs and figures. Ethical approval to conduct this study was provided by MakSPH research and ethics committee and the Uganda National Council for Science and Technology (UNCST).
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