Module 5: Transportation

According to experts, transportation should be the third largest healthcare expense after personnel and drugs. This is not the case in many developing countries.(1) Usually, there are few qualified mechanics and transport managers; moreover, the new vehicles donated or purchased are often not appropriate for Africa’s low quality roads, meaning the vehicles break down prematurely. Consequently, healthcare is either not delivered to patients, or patients are unable to access healthcare. As mentioned in the previous module, if the last mile between help and need is not met, all of the previous miles are traveled in vain.

A Case Study: Riders for Health

In the late 1980s, Riders for Health (RFH) was established to try to improve transportation in The Gambia. The RFH model consisted of using relatively inexpensive methods to regularly provide maintenance for healthcare vehicles, which can extend the life of vehicles by four times.(2)  At the time of its establishment, RFH managed government-owned vehicles, but eventually was able to purchase its own fleet. When RFH purchased its own fleet, its social entrepreneurs realized that if donations were used for the purchase, the model would be unsustainable and reliant upon donor support. Instead, RFH decided to have a self-sufficient operating model. Ultimately, RFH realized that the best solution would involve securing a loan from a bank to purchase the fleet, and recouping the loan by lending its vehicles to the government on a per-kilometer basis. The only outside intervention necessary was that a creditor, the Skoll Foundation, was recruited as a creditor to the bank in case RFH defaulted on its loan.(3)

The RFH model has proven to be very successful, and the regular payments that it receives from The Gambian government will be enough to not only repay its loan, but also to have sufficient capital to buy a completely new fleet without having to secure a loan.(4) Beyond financial solvency, RFH has been able to secure enough funds that it will be able to purchase a replacement fleet outright without needing to secure a loan, meaning that RFH will be completely self-sufficient and sustainable. Furthermore, 5-year contracts are set up between RFH and the Ministry of Health, meaning that both partners gain financial stability, replacing the previous scheme in which governments paid for vehicles based on a fluctuating budget. Yet, just as with all social enterprises, positive results are measured not just by financial return, but also by social impact. As a result of the interventions by RFH, The Gambia is now the first African country with enough healthcare delivery vehicles for its entire population.(5) RFH is also expanding to other African nations. Over 1200 vehicles are now in use, serving 10.8 million people in nine different countries.(6)

The financing system of RFH has changed how transportation operates financially, which has presented unique challenges. The Ministry of Health no longer needs donations to purchase new vehicles, but instead uses the money to pay RFH, and this subtle but important adjustment has to be communicated to donors. On the RFH side, they need to hire and train specialized personnel with expertise in borrowing money.(7)   

Emergency Transportation

Imagine witnessing a car accident, a physical assault, or a drowning person. In the developed world, one’s immediate reaction would be to call an emergency help line: 911 in North America, 112 in Europe, 000 in Australia. In these countries, the availability of emergency medical care is taken for granted and is always just a few minutes away. However, in India, a developing country of 1.1 billion people, an emergency safety net has not been established. Instead, most people take their own cars or taxis to the hospital, 75 % of deaths occur in the home, and 90 % of state-owned ambulances are used to carry dead bodies.(8) Compounding this challenge, India’s population is poor, and 84 % of Indians have an income less than 250 USD a month.(9) According to P. Predeep, Chief Information Officer of Aavishkaar, a social rural venture capital firm, these factors mean that social enterprises have an important role in India:

“Social enterprises are critical in a country like India where there is vast geographic and economic unevenness. There is a huge opportunity for entrepreneurs to rise up and mitigate the problems of the underprivileged in a sustainable way.”(10)

A Case Study: Dial 1298 for Ambulance

Dial 1298 for Ambulance was designed with the mission to become the leading network of Life Support Ambulances in India. Having supplied their own distinctively-colored yellow ambulances, Dial 1298 has provided 24 hour service, 7 days a week, originally starting with the population of Mumbai.

One of the major challenges for ambulances in India is being able to navigate ambulances through heavy traffic. Mumbai in particular is one of the densest major metropolitan cities in the world. Dial 1298 has circumvented this difficulty by not only having an ambulance stationed in various zones around the city, but also by using a GPS system to detect real time traffic and to route the ambulances to their destination in the shortest time possible. Increasing social awareness of Dial 1298 ambulances have also helped, as many Indians now recognize the yellow ambulances as carrying emergency medical care and now frequently give way in traffic.(11)

Dial 1298 now provides emergency care within 20 minutes. In Mumbai, Dial 1298 receives between 70 and 150 calls a day, and it has saved an estimated 50,000 lives.(12) For patients who are poor or who are victims of natural disasters or terrorist attacks, care is provided at a subsidized rate. In 2007, Dial 1298 expanded to Kerala, and the organization plans to expand to eight other cities by 2013. Dial 1298 also has a broader scope than just providing emergency medical relief. The organization has partnered with a local nonprofit to provide free First Aid and basic life support training to schools and colleges, a training program specifically designed for busy healthcare professionals. Dial 1298 also functions as a women’s help line, where callers can be directed to the appropriate organization to receive further aid.

Some new challenges of Dial 1298 going forward will be expansion into poor areas. Mumbai and Kerala are among the richest areas of India, where infrastructure is more developed than in the poor regions. These regions will have less access to phones, meaning that contacting Dial 1298 could prove more difficult. A lower density of hospitals in these regions could mean that ambulances would take more time to bring patients to hospitals. This delay would require more coordination between Dial 1298 and the hospitals to ensure that patients brought to these hospitals receive immediate care.

Footnotes

(1) Rammohan, S. “Fueling Growth.” Stanford Social Innovation Review. Summer 2010. https://ssir.org/articles/entry/fueling_growth.

(2) Ibid.

(3) Ibid.

(4) Ibid.

(5) Ibid.

(6) Ibid.

(7) Ibid.

(8) Utz, L,. Currie, M., Fegan, M. (Producers) and Owens, M. (Director). “GOOD: Dial 1298!” [video clip]. 2009. https://www.youtube.com/watch?v=OC7LqVqkrY8.

(9) Desai, S. “Business of Benevolence.” 29 Aug 2009. The Times of India.

(10) Ibid.

(11) Ibid.

(12) Dichter, S. “Dial 1298 for Ambulance: Access for All.”Acumen, 13 Aug. 2008, https://acumen.org/blog/on-the-ground/dial-1298-for-ambulance-access-for-all/.