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Opinions of Thursday, 6 December 2018

Columnist: Dr. Grace Ayensu-Danquah

Drones for medical supply - FAQS

Ghana’s Ministry of Health is launching the largest and most advanced medical drone delivery network in the world. Given the fact that developing countries such as Ghana face significant health deficits, issues of primary health care delivery require innovative means and practices. Health deficits that are totally unacceptable include the fact that about 30% of women die in labour due to excessive bleeding. Issue of immediate intervention after a snake- bite is also deplorable. This would have not been the case if Ghana had installed advanced technology to supply blood pints and other medical products to remote areas, where the need is more.

First of all, we don’t need the biggest, largest and best of anything for our healthcare in Ghana. What we need is a tried and true evidence proven systems that works. We don’t have time for experimentation with our lives.

Yes, it is true that “about 30% of women die in labor due to excessive bleeding” and that there is the need for “immediate intervention after snake bite”.

Unfortunately, the solution to these problems -:is not the drone technology that will deliver blood to the rural areas. The fact is in Ghana only a doctor can prescribe blood transfusion and blood transfusions are only done in the district hospitals. Such patients are transferred to the district hospital to be treated. The rural hospitals do not have the technical capability to give blood.

A hospital transfusing blood should have a laboratory that would take the recipients blood and run tests called Type and Cross match to make sure that the patient does not die during the transfusion from blood type ABO mismatch. Only the district and regional hospitals are equipped to do such laboratory analysis.

In Ghana, most rural hospital already stock snake anti venom and vaccines so they do not need the drones to deliver them. When someone has a snake bite they need the anti-venom immediately the 30 minutes (drone fight time only) it will take for the drone delivery is too long. It is much much better and cost effective and life saving if the facilities stock these medications and have them on hand.

ACTION

? Health is not politics. We should have a little sense of dignity when discussing health related matters.
? We agree so please so stop playing politics with the health of the people!!!
? We value the health of Ghanaians and will put in place all necessary measures to ensure good health care.

We as Ghanaians also value our health more and we want to know “all the necessary measures” you have put in place. We won’t believe you because you said so... we need hardcore evidence.

Where is the policy paper including all the details? Please provide this document to us so that we can all read and evaluate your claims. We are tired of “words”. We see what happened to the poor implementation of the FSHS with the serious overcrowding in schools and we have not forgotten the deaths of the 19 students from Kumasi Academy who died of overcrowding and poor sanitation last year (May their souls RIPP). We also remember what happened with the expensive and now defunct GhanaPostGPS which we could have obtained for free from Google.



Please show us the detail???

Indeed, the Akufo-Addo government has responded by vying for a health care project that would deliver medical supplies through drone technology.

We are not against the use of technology to solve some of our healthcare issues. However, there seem to be a basic Mis-understanding of the meaning of emergency healthcare. What the government has to do is to vie for delivering the sick patients to immediate medical care through technology and not the other way around!!! Helicopter ambulances, fully equipped and stocked with emergency medicine and well trained personnel will be the best way to go.

This drone system is NOT what Ghana currently needs. This drone technology is not the solution to our current health problems. Currently our hospitals are understaffed, equipment are broken and non-functioning and the hospitals are severely over crowded. Pregnant women sleep on the floor, sick babies share incubators and cross contaminate each other, our emergency rooms are overcrowded and we have the serious “no bed syndrome” So, if this government wants to help they should:

1. Fully operationalized all completed hospitals or clinics and CHPS centers.

2. Equip all pre-existing CHPS compound with supplies and community health nurses

3. Existing facilities should be provided with much needed supplies and equipments and provided with adequate staffing. This will improve the number of available inpatient and emergency beds across the country thereby relieving the pressure placed on existing hospitals and staff.

4. Use the money used to purchase this drone technology to re-habilitate all major emergency/casualty departments across the country. More emergency and in-patient beds, more medical supplies and more emergency medicines. Also, all emergency rooms across the country should have “crush charts” stocked with emergency medicines and supply ready to be deployed at all times (currently none of our causally/emergency rooms have them)

5. Use the money to purchase more ambulances and have trained EMT’s in the ambulances provide the much-needed emergency interventions. Stock all ambulances with these emergency medicines and blood and have the trained personnel provide the much-needed emergency care enroute to the major hospital. Currently our Ambulances are JUST transportation devices. No serious stop-gap temporizing critical medical interventions takes place in them. So, change the rules and spend the money to have all ambulance personnel fully trained in emergency field medicine and stock them with “the blood and life saving medicines” you are going to place in the drone centers. Allow Ambulance personnel to have blood on board and transfuse en-route. That will certainly save countless lives.

6. Finally, the option of proper air ambulance is much better than the drone idea and probably at the same cost. In case of an emergency, stabilizing the patient in a ground or air ambulance and quickly transporting them to the proper hospital/appropriate care is much better than getting the medicines to them via drone in the middle of nowhere. Emergency medicine/blood etc are ONLY temporizing measures until the patient is transferred to a proper hospital for proper emergency care.

For instance, a woman who is bleeding from post-partum hemorrhage will need blood to stabilize them but if they do not get emergency surgery to stop the injured uterus from bleeding they will still die even if you transfuse a 1000 liters of blood. The blood is only to stabilize them until they have definitive surgery to stop the bleeding.



If the uterine artery is not surgically ligated in a proper operating theatre the patient will continue to bleed despite the volume of blood you transfuse and after a few liters of large volume of blood has been transfuse the patient will develop Disseminated Intravascular Coagulopathy (DIC) and get into the “terrible triad of death” …which consists of coagulopathy, hypothermia (cold) and acidosis.

In other words, their blood gets even more thinner and does not clot and the body temperature is cold and the patient develops low blood pressure which leads to rapid death. So, as you can see, giving that woman blood transfusion alone is not the final solution. The woman needs to be transferred from the rural hospital to a district hospital or regional hospital as quickly as possible via the fastest route so she can get the proper surgery to save her life.

?The drone delivery network will give Ghana the most advanced health care supply chain on the planet.

First things first, we have to crawl before we walk. Ghanaians don’t have equipment in the hospitals. Hospitals don’t have enough beds. The sick people are sleeping in the floor. Our emergency rooms are over crowded with patients in chairs. Some even have to bring their own chairs or purchase plastic chairs in the emergency rooms to use. Currently, in our emergency rooms people are paying for everything from beds, to chairs, to labs to blood to emergency medicines even though it is covered by NHIS. Some family members have to go out and buy emergency supplies and medicines before the sick relatives can get any emergency care and if they can’t afford the family member dies. So please first focus on equipping our emergency rooms with these “medicines and blood” before you provide them to a drone company.

?DRONES are aircrafts that can be navigated without a human pilot on board the aerial vehicle. Drones can be navigated via control from the ground, using a GPS tracking system.

No one doubts that and most of us know what drones do. But this is not what we need for our current health system?

?The drones will operate 24 hours a day from 4 distribution centers across the country. The first distribution center will be located near Suhum. The sites for the remaining 3 will be finalized by GHS subsequently, but are expected to cover much of the country.

Are these drone centers to be new Central Medical Supplies stores for the country? What happened to the report after our main Central Supplies was maliciously and deliberately burned down? What has happened to the culprits and what measures have been put in place to prevent another similar episode? Please we need to know that before you start building more Central Medical Supply Depot with all its inherent fraud. In any case don’t we already have a Central Supplies Depot? Who controls the drone centers?

?The entire project took about 6 months to implement. A committee was set up, comprising of representatives from the ministry of Health, Ghana Health Service, National Ambulance Service, Civil Aviation, National Security etc.

Who were the members of the committee? What was their recommendation? And where is the committee’s report?

?The above stakeholders sent delegations to inquire about how Rwanda had implemented the first Zipline program; it was a very successful venture. To the extent that the Ghana Civil Aviation has approved the project and all security factors have been considered as well.

The Rwanda system is a completely different drone system. The drones deliver to well established well resources facilities (similar to our district hospitals in Ghana) and each district in Rwanda has at least 5 ambulances per district and air ambulances as well as 4 marine ambulances. “Rwanda as at 2017 before the drone blood supply service, had over two hundred (200) functioning ambulances distributed in all districts of the country”. How does that compare to Ghana with 50 functioning ambulance for a population of 27 million people? The Experts from the Disease Control Priorities in Developing Countries (2nd Edition) recommend 1 EMS unit (i.e. ambulance and crew) per 100,000 population, in low-resource settings while Ghana EMS/Population ration is currently at 1/325,000 people. Obviously, Ghana is far behind in this health index. Who were the members of the delegation that went to Rwanda and where is their report?

?The Ghana Health Service has asked Zipline to stock 148 products that range from blood, snake venoms, essential medicines such as tuberculosis & HIV medications etc. When fully implemented, 14 to 16 million people will be covered.

First of all, TB, HIV medicines and vaccines are NOT emergency medicines and do not require emergent delivery by drones. These could be stocked in the facilities themselves for use when needed based on the traditional systems already in place. Second, most of the other emergency medicines are not used in remote areas. Any emergency medicines can be given to a district center. Rural hospitals are not licensed to administer other kinds of emergency medicines and blood. Where is the list of hospitals the drugs will be distributed to from Suhum? And please provide a comprehensive list of the said emergency medicines.



?In relation to why the project was sole-sourced, zipline is the only company in the world that is currently in the medical drone supply business, as such sole-sourcing was applied, which out procurement laws permit. In fact, the National Security has also done their checks, and there is no company operationalizing drone medical supply apart from Zipline.

There are other companies that do the same thing. A least three I can think of. But I sure you know that… or? I heard that the University of Michigan in the United States offered the technology to Ghana for free. Who are the local partners to ZIPLINE International in Ghana?

?Ghana is not procuring drones to supply medical supplies to health centres. Ghana is only paying for the drone services for delivering the supplies. The ministry of Health (MOH) bears no risk of installation, operation or maintenance of facilities. MOH only pays when Zipline succeeds in setting up distribution centers and meets the performance specifications agreed as in the Service Agreement.

Who pays for the drugs in the distribution center? Who trains the employees? GHS?

If Ghana does not own the drones what if the company decides to take them away after we have spent all the money building the distribution centers?

?The contract is a performance driven contract, which means that the zipline company will be paid based on the daily supplies per distribution centre. Hence payment is done based on performance specifications. It has nothing to do with the suggestions of some MP’s.

Who signs a contract like this? Who pays for the drone distribution centers? ZIPLINE is Ghana? Who assess the performance of ZIPLINE or how many daily supplies they have made???

?The zipline service works through 4 simple steps: placing an order to the recipient zipline pharmacist, pharmacist prepares the product for delivery, product in placed on a drone, the health facility receives the supplies in less than an hour.

How will the order be placed from the recipient hospital via computer? internet? Phone? Will all these facilities be provided with internet and computer systems if not how will the request get to the drone distribution center in time for the medication to be deployed within “less than an hour”. In a true emergency, an hour is too long. It would be better if the facilities store the emergency medicines on site reducing the 30 minutes to 5 minutes? How will the rural hospitals determine what kind of blood such as A+ AB blood type they need before they order the blood from the distribution center?? Because ordering blood is not like ordering Koko... the recipients blood needs to be tested against the donor blood and the recipient has to receive very specific blood that is compatible with their own blood otherwise even one drop of the wrong blood will kill them. How will the rural hospitals do that and in what time frame?

Currently in Ghana people are buying blood from blood banks or people needing blood have to bring a relative to donate blood before they can receive blood. Blood donation is very limited in Ghana. Most people do not like to donate so how will the drones resolve this basic issue????

According to The National Blood Service, Ghana (NBSG) it was unable to reach its 50 per cent target of Voluntary Unpaid Blood Donation across the country in 2017. So, as you can see there exists a serious problem of shortages of blood in major hospitals and limited voluntary donation of blood.

Emergency cardiac or Trauma medicines cannot be administered in rural hospitals because the hospitals don’t have the services and capacity (Intensive Care Units, Specialist Surgeons and staffing etc.) to manage those case. The patients should be transferred minimum of a district hospital with the capabilities for appropriate care.

This money would be best spend on proper transportation (ambulance, airlifting)
patients to the appropriate level of hospital. If all hospitals are equipped with heliport and the government bought air ambulance helicopters we will be much better served. All the three new hospitals UGMC in Legon IMAH in Tema, Bank Hospital in Cantonments were heliports provide the air ambulance, train the staff and equip the hospitals to handle emergency before you start drone deliveries if needed at all.

QUESTIONS AND ANSWERS ON THE DRONE

It goes without saying that in an emergency, even under normal conditions, it is generally faster to go from one point to the other via air than land, via a drone than a motorbike, and via an aero plane than a steamship (steamer).

This is true for but you got it ALL Wrong. Yes it is faster to go from one point to another and generally faster to go by air but this is only true for THE PATIENT needing the care and NOT the medicine or the blood. This is why I say that there is indeed a lack of basic understanding of emergency care in this document as such so many things emergent, urgent and non-emergent are being mixed up.

The goal should ALAWYS be on how to transport the patient via fastest route to appropriate healthcare center with the right capabilities. This is what is done everywhere in the world. The gold standard around the world is to stabilize (in Ambulance either air or ground? Or health center and immediately transport to the nearest trauma/emergency center) this method is tried and true and has NOT failed in centuries!!!!

WHAT IS THE STRUTUCRE OF THE MOH’S CONTRACT WITH ZIPLINE?

1. The contract is a Service Agreement. Zipline is required to meet detailed performance requirements, such as range, payload, and number of flights per day.

What facilities will these drones be flying to from the first distribution center in Suhum? Please provide the complete list?

2. MoH will not own the facilities or equipment, so it bears no risk for construction cost overruns, maintenance costs, or technology obsolescence. MoH will only pay if Zipline meets its service commitments.

This is not good. So, who will be in charge. I heard the director of GHS say that GHS would run these facilities so please clarify. Which is which? Again “who watches the watchman” ????????????

WHAT DOES THE CONTRACT OBLIGATE SIPLINE TO DO?

1. Zipline must build 4 distribution centers at MoH-specified locations across Ghana.

Will these be 4 new distribution-centers? Where will the stock be coming from? Who will be in charge? Will these be run by MOH or GHS will this be a new arm of our healthcare? Will these be run by ZIPLINE staff???

2. Each distribution center will include at least 20 drones, launch and recovery equipment, state-of-the-art medical refrigeration equipment, computerized order management systems. Each will be staffed by up to 50 Ghanaian employees.

If the blood is refrigerated at the depot. What about the drone delivery box itself will it be refrigerated? Because from the videos of ZIPLINE which I have viewed over and over again the blood is wrapped in a cloth and place on the drone(correct me if I am wrong) there is no refrigerator on the drone carrier. So are you saying the blood will be in the air for 30 minutes unrefrigerated??? Would that not be a break in the cold-chain? And will that not contaminate the blood???

Will these be 50 people be new employees of ZIPLINE or existing GHS employees? What will be their level of expertise? Who will be training them and how much will the training and re-designation of job titles be?????

3. Zipline must operate drone flights from the distribution centers on a 24/7 basis to deliver medical products on request to health facilities within an 80 km service radius.

Where are these health facilities located?
Please give us the list so we can check if they are licensed or equipped to transfuse blood. If they have the proper staffing doctor, nurse, perfusionist, the proper laboratory to check the patient’s blood for Type and Cross Matching of the blood. Because it is only when the recipient’s blood is properly typed and crossed against the donor blood by a licensed laboratory will the receiving facility know what blood type to order from the drone center. Also while the patient is being transfuse the patient requires special attention by nursing staff are these rural facilities well staffed?
At least give us the list of the facilities within the 80 radius to be serviced by the first drone distribution center in Suhum.

In conclusion this Drone system is really not the solution to the myriad of important life threatening problems we have in our healthcare. When it comes to emergency services the patient/the sick/the injured is much more important than the medicine or the blood that will be delivered and therefore, attention should be paid to getting the injured or the sick to proper healthcare facilities either by road(better ambulances) or more quickly by air(air ambulances) to enable them to receive the appropriate care. Lastly, what Ghana really needs to begin to solve our healthcare is is proper primary care services and education of the people so that Non-Communicable Diseases are brought to medical attention in the early stages and not when it is often too late as we currently have in our system. We also need to emphasis routine health maintenance/screening care. Doing these things will immediately transform our health system.
Thank you.

Your humble Citizen Not Spectator

Ps. Just as the VP was airlifted to London and the MP was airlifted from Wineba to Accra .. and it saved their lives so will it save a ordinary Ghanaian life. Airlifting has been proven to be the fastest way to obtain immediate emergency care.

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