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Opinions of Tuesday, 19 June 2018

Columnist: Kojo Tordjo Victor

Kojo Tordjo Victor writes: The 'Aboboyaa' ambulance, is it out of place?

A tricycle branded and being used as an ambulance A tricycle branded and being used as an ambulance

“One thing is sure. We have to do something. We have to do the best we know at the moment; if it doesn’t turn out right, we can modify it as we go along” – Franklin D. Roosevelt, former US president.

Last week, a story was trending like wild fire on social media regarding an “Aboboyaa” (a tricycle) submitted to Salifu-Krom Health Center in the NKwanta-South Municipality by the Volta Regional Health Director, Dr. Timothy Latsu to be used as a miniature ambulance by the Health Center.

When the image of the said tricycle was shared by Joynews, Ghanaians penchant for unsavory comments came into full display. The barrage of harsh criticisms and insults on our political leaders were mind-boggling. After going through the comments one is left with no option than to worry for the future of this nation.

As people we are always concerned about what government or country will do for us but not what we can do for our country. The solution is not only in paying taxes. Let’s stop the “tax payer” noises.

In my opinion, the Regional Director must be commended for implementing such a good initiative in improving the health care of his people.

Also, what I deduced from the comments was that most people were angry about the fact that, the whole country had only 55 ambulances while our MPs and Ministers ride in V8s. Yes, that is true but should our MPS and Ministers walk or ride on motorbikes?

They felt using ‘Aboboyaa’ as a miniature ambulance was out of place and inhumane. Like seriously? Others were comparing our Health Care delivery system to the likes of US, UK and other advanced nations. I haven’t travelled to the UK or US before but the little I have heard and read about their Health Care system is that, the citizenry are ready to pay for their health care no matter how expensive it is. Hence the government and other private agencies have invested heavily in providing quality and equitable health care in terms of hospital infrastructure, holistic insurance packages (which their citizens are ready to pay for) and others.

Contrary to the Ghanaian situation where a patient with our NHIS which pays peanuts to hospitals thinks everything must be covered by it including food sold in hospital canteens. How can such a country be comparing itself to the UK and US.

The truth is that, using a well-equipped tricycle or Aboboyaa as means of transporting patients from one health facility to the other is not a new thing in Ghana’s Health Care system. This thing started way back and I think is should be implemented in all Health Centers, Clinics and CHPS compounds across the country. We cannot wait and keep dying until all these facilities get the required number of ambulances; an unlikely event in our generation.

We must start from somewhere and that is why I believe Dr. Latsu and other folks like him such as my former industrious District Director of Health for Jirapa, Mrs. Phoebe Balagumyetime deserves some accolades and commendation. Their local level initiatives backed with action have saved many lives and helped Ghana get close to achieving the Millennium Development Goals specifically goal 4 and 5 and to some extent goal 6.

Let’s look at the objectives of the ‘Aboboyaa’ initiative.

Predominantly, the whole concept is for it to serve as an emergency transport system in remote areas, where individual who at any material point in time needs immediate medical attention can be transported to a facility deemed fit. While we continue pushing our leaders to buy more ambulances and improve our health care infrastructure which may take years to happen, we must not relent in thinking outside the box and devising other cheap and innovative ways to solve our problems.

This is where the tricycle (Aboboyaa) as a miniature ambulance comes in, though not the ideal situation. As Ghanaians, what we ought to note is that our health care system is plagued with myriads of problems which insufficient ambulances forms just a small part of.

Issues of inadequate hospital beds, inadequate hospital consumables, inadequate drugs, non-payment of health insurance claims, poor remunerations packages and conditions of service for health care professionals, inadequate human resource, lack of well-functioning medical equipment such as dialysis machines, CT SCAN, MRI Machines and others are the real problems. If after the patient is carried in a world class ambulance to the facility and there are no beds, no drugs, no medical gadgets to diagnose and treat, what happens?

For us to get the world class health care that we always imagine to have, we must be willing to pay more in terms of NHIS Premiums and levies.

The real ambulance vs. the Tricycle (Aboboyaa) ambulance, a comparative review;

By rough estimation, one ambulance will cost about 150,000USD (GHS 675,000) while a tricycle which is fully furnished with almost the same components of a normal Ghanaian ambulance (e.g. a stretcher and oxygen cylinder) will cost a little above 5000USD (GHS 22,500). Meaning one ambulance can buy almost 30 furnished tricycles.

Secondly, fuel and maintenance cost of the two are not the same, obviously the real ambulance will be higher.

Statistically, there are about 3,335 CHPS compounds, 1,774 health centers and Clinics combined, 134 District Hospitals in Ghana owned and manned by MOH/GHS representing 58% of the total health infrastructure in Ghana (Source: CHIM/PPME – GHS, 2015). Obviously there cannot be ambulances for all the Health Centers and Clinics in the country.

On referring a patient, the cost of referral (usually paid by the patient) is between GHS 300-GHS500 depending on where the patient is being transported to. Unfortunately, majority of our patients are not able to pay for this. They will rather die!

The Ghanaian terrain

Majority of our CHPS compounds, Health Centers and Clinics are located in the very remote areas with bad road network and topography. The terrain is so bad that procuring ambulances for these areas will be an economically unsound decision to make. Over time, the cost of maintaining these ambulances will make it difficult for the objectives of its establishment to be achieved.

This is where the well-furnished tricycles comes in handy. Tricycles are economically savvy in terms of cost of buying, fueling, maintenance and even personnel.

There are several facilities in Ghana here in which sometimes motor bikes cannot even get to. Health professionals are forced into walking bare footed to deliver health care to these people.

Our health care delivery system is such that government cannot procure ambulance for all the health facilities in Ghana, but government can rather complement the few ambulances with well-equipped tricycles to achieve the set objectives in remote areas.

Operations of the real ambulance service in Ghana

Let me take you through how the ambulance service works in Ghana, quite a tedious encounter.

Upon the decision to refer a patient, the health worker gets the phone numbers of the various ambulances nearby usually 40-100km away. You call them and they will have to confirm whether they can make it or not and whether the patient can afford the transport fare or not.

After all is discussed on phone and they are satisfied, the ambulance driver will now have to also call and mobilize his other team members, usually paramedics who will now drive all the way from wherever they are to the referring facility.

And mostly when they finally arrive, either they don’t have disposable gloves, their stretcher isn’t well fitted or their oxygen cylinders are empty and the referring facility must have to provide all or some these before the patient is transported to the referral center.

Sometimes in the process of getting all these arranged, the patient dies and they have to drive back.

Looking at this, getting well equipped tricycles, fitted with strong stretchers, oxygen cylinders and medical consumables supplied to all the 3,335 CHPS compounds and 1,774 Health Centers will go a long way towards improving our health care delivery system, especially in the remote areas where referral services are needed most. In so doing, CHPS compounds will be able to refer patients easily to Health Centers, Health Centers and Clinics will be able to refer easily to district hospitals while the few real ambulances are given to the District Hospitals to also refer to regional hospitals and teaching hospitals. That way Maternal, Infant and Child mortality rates will dwindle. We cannot wait to get real ambulances for all these facilities before improving on our health service delivery indicators.

Tricycles are cheap to buy, cheap to maintain, portable and cheap to fuel while achieving almost the same objectives the real ambulance would have achieved.

See, I fell in love with the ‘Aboboyaa’ concept in 2014 when I was in Upper West Region, Jirapa to be precise.

We called it Emergency Transport System (ETS), it didn’t matter whether it was a real car or a tricycle.

As heads of the four main Sub-District Health Management Teams (SDHMT), we were tasked by our District Health Director to implement initiatives that will help ease the transfer of pregnant women, neonates and children who needed emergency medical attention to nearby facilities well-resourced to do so with realistic timelines attached.

How did we do it? With our team of Physician Assistants, General Nurses, Community Health Nurses, Enrolled Nurses and Midwifes, we mobilized the community members through their chiefs and opinion leaders, we sensitized them on the Aboboyaa (tricycle) initiative and how it will improve healthcare delivery in the catchment area.

After series of meetings and discussions with community members, they agreed to buy their own Aboboyaa (tricycles) through communal contributions and with little support from the Health Center’s Internally Generated Fund, we got well-resourced Emergency Transport Systems (ETS) in place and with some support from JICA (Japan International Cooperation Agency) we furnished them with oxygen and other health consumables at the point of referral.

In the process, we saved many lives, pregnant women who went into complications during labour were transported with ease to the Jirapa St. Joseph’s Hospital for medical attention. Also pregnant women who went into labour at home were immediately picked from their homes to the health center for delivery with much ease and convenience.

In the end we achieved the same objectives the real ambulance would have achieved at a cheaper and affordable cost.

Aside all the achievements, the community members had a strong sense of belonging in the initiative because they got it from their own contributions, they fueled and did planned preventive maintenance on their own through the supervision of the health centers and CHPS.

During our mid-year and annual health sector performance reviews and presentations, facilities are highly commended and in some cases awarded for implementing the initiative of getting transport systems for their communities and other catchment areas.

The initiative is not out of place and it’s a call in the right direction. Government must consider making it a national policy while measures are being put in place to procure more ambulances for the sector.

Thank you for reading. Feel free to critique and share.

The write is a Physician Assistant and a Public Health Analyst.