The ride of their lives

Tuesday, June 23, 2009

Clarisse Cunha Linke, of the Bicycling Empowerment Network Namibia, addresses the promotion of equitable access to health

Okathitu, Namibia, 2009. Ana Ekandjo walks 5km to catch a lift on the tarred road. The lift costs her N$14 (US$2) – almost all her money, but she has no options. She arrives at the clinic to get her anti-retroviral treatment (ART) but the nurse on duty insists on the discretionary N$10 fee for the visit. Although this widespread practice contravenes Namibian policy, with only a few dollars in her pocket, Ana is forced to leave without her ART. It happened to Ana before and it will probably happen again. Ana often receives visits from a home-based care volunteer, Johanna Shilongo, who walks 16km twice a week to help her and other clients in villages nearby. Most days she would like Johanna to stay longer during her visits. Ana feels isolated, but Johanna has a long walk back home to care for her own family. There are thousands of Anas and Johannas in Namibia, and stories like theirs play out every day. Ana is a HIV positive client, Johanna is a caregiver, and they face one thing in common: daily transport constraints, leading to lack of equitable access to healthcare, support and treatment.

Transport has a crucial role to play in increasing clients' access to health services; enabling better servicing of health outposts; providing timely emergency care; improving and expanding drug distribution; and facilitating the movement of health extension workers. It is intrinsic to the achievement of the Millennium Development Goals, particularly in reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other diseases. However, the importance of transport is yet understated or neglected by researchers, policy-makers and workers in the field. One of the challenges in health research and practice is to broaden its scope, recognising that there is dramatic potential to enhance access to healthcare, including non-medical fields of expertise.

Namibia is one of the youngest and most stable democracies in Africa. Since its independence in 1990, the government, together with the international community, is making an enormous effort to change its position as the most unequal country in the world, with the highest level of income disparity. Despite the efforts to date, the legacy of apartheid pervades Namibian life and the majority of the black population still lives in poverty. The country has one of the world's lowest population densities, with less than two million people in an area of about 2.5 times the size of Germany. More than 40% of the population lives in the north-central regions, and about 67% inhabits rural areas. The limited road infrastructure in Namibia makes motorised transport difficult, and for several months, whole areas are inaccessible due to rain. Motorised transport is also unaffordable for the majority of households, which rely on small-scale farming for their incomes. Household income survey data (2004) shows that over 60% of rural Namibians have absolutely no access to motorised transport. What characterises the rural setting are distances between villages, homesteads, schools, clinics, markets and churches. Namibia is a country of great inequality and vast empty spaces.

Difficulties with distances are exacerbated as Namibia faces the combination of ineffective social services delivery and a staggering 17.7% prevalence of HIV/AIDS amongst the adult population. The health system has been struggling to cope with the number of people admitted to hospitals with AIDS related illnesses, but the shortage of healthcare professionals remains a hindrance. In rural areas, the lack of a transport system isolates communities from access to healthcare, treatment and support.

In 2006, the 'Parliamentarians for Women's Health', a consortium led by the International Community of Women living with HIV/AIDS, released an assessment on women's health related needs, experiences and issues in Namibia. Their aim was to identify barriers that women face in accessing a comprehensive range of healthcare services. Among other barriers, lack of transport emerged as one of the most important hindrances to accessing healthcare, as Ana and Johanna's stories show. The cost of the scarce existing transport constitutes a further barrier for clients and caregivers. Combined with the impact of policy directives like discretionary medical fees and the insistence that clients must collect their ARTs individually in the hospitals, transport costs and availability have a devastating impact on effective identification, treatment, care and support of people living with HIV/AIDS (PLWHA).

The National Policy on HIV/AIDS recognises that communities are the best source of support to those infected and affected by HIV/AIDS. More tangible assistance at the local level is required for monitoring of patients, access to food and clean water, and access to medication. Approaches include home-based care projects implemented by community-based organisations. Home-based care enables families infected and affected by HIV/AIDS to receive visits from trained volunteers who assist with household chores; provide counselling and information on adequate nutrition, hygiene and health; deliver medication and sanitary supplies; and provide basic alleviation from common symptoms. Home-based care volunteers' role is to overcome social isolation faced by PLWHA. Besides carrying medications and supplies, they carry prayers, patience to listen, and words of hope. Over 50% of volunteers are more than 50 years old. Over 90% are women. The majority are also HIV positive and as poor as their clients. However, rather than facing age, gender, poverty or health related pressures, they have the strength to help their neighbours. Without appropriate means of transport, they walk up to 20km a day to help infected and affected families to live more comfortably in their homes. Lack of adequate transport facilities increases the volunteers' workload and consumes their time; it dramatically affects equitable access to healthcare, and perpetuates their disadvantaged position in their communities.

In an attempt to provide localised, affordable and sustainable transport solutions that reach poor communities, since 2005, the Bicycling Empowerment Network Namibia (BEN Namibia) has arranged the delivery of about 8,000 bicycles through about 64 grassroots organisations in the northern regions, and has provided tools, spare parts and maintenance training to beneficiaries.

Numerous studies have shown that bicycles are an appropriate technology for travelling short distances in developing countries, with the lowest operating costs of all available modes in Sub-Saharan Africa. Even on untarred rural tracks, a bicycle carries up to four times the weight, goes twice as far, and travels twice as fast as a person walking.

Bicycle related activities can also create income generation opportunities. There is a ready supply of second-hand bicycles being donated by groups in the West to developing countries. With appropriate mechanical skills, tools and spare parts, community members can refurbish the bicycles, sell them at affordable prices, and provide repair and maintenance services. This ensures bicycle adoption in a community and offers high likelihood of ownership at the grassroots level.

Besides distributing bicycles to home-based care workers, BEN Namibia also manufactures bicycle-ambulances, 'stretchers on wheels' capable of moving sick clients to hospital from rural areas where there is limited medical transportation infrastructure. The client may ride in comfort and privacy, protected from the sun and rain, and reclining or laying flat. 73 ambulances were already delivered to home-based care projects and 30 more are in fabrication process.

Monitoring and evaluation of BEN Namibia's work has confirmed that bicycles do help volunteers to expand and improve their service delivery. Home-based care volunteers with bicycles can see more clients, deliver more supplies, and stay longer with each client. Bicycles boost the flow of information in the village, ie. volunteers can easily arrange meetings, or search for help. Bicycles save time for women to do domestic activities in their own houses and take care of their own families. It also makes it easier to assist clients to get to clinics and to help them stay on treatment.

Policy-makers still have a narrow focus solely on large-scale motorised transport – that do not always reach communities, let alone marginalised groups. They also often fail to consider gender issues, and do not implement comprehensive monitoring and evaluation systems capable of measuring people's sense of vulnerability and powerlessness. The focus should be on affordable and sustainable transport solutions for all.

Besides the tangible and straightforward impact that access to transport has on access to health, there is the intangible impact on PLWHA, their families, and communities. With a bicycle and access to tools and maintenance, Johanna could stay longer with Ana and listen, and talk, and share. Ana and Johanna would both feel less vulnerable and powerless. Johanna could bring more supplies and medications, and help Ana to visit the clinic without cost. More than that, Johanna could bring a little more happiness, trust, and confidence to Ana. Ana, in her turn, could live a more dignified, human, and less isolated life.