Unaffordable or cost-effective?: introducing an ... - Wiley Online Library

Tropical Medicine and International Health volume 10 no 9 pp 879–887 september 2005

Unaffordable or cost-effective?: introducing an emergency referral system in rural Niger Paul Bossyns1, Ranaou Abache2, Mahaman Sani Abdoulaye3 and Wim Van Lerberghe4 1 2 3 4

Belgian Technical Cooperation Agency (BTC), Brussels, Belgium Ministry of Health, Niamey, Niger Ministry of Health, Ouallam District, Niger WHO, Geneva, Switzerland

Summary

objectives An important investment was made in two health districts in Niger to organize an emergency referral system. This study estimates its impact and cost-effectiveness in relation with external determinants. methods After installing a solar radio network in the health centres, emergency calls and related data were monitored over 7 years and investment and recurrent costs for the system were estimated. results The number of emergency calls increased significantly in both districts. In 2003, the total yearly cost for the district amounted to US$ 14 147, the cost per useful and successful call was US$ 49 and the cost per inhabitant and per year was about US$ 0.06. conclusion The impressive and immediate impact on the health system, the relatively low recurrent cost and the minimal management requirements for the health service make the investment very worthwhile. Organizing emergency evacuation systems should be a priority for any health district in the world. keywords referral system, emergency transport, accessibility, cost-effectiveness, communication

Introduction Referral and counter referral are key features of district health systems, particularly in case of emergencies (WHO Expert Committee 1987; WHO 1992). They allow for a rational division of labour between health centres (HC) and hospitals. In scarcely populated areas with dispersed populations, such as rural Niger, they are vital: HCs offer only a limited range of interventions and access to the hospital is difficult and costly. Distance and lack of transport are major obstacles and causes of delays for surgical and obstetric referrals (Van Balen 1997; Nkyekyer 2000; Maine et al. 1996; Le Bacq & Rietsema 1997; Urassa et al. 1997; Koblinsky et al. 1999; Coulibaly et al. 2000; Nordberg et al. 1996) Many studies including focus groups with members of the public in Nigeria, Ghana and Niger blame poor roads, scarce vehicles, and high transportation costs for the malfunction of the referral system and the delays in reaching emergency care (Fawcus et al. 1996; Samai & Sengeh 1997; Wilson et al. 1997). There are not many options for dealing with obstetric and other emergencies that go beyond a HC’s capacities. Although HC could improve their competence in order to avoid evacuations to a certain extent, it is hard to imagine

ª 2005 Blackwell Publishing Ltd

that the necessary technical means (diagnostic and therapeutic) could be significantly decentralized beyond the present level. Emergency evacuation can be improvized relying on private transport or organized by calling for an ambulance – provided there is a way of communicating between the HC and the district hospital (DH) (Blaise et al. 1997; Essien et al. 1997; Le Bacq & Rietsema 1997; Samai & Sengeh 1997; Shehu et al. 1997). Although there is an obvious need to deal with this problem, it remains difficult to convince decision makers in poor countries that it is feasible and worthwhile to provide for emergency evacuation. This paper shows that even in the extremely difficult circumstances of rural Niger it is possible to organize a radio-ambulance system for emergencies that increases the number of useful referrals at a limited marginal cost. Women in Niger who face problems at childbirth – or any other person with a health emergency – have few chances of getting to the hospital in time. Less than two per thousand births in rural Niger benefited from a caesarean section in 1998 (Ministry of Health 2001) and maternal mortality is among the highest in the world: 1600/100 000 live births (AbouZahr & Wardlaw 2003). Widespread poverty, isolated and underused HCs, huge distances to the DH, bad roads, and lack of transport (many HCs see a car 879

Tropical Medicine and International Health

volume 10 no 9 pp 879–887 september 2005

P. Bossyns et al. Cost-effectiveness of an emergency referral system in Niger

passing by only once a week and drivers are often unwilling to carry patients) all contribute to the infrequency of emergencies reaching near empty DHs (Krasovec 2004).

Tiloa Tizegorou

Banibangou

HC in Ouallam

Context

Mangaize

It is in this context that a radio-ambulance system was introduced in two districts in rural Niger: Ouallam and Tahoua. Ouallam and Tahoua are two of Niger’s poorest districts (Coordination Re´sidente du Syste`me des Nations Unies au Niger 2002); they have a scattered population, often living far from HCs and the hospital (Table 1, Figures 1 and 2). Niger is the second-to-last ranking country for the Human Development Index 2004 (Ministry of Health 2001). Tahoua district is the smaller of the two, covering 9000 km2. Population density is estimated at 32 inhabitants/km2 and the population living within an area of 5 km from a HC was 28% in 2003. The general conditions for the rural population – its isolation and the inaccessibility of the hospital – are similar to the situation in Ouallam district. With its 22 000 km2, Ouallam district is nearly the size of Rwanda. Not a single tarred road crosses the territory and there are hardly any cars circulating. An experiment with tricycles to transport patients from their home to the HC was stopped early because they could not pass the sandy roads in the dry season, nor the soaked clay in the wet season. Considering the average travel distance (Table 1) and the virtual absence of a road network and private vehicles, evacuating patients from HCs to the DH is not feasible by any means other than a four-wheel vehicle. The few villages with donkey carts would need an average of 18 h non-stop travelling to reach the hospital. No

Inhabitants (out of which in the district capital) Size Rural population density Number of rural HCs in 1996 Number of rural HCs in 2003 Population within 5 km (10 km) from a HC (2003) (%) Population-weighted average distance to hospital** Number of beds Bed occupancy Radio-ambulance system

HC in 1996 HC opened between 1997 and 2003

Tondikiwindi

Sewane

Village distribution Farka

Harigana foyma DH Dabre

Ouallam Simiri

Banne

Dingazi Banda Guineo-Bangou km

Samari

0

50

Figure 1 HC with 10 km radius in 1996 and 2003, Ouallam District (DH ¼ district hospital).

wonder that in such circumstances, the DH only hospitalized 391 patients in the whole of 1995. In February 2000, Ouallam hospital’s construction of additional wards, an operating theatre and a radiology room was finished and new equipment for maternity and the laboratory was installed. This allowed Ouallam hospital to upgrade its performance gradually. The first caesarean section was possible in April 2000 and the first blood transfusion 3 months later. Both districts started to benefit from an externally funded project and technical assistance from GTZ in 1995, which invested about US$ 1/inh/year in the health sector until 2003. Part of this investment was to create an emergency evacuation system.

Ouallam

Tahoua

250 000 (6500)

350 000 (60 000)

22 000 km2 12 inhabitants/km2 7 14 21 (54)

9000 km2 32 inhabitants/km2 10 14 28 (69)

74.6 km

40.5 km

52 beds 20% End 1996

250 beds 50% Mid 1997

Table 1 Ouallam and Tahoua district

**, R (Pop. < 5 km from HC*distance between HC and Hospital)/Total pop. < 5 km from HC.

880





HCs in 1995 Taza

HCs opened between 1997 and 2003 Village distribution

Amaloul

Affala Barmou

Takanamat

Tebaram

Edir

Tahoua Bambey

Toro Kalfou DH

Hada Chimou Sano

km Mogeur

0

25

50

Figure 2 HC with 10 km radius in 1995 and 2003, Tahoua District (DH ¼ district hospital).

Intervention package and method The intervention package consisted of a solar-powered radio-link among the HCs and the DH and a rudimentary ambulance service, with a (partial) cost-recovery system to ensure fuel and maintenance. The solar energy installation for the radios would be easy to maintain. The radio link was supposed to facilitate communication between HCs and the DH, which would make evacuation feasible and less expensive; people are more inclined to look for help in the HC knowing that evacuation would be possible if necessary. The radio installations were completed in November 1996 in Ouallam and mid-1997 in Tahoua. They were fed by a 55 W solar panel, which provided 15 Ah/day 96% of the days in Niger. The panels were linked with maintenance free batteries with a life expectancy of minimal 5 years and a large capacity (200 Ah, 65 kg), allowing minimal communication for 3 weeks without recharging. These rather expensive batteries were chosen because they were sturdier and less likely to be stolen than ordinary car batteries, and because in this isolated region it was difficult to find the distilled water ordinary car batteries require. Maintenance was limited to cleaning the solar panels and dusting. To encourage the staff to do this, a lamp and a socket for a radio were installed in the staff housing. With normal use, the radio consumed an average of 3 Ah/day, with exceptional peaks of up to 20 Ah in the case of 150 min of continuous emission. To allow for round-theclock response to calls, the radio in the hospital was placed in the emergency room with a link to the night duty room of the nurse on call. The solar panels were bolted on the roof to protect them from children and theft. Initial problems (damage to the


roof when cleaning, wrong orientation – some had simply been oriented towards the position of the sun at the moment of installation – and walls that had too little cement to support a panel) had to be overcome. Several radio antennas were brought down by storm winds, camels or donkey carts because the local contractor had not respected the norms for the thickness of the poles and cement in the anchoring system. The HC radios (VHF, 1.8–150 MHz, 100 W) were switched on at midday and in the late afternoon to allow the district management team to communicate with the HCs. In case of emergency, the HC staff could call the referral hospital at any time. On Monday mornings, the HCs used the radios to transmit their weekly epidemiological report. Staff were only supposed to use the radios for these purposes, but this rule was not strictly enforced. The ‘ambulance’ was a common closed ‘Land Cruisertype’ vehicle with a mattress in the back on which the patient could lie. It was possible to maintain an i.v. drip. Before the installation of the radios, there was an ambulance but it could only be ‘called upon’ by relatives of patients reaching the hospital on foot or camel. These ‘calls originating from the public’ were always responded to. Before the installation of communication means, ambulance transport was provided for free. Afterwards, in consultation with the population, fees for an emergency evacuation were set at 65 fCFA/km (US$ 0.2/km), and later increased to 90 fCFA. This could tally up to more than 25 000 fCFA per evacuation. When the cost recovery principle was discussed with the population, these fees were widely accepted also because private transport costs were up to three times more expensive than the proposed fees. In principle, the ambulance was not supposed to leave the district health office before the personnel in the HC had verified that the patient had the money, but in practice arrangements were sometimes made for deferred payment. Families were supposed to pay even if the patient died before arrival at the hospital. In the exceptional cases that families of patients were allowed credit, they always covered their debts afterwards. From the beginning of 1996, a prospective study was set up to follow the performance of the system. Reliable baseline data for the two districts were collected in 1996. The DMT supervised the quality of the routine data provided by the HC and the hospital and cross-checked them with the records kept by the ambulance drivers and the district accountant, who was responsible for the payment by the patients. At the HC level, staff were instructed to keep records of all emergency referrals. Data on running costs for the ambulance and outcome of the evacuations were collected specifically. The cost analysis 881




followed WHO guidelines (Creese & Parker 1994; Shepard et al. 2000). Fairly detailed data could be obtained in Ouallam since 1996. They include information on the emergency calls, on recurrent costs, on maternal deaths at HC and the DH and, for a 5-month period, on the outcome of evacuations. Due to operational problems within the DMT, data for 2002 became unreliable. For Tahoua, information is limited to the number of emergency calls 1 year before and after the installation of the radios in 1997. The instability of the Tahoua DMT from 1999 onwards did not allow further reliable data collection. General conditions did not change for the rural population during the whole period of the study in the two districts. The road network did not improve, the number of private-owned vehicles did not increase and the purchasing power of Niger’s population decreased by 1%/year. Health service performance did not significantly improve in Tahoua between 1996 and 1998. For Ouallam district, general health service performance improved gradually over the 9 years.

Results Requests for emergency assistance and emergency evacuations In Tahoua district, the number of emergency evacuations from the rural HCs 1 year before and after the introduction of the system was recorded. In that period, there were respectively 46 522 and 36 579 recorded in the rural HCs (the introduction of a cost recovery scheme in the latter period caused the number of consultations to decrease). The number of HC did not increase in this period. Emergency evacuations increased significantly after the introduction of the radio-ambulance system in Tahoua district (Table 2). In Ouallam, the number of emergency calls initially picked up more slowly than Tahoua. It accelerated in 2000 when the hospital became operational. The increase from 117 in 1998 to 433 in 2003 was exclusively due to an increase in the calls originating from HC staff (Figure 3). Table 3 shows the influence of distance between the HC

500 450

8 calls from 10 calls from 26 calls from 7 HC 8 HC 8 HC =1.1/HC = 1.3/HC = 2.9/HC

29 calls from 67 calls from 118 calls from 12HC 9 HC 12 HC = 6.7/HC = 3.2/HC = 9.8/HC

352 calls from 14 HC = 25.1/HC

400 350 300

Calls originating from HC Direct calls from the public Total emergency calls

250

Year hospital was upgraded

200 150

Radio-ambulance system in place

100 50 0 1996

1997

1998

1999

2000

2001

2002

2003

Figure 3 Calls for emergency assistance in Ouallam.

and the DH on the number of emergency referrals. In 2003, three HCs evacuated more than one patient per month; at an average of 38 km from the DH, they accounted for 58% of the evacuations. Five other HCs, somewhat further away at an average of 43 km, sent about one patient per month and accounted for 29%. The remaining six HCs, at an average distance of 88 km, sent less than one patient per month and accounted for