Building a sustainable model to ensure mums have access to high-quality, safe, and affordable and urgent and emergency transport in Kakamega
Medics examine a pregnant woman in an ambulance during the coronavirus night curfew in Nairobi, Kenya June 19, 2020. REUTERS/Baz Ratner
[7 minute read]
Introduction: While the last 15 years have seen a significant increase in facility-based deliveries, decreases in maternal and newborn mortality appear to be stagnating in Kenya. Kakamega is one of the most populous of Kenya’s counties, with a population of approximately 2 million. In 2018, the estimated annual deliveries in the county stood at 70,084, yet of these deliveries, 35% occurred at home and 28% in a primary care facility (Level 2 or 3), which are frequently unprepared and under-resourced to manage any complications or emergencies even with the best efforts at risk stratification and referral. Only 37% occurred in a facility equipped with those services (a Level 4 or 5 facility).
Service delivery redesign for maternal and newborn health, means reorganizing maternal care so that all women deliver in advanced facilities that offer definitive care for complications (Caesarean section, blood transfusion, care for sick mothers and newborns) or in nearby affiliated birthing facilities, with health centers and dispensaries focusing instead on provision of quality antenatal, postnatal, and newborn care. For redesign to be successful, we need to interrogate gaps across the full spectrum of care referral and delivery to ensure mothers have access to a comprehensive, affordable service when and where they need it. This includes looking at the ‘three delays’ driving maternal mortality; (1) delays in recognizing when to seek care, (2) delays in reaching a facility, and (3) delays in receiving quality obstetric care in the facility.
Poor emergency transport coordination and financing costs lives: In Kakamega, around 99% of all pregnant women currently live within 1-hour travel time of an advanced facility, however there is a lack of safe, affordable emergency transport options - especially for women in the lower wealth quintiles - and especially during the night when some ambulances go off duty. Recognizing a need for stronger emergency transport options, Kakamega’s county government partnered with e-Plus, a Red Cross-owned service provider for prehospital medical care and ambulance services, in [year] to deploy nine ambulances to serve a population of two million +. However, a number of bottlenecks - ranging from operational to resource-based - continue to severely limit their effectiveness;
Lack of basic emergency equipment and trained personnel
(i) Inadequate capacity to provide for essential maternal health care provision in ambulances: To avert maternal deaths on route to hospital, ambulances must be adequately equipped to manage a cross-section of ALS (Advanced Life Support) and BLS (Basic Life Support) maternal emergencies. Whilst the county’s fleet of ambulances currently offer all utility services, three ambulances lack a stretcher system, oxygen, obstetric kit, and several other vital drugs, and equipment to manage maternity or obstetric and gynaecological emergencies.
(ii) Shortage of trained frontline emergency staff: An initial assessment of providers in Kakamega estimated that all county ambulances lacked a dedicated team of paramedics, as well as adequate, routine training in basic life saving support, with a particular gap in maternity care.
Lack of oversight to identify these gaps
(i) A lack of routine data to identify gaps in emergency transport services and direct available ambulances to the right place and time. One major contributor to the fragmented emergency response system in Kenya is that there is little to no visibility of where ambulances actually are in the county at any given time. When a mother in need requests emergency transport, emergency response teams currently undergo a slow and error-prone manual process of calling the nine ambulance drivers to check which is closer to the emergency. This results in a lengthy turnaround time; ambulances are often travelling from one end of the county to the other which, in the case of an emergency, can be life-threatening.
(ii) Poor coordination of emergency services. There is currently no centralized unit in county government to ensure emergency vehicles, equipment, and first responders are tracked, coordinated, deployed, and maintained. Emergency vehicles are often undersupplied with even basic medicines and equipment and shortages go unreported to county health managers, leading to inadequate funding for unseen issues …..
Poor financing to sustain them
(i) Inconsistent allocation of funds towards emergency services: Whilst Kakamega county has resources - both internal and through external funding - they are poorly allocated towards emergency services. Annual work plans often appear as wish lists, yet the resulting budgets to fund them are not always aligned with urgent MNCH health priorities.
Building a sustainable model to find, fund, and deploy quality emergency transportation across Kakamega: A feasibility assessment conducted at the start of the project analyzed geographic and physical access to delivery facilities, concluding that redesign should offer solutions to increase availability of transport whilst decreasing its cost. The partners are therefore working on three integrated solutions to;
Strengthen visibility of gaps in emergency services through data and insights
Improve the quality of pre-hospital emergency care through routine training
Ensure sustainability of these solutions by building county capacity for urgent and emergency service coordination and financing
Introducing the Coalition of Partners: Developed with and for Kakamega’s County Department of Health, the project unites several well-recognized public and private players in Kenya around four key project phases; a feasibility assessment (conducted by the Council of Governors, the Kenyan Ministry of Health, and Harvard University), a design phase, an improvement phase, and finally, implementation where facilities and care-support services, such as transportation and blood supply, are aligned with the new model of care. Via funding from the Bill & Melinda Gates Foundation, Jacaranda serves as the project’s key implementation partner, with Thinkwell and Accenture Development Partnerships (ADP) offering Kakamega county strategic financing support.
A In late 2020, Jacaranda sub-contracted Rescue, a dispatch service connecting available, qualified, and trained private sector transportation (bodas, taxis, ambulances) in Kenya with customers in need. Rescue’s approach of aggregating emergency services mitigates the need for counties to actively maintain and operate their own fleet of vehicles, which has proven ineffective in managing emergency transport services. During COVID-19, Rescue launched a Nairobi-based initiative to provide free ambulances for pregnant women needing emergency care, averting delays in both women seeking care for fear of infection in hospitals, or drivers taking them to hospital for fear of breaking movement restrictions. This experience of maternity-focussed, equitable emergency response tied with their capacity to collect and share real time data through Flare made them a compelling partner to help strengthen the county’s management and coordination of emergency services.
Improve visibility on gaps in emergency service provision, and ensure innovations reach high-priority areas through routine data and insights: Emergency response and medical transfers are time sensitive and strategic. Without oversight of the situation on the ground, it’s impossible to identify and rapidly address gaps like poor distribution of ambulances across the county, shortages of medical supplies within ambulances, or personnel challenges - such as untrained drivers and first responders. Through its cloud-based service Flare, Rescue is able to offer counties real-time, actionable data which, in turn, helps them manage resources more efficiently, and make targeted improvements to the quality and coordination of emergency services. In particular, this will include efforts to;
(i) Improve resource management: Jacaranda and Rescue will supply county governments with real time, geographic data and insights to help them better coordinate resources from personnel - like dispatchers and first responders - to vehicles - such as ambulances, medical taxis, and bodas.
(ii) Helps medical and response coordination teams instantly dispatch and coordinate urgent rescues with optimal visibility on available care, treatment options, and incident progress. This includes offering real-time updates and end-to-end support to mothers, from the rescue crew dispatch and arrival, to hospital admission and insurance approvals.
Ensure frontline emergency responders are adequately and routinely trained to mitigate loss of life en-route to hospital: Training health providers in emergency obstetric and newborn care (EmONC) is critical to averting maternal and neonatal mortalities. Yet across Kenya, many frontline emergency response teams lack sufficient, or routine training to deal with complications (such as excessive bleeding) on the way to hospital. Through its nurse mentorship program, Jacaranda is already building critical EmONC skills and knowledge among health coordinators, maternity nurses and providers in facilities across Kenya, and now sees an opportunity to extend this training to frontline emergency responders.
(i) Ensure frontline emergency responders have access to routine emergency training: Leveraging county-endorsed learning content from its EmONC Mentorship program, Jacaranda is equipping frontline EMTs with the knowledge to respond to emergency situations like excessive bleeding, and the communication skills to ensure all women receive respectful, dignified care before they reach hospital.
(ii) Equip drivers of medical taxis with basic training and equipment. Rescue plans to partner with, vet and train a total of forty private sector bodas (Kenya’s affordable moto taxi service), standard taxis and ambulances with basic life support training and first aid kits to help them provide non-emergency support to mothers on the way to facilities. By helping equip bodas and taxis with training and equipment, we aim to address current gaps in ambulance coverage - especially at night when emergency transport is even more scarce.
Build a sustainable model to ensure a continued focus on advancing emergency services for mums;
Jacaranda, Rescue and Thinkwell are working together to ensure these solutions are co-designed with and ultimately owned by county-government, embedded into health policy, and sustainably funded through an innovative health financing model. This includes;
(i) Building capacity within the county government to own and manage emergency services: The partners are working to strengthen an existing emergency unit within county government to help better oversee where, when, and how emergency services are deployed across the county.
(ii) Ensuring existing health policies are updated to include adequate provision of emergency transport: Jacaranda is working with county government to ensure the procurement, deployment, and consistent management of emergency transport is entrenched within current policies to ensure their sustainability within the current leadership regime.
(iii) Introducing sustainable financing for emergency services: Thinkwell is helping build county capacity to identify untapped revenue options, allocate resources more efficiently, and spend smarter. This includes introducing new frameworks to help county and national governments to better use evidence (collected through Jacaranda and Rescue’s solutions) to strategically plan, budget, and utilize available resources to improve maternal emergency service delivery, as well as ensuring a budget line is consistently carved out to adequately cater for emergency services across the county.
Strengthening emergency services for mums and babies in Kakamega is just one piece of the puzzle. For a complete and successful redesign, we need to ensure women receive quality care by well-trained providers at every stage of the referral process - both on the way to hospital and when they reach there. Our evidenced approach of combining data-driven, innovative solutions with revenue to pay for them will not only mean improved health outcomes for women and newborns, but also better health system efficiency where counties are empowered to sustain these services, and obstetric and neonatal services are concentrated in fewer facilities.