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transportMYpatient: an initiative to overcome the barrier of transport costs for patients accessing treatment for obstetric fistula

This is one of the stories from the September 2012 issue of International News. People with disabilities are among the poorest and most vulnerable in the world. Even when health care is provided free, transport costs may pose an insurmountable barrier to accessing treatment. In this report Alison Fiander and Tom Vanneste outline an initiative in Tanzania that uses mobile phone technology to transfer funds covering transport costs for patients with obstetric fistulae.

Use the table below to access other stories in this issue.

Editorial In their own words: 12 stories of vesicovaginal fistulae
The problem of obstetric fistula: a personal view Provision of fistula services and programmes
Update on the FIGO/RCOG and partners competency-based fistula training manual The problem of continuing urinary incontinence after obestetric vesicovaginal surgery
Creating a balanced narrative about women living with fistulae Moving beyond incontinence
Vesicovaginal fistulae in Nepal Vesicovaginal fistula repairs at Aberdeen Women’s Centre in Sierra Leone
Vesicovaginal fistulae in Bangladesh Vesicovaginal fistula repairs in Tanzania
Obstetric fistula surgery in Uganda Journal club

 

The Tanzania Fistula Survey1 found that many girls and women with fistulae must travel more than 500 km to reach one of the major centres for fistula repair, with some travelling as far as 1000 km. Many respondents in the survey commented that the cost of fistula treatment and transport makes it difficult for girls and women to receive care.

The Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) Disability Hospital initiative ‘transportMYpatient’ was set up at the end of 2009 in order to tackle this barrier of transport costs. Prompted by an article in The Economist2 which highlighted the increasingly varied uses of mobile technology, CCBRT introduced the scheme to harness the potential of mobile money to cover transport costs. So far the focus has been on women with obstetric fistulae and patients with cleft lip and/or cleft palate.

The initiative was supported by the United Nations Population Fund with a grant to build the ‘ambassador’ network, pay transport and treatment costs for women with fistulae, and to convert an existing building into hostel lodgings for women with fistulae awaiting surgery.

Ambassadors are doctors, nurses, other healthcare workers and non-governmental organisation staff living in the community all over Tanzania, who are aware of the services offered by CCBRT. The network was established in early 2010 through a CCBRT outreach team who searched for appropriate individuals to serve as case finders/ambassadors.

CCBRT Disability Hospital in Dar es Salaam

CCBRT Disability Hospital in Dar es Salaam

One of CCBRT's outreach buses

One of CCBRT’s outreach buses

How the transportMYpatient initiative works

An ambassador identifies a patient in need of treatment and contacts CCBRT about the potential referral. The referral is screened by a CCBRT doctor to ensure that, as far as is possible, the patient’s symptoms are compatible with an obstetric fistula or cleft lip/palate.

Arrangements are then made to pay for the transport costs to bring the patient to CCBRT’s Disability Hospital in Dar es Salaam. Through an SMS from a CCBRT phone to the phone of the ambassador, the required transport funds are transferred. This transfer currently takes place through Vodacom’s M-PESA technology (M-PESA: M standing for mobile and PESA meaning money in Kiswahili). The ambassador collects the cash at the nearest M-PESA agent (there are over 6000 M-PESA agents in Tanzania), buys the bus ticket and puts the patient on to the bus. In order to cover their own costs of going to the M-PESA agent and dealing with the logistics of the bus ticket, ambassadors receive an incentive of TSH 10,000 (£5/$6) for each patient that successfully arrives at CCBRT with the correct and required transport receipts. The original 2010 target was to transport 60 patients to CCBRT via the transportMYpatient initiative.

Results of the transport initiative

In 2010, a total of 239 patients came to CCBRT via the transportMYpatient initiative and were operated on as shown in Figure 1; comprising 129 women with obstetric fistulae and 110 patients with cleft lip and/or palate, representing four times more patients than the original target set for 2010.

Through the transportMYpatient scheme, CCBRT increased the number of fistula operations carried out in 2010 by 65% compared with 2009. During 2011 166 women with obstetric fistulae came to CCBRT via the transportMYpatient scheme, representing a 29% increase compared with 2010 and the total number of fistula repairs increased again as shown in Figure 2.

Graph showing number of patients with vesicovaginal obstetric fistulae or cleft lip and/or palate referred to CCBRT during 2010 via the transportMYpatient initiative

Figure 1: Number of patients with vesicovaginal obstetric fistulae or cleft lip and/or palate referred to CCBRT during 2010 via the transportMYpatient initiative

Graph showing total number of fistula repair operations carried out per year at CCBRT's Disability Hospital, 2005–2011, indicating launch and impact of transportMYpatient initiative

Figure 2: Total number of fistula repair operations carried out per year at CCBRT’s Disability Hospital, 2005–2011, indicating launch and impact of transportMYpatient initiative

Discussion

One of the strengths of the transportMYpatient is efficiency and responsiveness. Within a few minutes of receiving a request for transport money, a transfer to the ambassador is completed and the ambassador is able to collect the money from an M-PESA agent and buy a bus ticket for the patient.

CCBRT is looking at methods to expand the ambassador network to locate more hard-to-reach individuals living with treatable disability such as obstetric fistulae. The possibility of using traditional birth attendants, community elders and community meetings to spread the word is also being investigated. Expansion of the ambassador network addresses lack of knowledge that medical treatment exists for these disabilities as well as overcoming the financial constraints. Many patients live in rural villages without access to the media, some are illiterate and some may need to hear the message that treatment exists more than once before deciding to access the services. CCBRT is also investigating the possibility of asking successfully treated patients to be ambassadors and find others living with obstetric fistulae. At the start of 2012 CCBRT has 144 ambassadors spread over all the regions in Tanzania. However, the density of ambassadors is low in some regions and this requires addressing.

The transportMYpatient initiative surpassed the initial targets set in 2010 and continued to see an increase (29%) in obstetric fistula referrals using the scheme in 2011. To support the ambassador network an ambassador conference was held in 2011 and early 2012 at CCBRT to update participants on progress of the transportMYpatient initiative with interactive sessions on how to find patients with treatable disability including obstetric fistulae, along with a hospital tour.

Using mobile phone technology to transfer funds represents an innovative means to overcoming a significant barrier to healthcare access for patients in developing countries.

Alison Fiander, Technical Advisor to CCBRT’s VVF service

Tom Vanneste, Deputy Disability Hospital Director, Dar es Salaam.

References

1. Bangser M. Tanzania Fistula Survey. Women’s Dignity and UNFPA. 2001.

2. Standage T. Mobile marvels: a special report on telecoms in emerging markets. The Economist 24 September 2009;1–14.