| 4. In which ways is the initiative creative and innovative?
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A Community Health Officer in the Dabo community in the Wa West District recognized that irregular transport made it very difficult and sometimes impossible for people who are critically ill and women in labour to be transported swiftly to the hospital on time. Discussions by the community members led to the development of a simple but effective system. The community identified one person who had a vehicle and arranged with him to make the vehicle available when someone needed to be transported to the hospital under emergency conditions. The community contributes to buy needed fuel.
CETS is creative and innovative because of its simplicity and effectiveness. It involves all major stakeholders of local government; community leaders; women groups; and male groups. It also ensures resource mobilisation locally by relying on private transport owners. It eases the burden of payment on beneficiaries and achieves zero default rates. With the above attributes this initiative has guaranteed sustainability and will not be constrained by lack of resources and/or interest as with most externally introduced initiatives. CETS has increased awareness of maternal health needs and uptake through the simple collective ownership of the process of mobilizing emergency transport for critical maternal health needs.to join the CETS scheme and make initial payment
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The original implementer for the CETS was the Wa West District Health Directorate, under the umbrella of the Ghana Health Service (GHS). A Community Health Officer (CHO) mooted the idea as an effective means of minimising or eliminating delays to health centres for rurally dispersed women seeking urgent maternal health care and other related emergencies. Once the idea was discussed and accepted, the leadership of the Wa West District Health Directorate sprang into action mobilizing various Sub-District Health Teams (SDHT) and the District Health Management Team (DHMT) to start up and launch the project.
With funding from the UNFPA, the District Health Directorate was able to train a healthy number of Community Health Officers (CHOs) through whom training sessions and community sensitization engagements were held to whip up enthusiasm in this community-led initiative called the CETS project. Details on the actual work plan of the project such as identify drivers and vehicle, cost for transport and the selection of executive members of the CETS board are agreed upon by the community members, who thereafter run the CETS themselves.
Wa West district has a population of close to 100.000. In 2015 a total of 23 CETS was implemented in the district and intentionally clustered around CHPS Zones covering 79% of all CHPS zones (23 out of 29 in the district). On the 28th of February 2017, the Director General of the Ghana Health Services made a strong statement to the effect that “the GHS would also support and promote local initiatives to expand Community Emergency Transport System for pregnant women and children among others” (http://www.ghananewsagency.org/health/ghana-health-service-to-accelerate-training-of-emergency-medical-teams-113746). As described in more detail later in the result section, the CETS have improved health outcomes for thousands of people in different ways, mainly focusing on pregnant women and newborn.
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| 6. How was the strategy implemented and what resources were mobilized?
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In the Wa West District, UNFPA supported the pre-process orientation of CHOs, which included training of CHOs who are not midwives to conduct emergency deliveries, identify early pregnancies, detect unnatural foetus positioning, and other relevant capacities that concern pregnancy and delivery. This increased the capacity of the CHOs to provide appropriate Emergency Maternal and Newborn Care (EmONC) services. UNFPA also funded the community durbars to introduce CETS to the communities, and monitoring of the CETS, which was undertaken by the Wa West District Assembly and the District Health Directorate.
In response to questions during documentation of the CETS processes, a community member in Dabo described the CETS as follows:
“CETS runs as a scheme, like a local level savings scheme called susu which is well established and accepted. It is voluntary. You join the scheme if you believe you might benefit from it one day in case of illness. Members pay between GHC2 and GHC5 per month to be members of the scheme. You can pay in kind if you don’t have cash. We use the money to buy fuel for the vehicle that is used as emergency transport. Children do not need to join the scheme in order to benefit from it. If a child or a very poor person or an aged person in the community needs to be sent to the hospital quickly, we just send them. They don’t pay”.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The stakeholders of the CETS include the Wa West District Health Directorate who were initiators. As mentioned, the initiation was based on a recognition of a development need of rapid transport in support of emergency maternal health situations. The conceptualization by the community health officer, CHO, drove the implementation of the system. With funding from UNFPA, community meetings were organized by the Wa West Health Directorate at which CETS was introduced to the larger community. Community participation was cross-sectional including men, women, community leaders, religious groups NGOs, CSOs. Twenty three communities participated in the pilot system. Owners of vehicles were particularly sought out and convinced to participate in the system. Interested members were invited to register to join the scheme. From the community members CETS executives were elected comprising chairman, secretary, treasurer, organiser and a trustee.
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| 8. What were the most successful outputs and why was the initiative effective?
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• In some communities, no-one owns a vehicle. To form the CETS, nearby communities sometimes agree to form “joint CETSs” in which one vehicle serves up to six communities. This collaboration in tackling such an important health issue brings communities together and promotes unity and mutual support.
• The CHOs have shared lessons from implementation of CETS in their communities at the district level. The lessons were further shared by the District Director of Health at the Regional level, where the concept was learned by others. The CETS concept has since spread beyond the Wa West District to the Sisaala East, Sisaala West, Jirapa and Lambussie Karni Districts in the Upper West Region, as well as the Kassena-Nankana West District in the Upper East Region of Ghana.
• In replicating the concept, a motorbike ambulance system has been created as a variation to the emergency vehicle. This “ambulance” is made up of a motorbike strapped with a trolley and popularly called “Motorking”. In some places like the Kassena-Nankana West District, the “motorking” is laden with a mattress and a seat. The sides of the trolley may be covered with a curtain to introduce some level of privacy to the patient. With this motorbike ambulance, a woman in labour or a person who is critically ill or unconscious could be more comfortably laid in the “ambulance” while a relation or friend sits in the seat to monitor the patient during the trip to the health facility. The “ambulance” has come to augment the CETS, providing an alternative where a vehicle is not readily available.
• Male involvement in delivery and maternal health issues in general has increased from 45 in 2011 when the pilot CETS project was not in place to 73 in 2014 when CETS was operational in 79% of all CHPS Zones in the district. This is because men generally drive women in labour to the health facilities to deliver. With the comfort of a vehicle, some husbands, brothers and other male relatives often accompany the woman in labour (or the critically ill person) to the health facility for treatment. Graphical analysis shows increasing male involvement in delivery as well as increasing number of referrals
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| 9. What were the main obstacles encountered and how were they overcome?
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Two main challenges were encountered in the implementation of CETS. Some community members are unable to pay the agreed contribution as a result of poverty. This could affect the sustainability of the CETS in communities that do not plan well ahead and develop innovative ways of sustaining the CETS. The initiative accommodated this obstacle by making payments liberal. Those who could not pay were allowed to pay over a period of time and some were written off outright.
• Some vehicle owners are unwilling to release their vehicles to be used as emergency transport owing to the bad roads in the district. It took a lot of convincing for some vehicle owners to agree for their vehicle to be used for the CETS. A second way out was the reliance on the improved motorcycles (motorking) which came later to the rescue of the initiative since there was a larger mass of owners and quite a number agreed to participate.
• Accountability is vital to maintain trust in the system. CETS is very difficult to establish in a community where conflict exists. This is because the CETS requires community mobilization, agreement, participation and payment. Peace and unity are therefore a primary prerequisite for establishing and sustaining CETS and indeed for development interventions in general and steps were taken to avoid such conflict situations.
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