CETS
Wa West District Health Administration

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
1. The Wa West District is a large district spanning approximately 1,584km2 and containing 226 sparsely distributed communities. Members of the district are largely farmers and traders. There are few mini-buses (popularly called tro-tro) that run daily among communities. Public transportation is irregular, and few people own vehicles, some being private vehicles. When a person falls critically ill, or is bitten by a snake, or a woman goes into labour, it is very challenging to find a means of transporting him/her to the health facility on time. It was common to find women in labour being transported to the health centre on donkeys or bicycles. As a consequence of these transport problems, the number of health facility-based deliveries was low in the district - home delivery was the easier option for most women in labour. It is known that in settings where maternal mortality is highest, three crucial delays are directly associated with elevated rates of maternal mortality. These are: (1) delay in seeking health care, (2) delay in reaching a health facility, and (3) delay in obtaining appropriate care upon reaching a health facility. For, to improve obstetric outcomes, a woman must recognize that she is experiencing an obstetric emergency, her family must be supportive of her seeking care at a health facility, she must be able to access transportation and be successfully transported to the appropriate health facility, and she must receive the care that she needs. The second delay is a direct consequence of transportation systems that are poor, non-existent, or expensive—or a combination of these three. Historically in Ghana, women gave birth at home with the help of traditional birth attendant, who typically had little or no formal care training. This system needed to be changed. To encourage women to deliver at health facilities, the government made health care free for pregnant women and young children under the National Health Insurance Scheme, and discouraged traditional birth attendants from delivering babies at home. But many women continue to have babies at home, often because the clinics are far away and means of transport is not available. At most when the transport is sought for, the cost of payment is another issue and needless deaths continue to occur. Such deaths were of great concern to the families, communities and national government. These deaths across the country contributed greatly to Ghana not attaining Goal 5 of the MDGs. Across the country, at facility levels, local government levels, and at national government level, there efforts were made to address the situation. Maternal deaths were declared a national emergency in 2008 and additional external resources were sought to finance the provision of needed skills and supplies. The problem of maternal mortality persisted. Staff of facilities still had to grapple with some critical gaps that were inimical to maternal health.

B. Strategic Approach

 2. What was the solution?
In search of lifesaving solution, the Wa West District in the Upper West Region of Ghana initiated the Community Emergency Transport System with the primary objective to create and operate an appropriate, affordable transport system to convey people to the health facility during emergency situations. It is aimed at bridging financial inaccessibility, ensuring timely and effective referral of clients to prevent delays and avoidable deaths, especially for women in labour. The system also seeks to reduce cost and increase the availability of transport in hard to reach communities.

 3. How did the initiative solve the problem and improve people’s lives?
The Wa West District workplan of 2012 included expansion of the Community Emergency Transport System (CETS) in Dabo to other communities in the district. UNFPA identified this initiative as an important activity to contribute to their output of “increased national capacity to deliver comprehensive maternal health services”, and agreed to provide financial and technical support the initiative. With the financial support of UNFPA, the Wa District Health Directorate organized a series of workshops to introduce all community health officers, CHOs, in the district to the CETS. The CHOs were orientated to the concept of CETS, how it works and how it could be initiated in each community. The District Health Directorate also developed some guidelines on which CETS based on the lessons learned from Dabo including the following: 1) The community must set up a committee to oversee the CETS. The committee must be made up of trustworthy members of the community. 2) A vehicle must be identified within or near the community and the owner must be approached. It may be a commercial or private vehicle. 3) The owner of the vehicle must willingly permit his/her vehicle to be used in emergencies. 4) The vehicle must always have fuel in it to facilitate movement. 5) A few drivers in the community must be identified who are willing to drive a patient to the hospital in the vehicle. The telephone number of the drivers must be known to the CETS community executives and as many community members as possible. 6) One driver must be willing and available to drive a person to the health centre at any time. 7) A patient who uses the CETS would be required to pay for the service. A patient who is transported to a health facility urgently will not be required to pay immediately. Rather, she or he must pay for using the vehicle within an agreed period of time, ranging between one week and three months. The CHOs relayed the information about CETS to their community leaders to gain their support for a pilot CETS. Community meetings were organized, funded by UNFPA, at which the CETS was introduced to the larger community. Twenty-three communities agreed to pilot the system. Once the idea was mooted, the community members identified a commercial or private vehicle that runs in the community or in a nearby community, and discussed the CETS concept with the owner. If she or he agreed to release the vehicle when there was an emergency, the price for making the trip to the nearest health centre was agreed based on the distance to be covered. The community then invited interested persons to register to join the CETS scheme. Introducing CETS to the communities followed a process as follows, with the CHOs leading the process in this case: The project to introduce CETS in communities within the Wa West District yielded some positive results. By October 2015, a total of 23 CETS had been created in the district, clustered around CHPS Zones - 23 CHPS zones out of 29 in the district, i.e. 79% of all CHPS zones, have CETS. The CETS referred emergency cases to Community Health Compounds (CHPS Compounds), the district hospital, or to the Regional Hospital in Wa, depending on which is nearest where the emergency occurred. Women in labour in particular no longer arrived in the health facility on donkeys but rather in an appropriate vehicle. They arrived in the health facility in good condition and were promptly attended to. No maternal or new-born deaths were recorded in the CHPS zones where the CETS was implemented. The district, however, recorded maternal and new-born deaths.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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.
 6. How was the strategy implemented and what resources were mobilized?
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”.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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.

 8. What were the most successful outputs and why was the initiative effective?
• 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

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The WA West district is predominately a rural district with many hard-to-reach communities that suffers not only from sparse health care facilities but also from underdeveloped road network and poverty which results in time-consuming travels and absence of reliable fast transport. Added together, these factors cripple access to health centers for women in labour and others needing emergency services. The CETS have had a positive direct effect tackling the mentioned problems which have resulted in a significant increase in skilled birth delivery within just a few years of operation. Skilled delivery has increased from 28.1% (950) in 2012, to 32.2% (1109) in 2013 and further to 40.4% (1418) in 2014. Maternal health and new born health are closely correlated, hence it is crucial to improve the percentage of birth delivered by skilled professional (WHO, 2016). The CETS scheme have improved the attendance and at the same time increased the vital timely management and treatment that could make a difference between life and death for both the mother and the infant. The CETS program are extremely valuable for the most vulnerable and poorest people and it has proven to be effective in improving skilled delivery and cutting down maternal mortalities. This strategy together with a strengthened referral system has been adopted as the main focus by the Northern Region of Ghana to arrest the increasing numbers of maternal deaths in the region. As a result of access to more appropriate and faster vehicles, women in labour are no longer left with the option to arrive at the health clinics on donkeys or even bikes as before the CETS. The improved option of transport not only makes for a faster but also safer journey to the clinics. In 2015 a total of 23 CETS was implemented in the district clustered around CHPS Zones which covers 79% of all CHPS zones (23 out of 29 in the district). Results shows that since 2011 no maternal death nor new-born death was recorded in the CHPS zones where CETS was active, although the district as a whole suffered some maternal deaths. Overall, four (4) maternal deaths were recorded each year from 2012 to 2014 in the district; the number dropping down to three (3) in the year 2015. Furthermore, the CETS improved the referral system since transport arrangement against emergencies are planned in advance. And as mentioned previously, due to more safer and quicker transport, the amount of clients reaching facilities in good conditions have improved after CETS was introduced. The number, in the Wa West District, recorded a steady growth from a low of 23,000 in 2011 to a high of 33,000 in 2014 (Wa West district annual health records). The improved transportation has made it more accessible for men to accompany their wives into the health facilities and become more involved in maternal health. From 2011 when the CETS pilot started to 2014 reaching operations in 79% of all CHPS zones, male involvement in general health and maternal issues have increased from 45 in 2011 to 73 in 2015 (Wa West district annual health records).

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The CEST activity is managed by the communities themselves, with little support from the Ghana Health Service unit of the Assembly. This refrains the operation from being exposed to lacking integrity on a public level. Due to the CETS’s community-based model, the accountability is high around the people managing the operations and providing the vehicles and they have incentives and motivation to perform well since it is the business of a closely connected local inhabitants. Broadly, the inability of the Government of Ghana to adequately provide the necessary health care, including available emergency transportation, have generated this private initiative that have resulted in positive contributions for women in labour, based on a community working together on a local level.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
According to WHO’s research, maternal mortality is higher in women living in rural areas and poorer communities (WHO, 2016). Wa West is one of those areas which suffers from both poverty and high maternal mortality. As the result clearly showed in previous sections, CETS are improving the health care situation for the people and specifically the women in labour in these rural communities. The possibility to involve men in the health care system as enabled by the CETS also creates an improved gender equality in the villages by emphasizing on the importance of women’s health that is supported by the village people themselves. Young pregnant girls who may have had complicated and prolong labour easily have access to Caesarean section done on them to forestall the development of the debilitating condition of obstetric fistula. From an economical point of view, the CETS will supply support for the poorest during emergencies, acting like an insurance. This will prevent families to make forced irrational economic decisions i.e. selling belongings or properties at a discounted rate, due to time pressure, to supply funds which is vital for the health care needed.

Contact Information

Institution Name:   Wa West District Health Administration
Institution Type:   Local Government  
Contact Person:   Saalia Basilia Legib
Title:   Head of District Health Service  
Telephone/ Fax:   +233244223700
Institution's / Project's Website:  
E-mail:   basilia_salia@yahoo.com  
Address:   Wa West DHA, GHS, Wa West District
Postal Code:   P. O. Box 7
City:   Wechiau
State/Province:   Upper West Region
Country:  

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