Sustainable Emergency Referral Care, SERC: A System at Work
The Ghana Essential Health Intervention Program (GEHIP) launched a 5-month pilot project in 2012 to strengthen the emergency referral system in the Soe sub-district of Bongo District in the Upper East Region (UER) of Ghana. The Emergency Referral Pilot (ERP) project was established in line with GEHIP’s support for various health care interventions at both community and facility levels in rural Ghana, and assessed the impact of transportation and communication initiatives on reducing the second level of delay described by Maine and Thaddeus (1997). Last year, SERC was developed to scale up ERP based on lessons learned from a qualitative appraisal of the pilot project.
SERC is a comprehensive system of transportation and communication aimed at improving access to emergency care in 12 rural sub-districts of 3 UER districts — Bongo, Builsa North and Builsa South. The initiative targets pregnant women, neonates and children, although all genders and age groups irrespective of districts can utilize intervention emergency transport services. The transportation system uniquely utilizes 3-wheeled vehicles called ‘Motorkings’ that have been modified by the manufacturer into ambulances suitable for the rough terrain of the UER. Motorking ambulances were strategically deployed to health facilities guided by the Geographic Information System (GIS) data of each district. Community-selected volunteer drivers have been trained by the Motorking suppliers as well as other vehicle, safety and transportation departments in Ghana. Drivers also received relevant training on patient handling and transportation in emergencies.
Community members are very much aware of the presence of the Motorking ambulances in their communities, and they are confident in being able to access transportation to health facilities in emergency situations. As part of my work this summer as an intern with GEHIP, we conducted Focus Group Discussions (FGDs) to assess the level of knowledge on the signs of emergencies among community members in SERC intervention districts. Respondents demonstrated awareness and appreciation for the presence of the Motorking ambulance. For example, when asked what came to mind when someone mentioned ‘emergency’, a respondent replied, “I will first call a Motorking number”. Another respondent talking about what an emergency is, said “Like I have said about passing stools and you are vomiting and you get here and the motorking is there, it will take you to the doctor so that you will be saved. I know that is emergency.” No doubt, access to transportation has made a difference in these communities; what we question is whether community members are seeking access to these services early enough. This quote from a respondent in the Sikabisi community captures the perceived impact of the Motorking ambulance very well: “what am seeing is that this motorking has saved us, previously when we are sick you have to go and plead with someone if he is having a motor (meaning a motor bike) to come because it’s serious, but when the motorking came when we call the motorking driver and they will come and take him to the hospital and save our person for us.”
Health workers have complained that community members’ delay in seeking medical care during emergencies is partly due to their inability to promptly recognize signs of emergencies for which they need to seek medical care. The unique health seeking behavior — where medical intervention is considered as the next or last option once traditional methods have failed — also contributes to delay in seeking medical care. One would expect that community members seek medical care early during emergencies since they are aware of the innovative ambulances. The concerns about delay in recognizing and responding appropriately to emergencies have been elucidated by a 2-part qualitative assessment of the education needs of community members; the first being by In-depth interviews (IDIs) among health workers and the other through Focus Group Discussion (FGDs) among community members. It is in response to findings from these that efforts to formalize culturally appropriate Community Education Activities (CEA), to increase the capacity of community members to recognize signs of an emergency and seek medical care early, are underway. In collaboration with the Health Promotion Department of the Regional Health Directorate (RHD), the Center for National Culture (CNC)’s regional office and community women groups, educational instruments including flip charts for use by Community Health Officers and Nurses (CHOs, CHNs) for community education; educative dramas recorded for night video shows; educative songs; and posters are currently being developed. Utilization of SERC transport services to promptly access medical care in emergency situations is expected to improve with CEA.