The role of transport in helping to achieve the Millennium Development Goals is extensively recognised in the Millennium Project report to the UN Secretary General which was published on 18 January, 2005: Investing in Development: A Practical Plan to Achieve the Millennium Development Goals In preparation for the report the MP Task Forces which addressed Health goals identified transport as a key constraint on achieving the Child and Maternal Health goals in many of the poorest countries. This view was confirmed by the case studies which were undertaken by the MP Team in (Bangladesh, Cambodia, Ethiopia, Ghana, Tanzania and Uganda). However, there was not a detailed assessment of the extent to which limitations in transport must be reduced if the main targets are to be achieved: The Health and Transport sector groups at the World Bank are working jointly and with partners to collect and assess relevant material which is currently available. The purpose of this exercise is to improve understanding of important challenges for reducing poverty and, in particular to enrich discussion of the Millennium Project report. For the first phase of this exercise a range of documents is being collected on this web page. An initial assessment of the material will be carried out in the week of 7 February to identify main lessons and to determine significant gaps in knowledge. The findings will be shared with all contributors and with the MP team and will be used to guide subsequent phases. If you wish to comment on this exercise in any way or to contribute material or sources, please do so by email to: Jumana Qamruddin jqamruddin@worldbank.org and Peter Roberts proberts@worldbank.org HEALTH TARGETS It is widely accepted that achieving the key health targets in many developing countries and regions depends on improving inadequate transport services as one of the critical constraints. A presentation by the World Bank links transport and health outcomes: Benefitting from Transport in Achieving the Better Health Outcomes Maternal Mortality Estimates of maternal mortality (http://www.childinfo.org/maternal_mortality_in_2000.pdf) developed by WHO, UNICEF and UNFPA show that “the lifetime risk of death is highest in sub-Saharan Africa, with as many as 1 woman in 16 facing the risk of maternal death in the course of her lifetime, compared with 1 in 2,800 in developed regions.” An assessment carried out in the Zambia by UNICEF on emergency obstetric care reports that “Communication and transport were far from adequate at the health centres. Only 26% of health centres surveyed had radios. Ambulances were stationed at specific health facilities; however, accessibility to them was not always easy by all health centres. The road infrastructure is impassable in the rainy season and poses a great challenge to road users even in the dry season. Clients still have to cover great distances to reach a referral health facility.” The comprehensive evaluation report further details the of lack good roads and describes alternative methods of transporting the population to receive health care. In India there is increasing emphasis on the private sector delivery of health services and measures are being investigated to align transport and distribution with this. Several studies examine the impact of local interventions to improve the effectiveness of transport services. in Ethiopia there has been some work on looking at how some health outcomes for women are affected by transport: There is evidence of a strong relationship between maternal health and child health, in view of the importance of pre-natal and immediately post-natal conditions for both. UNICEF states that, “Maternal and newborn mortality continues to be high in Africa, the causes largely preventable and the same factors contributing to both. Emergency obstetric care and skilled personnel are most needed in rural areas, along with improved emergency transport, road and communication systems.” At least 35% of women in developing countries receive no antenatal care during pregnancy, almost 50% give birth without a skilled attendant and 70% receive no postpartum care in the six weeks following delivery. This lack of care is most life-threatening during. childbirth and the days immediately after delivery, since these are the times when sudden, life-threatening complications for the mother and the child are most likely to arise. Mitigating spread of HIV/AIDS The role of the transport sector both in the prevention (do no harm) and in proactive approaches to reduce HIV/AIDS transmission that is associated with transport and high ways -- is an important multisectoral issue. In the World Bank, a number of good practices in projects are emerging that are addressing this topic: TRANSPORT SERVICES UNICEF starkly describes the consequences of inadequate transport for the delivery of basic health care: “The most impoverished – usually rural – areas have few or no health care facilities, or the means to transport people for medical assistance. About 90 per cent of children dying from these diseases die at home, often without their families even seeking health care.” http://www.unicef.org/health/index_problem.html The International Forum for Rural Transport and Development reports on a recent TransNet workshop on mobility and Health aimed to bridge the gap in undertsanding the role of transport in improving poor people's health. At the Ethiopian Road Authority, John Hine has shown that there is a strong correlation between ‘road density’ and ‘life expectancy’. This is for a region where road density is generally very low. Transport managed by the Health Sector. There have been projects in several developing countries to assist the Health Sector to improve its management of transport for various purposes including emergencies. TransAid has undertaken an overview of some of these projects A paper from the Rural and Remote Health Journal of the Wits Medical School describes the critical importance of transport in the provision of primary health care and questions why this is not considered by the Council of Health Service Accreditation of South Africa. UNICEF describes the situation in Manhica district, Mozambique: “population is estimated at 139,000 inhabitants….The district has 12 Health facilities…..The average distance between health facilities within the district is estimated at 15 kms. The public Health sector in Manhiça district has 2 vehicles and 3 motorcycles to cover all the demands of Health services in terms of transport, including the referral transport of patients, outreach activities (Monthly Health Days with Community Participation) and other administrative services.” Read the note here. In some cases there may be a particular role for non-motorised transport such as bicycles. The Intermediate Technology Transport Development Group has summarised recent experience in Africa and is also sharing, in an article in Sustainable Development (Winter 2004, page 8; article text only is here) and is also sharing, on an informal basis a report on the opportunities in Senegal. Field interventions supported by Riders for Health (a non-government organization that assists operation of motorcycle services for healthcare) demonstrate the potential for well managed motorcycle fleets to improve health service delivery - under certain circumstances and provided that appropriate management arrangements are established to encourage effective maintenance and operation. There are particular transport issues in delivering health services to meet the needs of nomadic populations. A paper by Siyad A. Abdullahi of Boston University School of Public Health describes the situation in Northern Kenya. In India there is increasing emphasis on private sector delivery of health services. One example is the work Janani a non-profit organization which operates in the Bihar State. In recognition of this trend, mechanisms are being investigated to align transport services with the delivery of and access to health services and products. Community managed Transport Services. The International Forum for Rural Transport and Development draws attention to the range of constraints and impacts which are imposed on the health of communities by inadequate transport. International Technology Development Group is supporting field trials of community-based transport in several developing countries. IT Transport has studied low cost provision of transport to health facilities for communities in rural Tanzania (M). Emergency Transport. The provision of timely treatment during life-threatening emergencies is not a priority for many health systems in developing countries. WHO has published a paper which reviews evidence for the need to develop and/or strengthen emergency medical care systems in these countries. This argues for the role of emergency medical care in improving the health of populations and meeting expectations for access to emergency care. The paper considers emergency medical care in the community, during transportation, at first contact and at regional referral facilities. Some studies by IT Transport and others have attempted to develop low cost motorcycle and bicycle based vehicles and trailers which might be suitable to carry patients in an emergency situation. A pamphlet by Oxfam highlights the use of bicycles to reduce death from diarrhoea in Malawi. Transport and the Spread of Disease There is strong evidence linking transport routes to the spread of HIV/AIDS. International studies suggest that the transport sector is a major vector of the disease for two main reasons: - increased movement of people through the opening of new traffic routes and improved access and mobility (between areas of high and low HIV prevalence eg. from urban areas to rural areas and between countries);
- behaviors associated with transport sector workers and transportation hubs (for example, truck drivers constitute a target group because of their long distance mobility and high-risk behavior at truck stops and border towns).
A number of key documents and links are available on the World Bank Transport and Social Responsibility Website webpage. The sometimes large influx of construction workers employed in the construction of transport infrastructure (roads, ports etc), which is often in remote areas, can present a major risk of spreading HIV/AIDS to the local population. The International Labour Organisation offers important guidance on combating these risks in implementing such construction projects. UNAIDS gives guidance related to migrants and workers (Note: An acknowledgement to Chris Green and Ron Dennis of Developing Technologies at Imperial College, London for access to a literature review)
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