eBox Micro Enterprise: An Incentive for community health actors

This technical brief outlines the trial of an innovative solution to motivate community health volunteers (CHV) through establishing the transport-related Micro Enterprise eBox, improving CHV mobility, and establishing emergency transport systems. This brief is included in a series of fifteen MAHEFA technical briefs that share and highlight selected strategic approaches, innovations, results, and lessons learned from the programme.

Madagascar Community-Based Integrated Health Program (CBIHP), locally known as MAHEFA, was a five-year (2011-2016), USAID-funded community health program that took place across six remote regions in north and north-west Madagascar (Menabe, SAVA, DIANA, Sofia, Melaky, and Boeny). The program was implemented by JSI Research & Training Institute, Inc. (JSI), with sub-recipients Transaid and The Manoff Group, and was carried out in close collaboration with the Ministry of Public Health, the Ministry of Water, Sanitation and Hygiene, and the Ministry of Youth and Sport. Over the course of the program, a total of 6,052 community health volunteers (CHVs) were trained, equipped, and supervised to provide basic health services in the areas of maternal, newborn, and child health; family planning and reproductive health, including sexually transmitted infections; water, sanitation, and hygiene; nutrition; and malaria treatment and prevention at the community level. The CHVs were selected by their own communities, supervised by heads of basic health centers, and provided services based on their scope of work as outlined in the National Community Health Policy. Their work and the work of other community actors involved with the MAHEFA program was entirely on a voluntary basis.

Le Transport d’Urgence Communautaire: Les transports d’urgence améliorent l’accès aux services de santé en milieu rural à Madagascar

Afin de réduire la mortalité maternelle et néonatale, l’accès en temps opportun à des soins qualifiés avant, pendant et après la grossesse est critique. Le fait de maximiser le po-tentiel pour les communautés à développer et gérer leurs propres systèmes de transport d’urgence (STU) est une méthode efficace pour améliorer l’accès aux services de santé et permettre de renforcer le lien entre la communauté et l’établissement de santé afin d’accroître la demande. Cette fiche technique fait partie d’une série de quinze fiches techniques produites par MAHEFA, et qui mettent en évidence des approches stratégiques choisies, des innovations, des résultats et des enseignements tirés du programme.

Community-Based Integrated Health Program (CBIHP), localement dénommé MAHEFA, est un programme de santé communautaire intégré financé par l’USAID pour cinq ans (2011-2016). Le programme a été mis en oeuvre par JSI Research & Training Institute, Inc. (JSI), en partenariat avec Transaid et The Manoff Group, et en étroite collaboration avec le Ministère de la Santé Publique, le Ministère de l’Eau, de l’Assainissement et de l’Hygiène et le Ministère de la Jeunesse et des Sports. Il a été réalisé dans six régions du nord et du nord-ouest de Madagascar (Menabe, SAVA, DIANA, Sofia, Melaky et Boeny). Durant la vie du programme, 6 052 agents communautaires (AC) ont été formés, équipés et supervisés pour fournir des services de santé de base dans les domaines de la santé maternelle, néonatale et infantile; la planification familiale et la santé reproductive, y compris la prévention des infections sexuellement transmissibles; l’eau, l’assainissement et l’hygiène; la nutrition; la prévention et le traitement du paludisme. Les AC ont été sélectionnés par les membres de leur communauté, encadrés et supervisés par les responsables des centres de santé de base. Ils ont fourni des services selon le mandat qui leur est assigné dans la Politique Nationale de Santé Communautaire (PNSC). Dans ce cadre, à l’instar des autres acteurs communautaires impliqués dans le programme MAHEFA, ils ont accompli leur travail en volontaires.

 

Community Emergency Transport systems: Using transport to improve access to health services in rural Madagascar

This technical brief emphasises the importance of timely access to health services in reducing maternal mortality and how access to safe and efficient transport can help to address this issue. This brief is included in a series of fifteen MAHEFA technical briefs that share and highlight selected strategic approaches, innovations, results, and lessons learned from the programme.

Madagascar Community-Based Integrated Health Program (CBIHP), locally known as MAHEFA, was a five-year (2011-2016), USAID-funded community health program that took place across six remote regions in north and north-west Madagascar (Menabe, SAVA, DIANA, Sofia, Melaky, and Boeny). The program was implemented by JSI Research & Training Institute, Inc. (JSI), with sub-recipients Transaid and The Manoff Group, and was carried out in close collaboration with the Ministry of Public Health, the Ministry of Water, Sanitation and Hygiene, and the Ministry of Youth and Sport. Over the course of the program, a total of 6,052 community health volunteers (CHVs) were trained, equipped, and supervised to provide basic health services in the areas of maternal, newborn, and child health; family planning and reproductive health, including sexually transmitted infections; water, sanitation, and hygiene; nutrition; and malaria treatment and prevention at the community level. The CHVs were selected by their own communities, supervised by heads of basic health centers, and provided services based on their scope of work as outlined in the National Community Health Policy. Their work and the work of other community actors involved with the MAHEFA program was entirely on a voluntary basis.

Community Health Volunteer Mobility: Expanding the reach of community health volunteers through the provision of bicycles (Technical Brief)

This technical brief outlines the role of community health volunteers and how their reach can be extended through the provision of bicycles. This brief is included in a series of fifteen MAHEFA technical briefs that share and highlight selected strategic approaches, innovations, results and lessons learned from the programme.

Madagascar Community-Based Integrated Health Program (CBIHP), locally known as MAHEFA, was a five-year (2011-2016), USAID-funded community health program that took place across six remote regions in north and north-west Madagascar (Menabe, SAVA, DIANA, Sofia, Melaky, and Boeny). The program was implemented by JSI Research & Training Institute, Inc. (JSI), with sub-recipients Transaid and The Manoff Group, and was carried out in close collaboration with the Ministry of Public Health, the Ministry of Water, Sanitation and Hygiene, and the Ministry of Youth and Sport. Over the course of the program, a total of 6,052 community health volunteers (CHVs) were trained, equipped, and supervised to provide basic health services in the areas of maternal, newborn, and child health; family planning and reproductive health, including sexually transmitted infections; water, sanitation, and hygiene; nutrition; and malaria treatment and prevention at the community level. The CHVs were selected by their own communities, supervised by heads of basic health centers, and provided services based on their scope of work as outlined in the National Community Health Policy. Their work and the work of other community actors involved with the MAHEFA program was entirely on a voluntary basis.

Review of the Emergency Transport Scheme and Community Health Volunteer Mobility Initiatives in Madagascar, under the MAHEFA Programme, April 2016

The Madagascar Community-Based Integrated Health Program (CBIHP), known locally as MAHEFA, is a 5-year, USAID-funded community health program that provides basic health services in: maternal, newborn, and child health, family planning and reproductive health, including sexually transmitted infections, water, sanitation, and hygiene, nutrition and malaria treatment and prevention, to underserved populations in six remote and poor regions in north and north-west Madagascar (Menabe, SAVA, DIANA, Sofia, Melaky, and Boeny). JSI Research & Training Institute, Inc. manages the Madagascar CBIHP in partnership with the Manoff Group, Transaid and 15 Malagasy NGOs.
In Madagascar, two of the five most relevant barriers to access health care identified by women of reproductive age (NDHS 2008/2009) are related to transport: distance to the nearest health facility (42%), and the need to use a means of transport (31%). According to Thaddeus and Maine, one of the three delays in seeking care refers to transport as well. The challenges for transport provision in rural areas in Madagascar are many. Issues in the operating environment such as infrastructure, low density demand, socio-economic status of the population, and high vehicle operating costs combine to have a significant impact on the level of competition, the diversity of vehicles, service frequency and cost. Moreover, in MAHEFA areas specifically, the terrain is challenging. It is often mountainous, sandy, and with a majority of sites experiencing access challenges during the rainy season. More than half of the communes in MAHEFA program areas (54%, 149 communes out of 279) are inaccessible by car or truck at least two months of the year. Of these, one third (34%, 96 communes) are not accessible at least four months a year.

While transport has been widely recognised as a barrier to the provision of and access to health service in rural areas (46%, NDHS 2008/09), few community health programs have integrated transport interventions as an enabler to support the provision of services. From its onset, MAHEFA’s core strategy included the trial of innovative solutions using transport to improve community health volunteer (CHV) mobility, improve access to health services through emergency transport systems (ETS) and transport-related micro enterprise activities (“eBox”). MAHEFA also established community health insurance schemes ‘mutuelle de sante’. This report will be divided into two parts with a focus on a review of (1) MAHEFA’s CHV mobility and (2) ETS activities.

To conduct community health activities and provide services to the individuals and families who rely on them, community health volunteers (CHVs) in many settings must travel long distances. MAHEFA’s approach to address CHV mobility focused on delivering bicycles to CHVs to ensure that CHVs have access to an available, functional, and effective mode of transport to reduce time and cost of travel for their health activities. MAHEFA distributed individual bicycles to 1020 CHVs and trained them on topics such as safe operation, management, maintenance, and repair of bicycles.

In the MAHEFA regions there was often limited access to any type of affordable transport. MAHEFA worked to fill this gap by introducing a range of intermediate modes of transport (IMTs) including bicycle ambulances, wheeled stretchers, canoe ambulances, and ox-carts. These were placed within the community, they were non-motorised and they were chosen according to the terrain and context.
Between September and December 2015 a small review team completed a qualitative review of the CHV mobility and ETS activities in Menabe, Sofia and SAVA. Focus groups and semi-structured interviews took place with key stakeholders to understand technical performance of the bicycles and IMTs, the utilisation, management, equity of access and impact. In addition, routine programme monitoring and evaluation (M&E) programme data was also analysed. The findings from this review are presented in two parts; firstly CHV mobility and secondly the ETS findings.

Review of the eBox Initiative in Madagascar, under the MAHEFA Programme, April 2016

The Madagascar Community-Based Integrated Health Program (CBIHP), known locally as MAHEFA, is a five year, USAID-funded community health program that provides basic health services in: maternal, newborn, and child health, family planning and reproductive health, including sexually transmitted infections, water, sanitation, and hygiene, nutrition and malaria treatment and prevention, to underserved populations in six remote and poor regions in north and north-west Madagascar (Menabe, SAVA, DIANA, Sofia, Melaky, and Boeny). JSI Research & Training Institute, Inc. manages the Madagascar CBIHP in partnership with The Manoff Group, Transaid and 15 Malagasy NGOs.
Community Health Volunteers (CHVs) play an essential role in the delivery of health services where communities are isolated and under-served by health facilities. However, their voluntary status is a potential constraint to continuity of service and therefore their levels of motivation are key considerations. As well as addressing issues around CHV mobility, a focus of the MAHEFA program has been to develop income generating activities (IGAs) via the introduction of ‘enterprise’ boxes or eBoxes. This report focused on this eBox activity.
As part of a wider integrated approach to addressing transport-related barriers to accessing healthcare, eBoxes in Madagascar are social micro-enterprises functioning as cooperatives whereby bicycle sale and repair shops are set up which provide a small income for CHVs as well as contributing to wider community health projects in local communities. Each eBox employs approximately ten staff on a part time basis and is overseen by a management committee. Each eBox benefits approximately 40-50 members of the cooperative when dividends are paid. Training was carried out by MAHEFA to try and ensure that each eBox develops into a profitable, self-sufficient business whereby profits are re-invested in community health activities as well as further resupplies of bicycles and spare parts.
This report constitutes a review of the eBox initiative under MAHEFA and aims to improve the program’s understanding of its impact as well identify lessons learned and subsequently recommendations for future interventions. Questionnaires were designed to gather information including day to day operational data, bicycle quality and future sustainability after MAHEFA’s involvement finishes. Stakeholders from all four eBoxes in Madagascar were targeted to participate, either through focus group discussions or one-to-one interviews.
Out of a total of 43 people currently employed over the four eBoxes, 29 are CHVs and the findings point to high levels of motivation amongst CHVs specifically in response to the IGAs. A total of 2,562 bicycles have been supplied to the four eBoxes collectively, of which 82% have been sold with average earnings to date at USD16,000 for each eBox. Three out of the four eBoxes had contributed a proportion of their profits to support local community health insurance schemes (mutuelles), community based emergency transport schemes (where applicable) and improving the CHV huts (toby), averaging between USD100 to USD200 annually. Additionally, three out of four of the eBoxes are beginning to diversify their activities to include the sale of rice and fish.

Clients who have bought bicycles from the eBoxes report doing so for a variety of reasons, for example for children to travel to school, or for farmers to transport small quantities of produce to markets. The review found that with the creation of the eBoxes, communities can access affordable spare parts and repair services for bicycles, which is particularly important in areas where large numbers of bicycles have been provided to CHVs.
The quality of the bicycles was reported to be very high by all of the cooperatives, with people favoring mountain bikes and BMXs. Two management committees stated preferences for bicycles with aluminum frames, suspension and disk brakes as these are most appealing to customers. It should be noted that whilst these features may be attractive, features such as disk brakes are likely to cause difficulties when sourcing parts for repairs in the future. The cooperatives advised they were happy with the variety of bicycles in the container as people can choose according to the own preferences, although adult bicycles fetch a higher price so are more attractive to cooperatives in that regard. The bicycles arrive in the containers in a ‘semi-knocked down’ state and then they are reassembled by the technicians at the cooperatives. Often handlebars needed tightening, brakes adjusting or saddles/pedals attaching before sale. The cooperative also advised that they often needed to fix gear and break levers prior to sales. After sales, bicycles are typically brought in for repairs to brakes, cables and gears, pedals, tyres and derailleurs. Customers frequently look to buy wheel rims, tyres, inner tubes, aluminum pedals, saddles and gear and brake levers, 24 inch and 26 inch tyres, chains and rims.
Several challenges were identified during the review. The cooperative structures were new and were comprised of people who had not worked together before, although they were all involved in community health activities. Two of the four eBoxes changed their President in the first year and, initially, there were some internal communication and trust issues. When the bicycles arrived, there was haste to move straight to a sales stage. In some cases, there was pressure from the cooperative members and management committees to begin sales before training had been completed. All four of the cooperatives have focused on selling bicycles rather than running a bicycle repair shop on an ongoing basis. This is most likely due to the higher profits that can be realised in a shorter time when a container of bicycles arrives as well as issues of confidence on repairs in some places. All four eBoxes are missing out on potential revenue from offering repairs.
Some important recommendations for future programmes emerged. It would be important to consider choosing cooperative participants with prior experience of collaboration, potentially through already-established NGOs or other local organizations. Additional capacity shortages should be addressed in future training with particular emphasis on the disbursement of payments either as salaries or dividends, with an extended period of support for wider training needs. In addition, the development of well-defined standard operating procedures (SOPs) should also be developed collaboratively between implementing partners and cooperatives in advance of implementation. Refresher training for technicians should also be considered. Future programmes considering eBoxes would need to plan for more support both before the first shipment of bicycles arrives (training and clear SOPs in place) and after (adequate support visits).

2014-2016- “Rural Transport Solutions for Maternal Health; the MORE MAMaZ Emergency Transport Scheme”

The MORE Mobilising Access to Maternal Health Services in Zambia (MORE MAMaZ) programme is an integrated programme that empowers rural communities to address the household and community-level barriers that prevent women and girls from accessing maternal and newborn health services. This programme builds on the successes achieved by a predecessor programme; Mobilising Access to Maternal Health Services in Zambia (MAMaZ), which was implemented between 2010 and 2013.

This technical case study outlines the emergency transport-related activities of the MORE MAMaZ programme. These activities aim to improve access to health services for communities in the five MORE MAMaZ districts.

Portuguese Transport Management Tools (Plus Manual) – Portugueses Ferramentas de Gestão de Transporte (e manual)

You can download T3-T19 as Word Documents using the links below, and  T20 as a PDF. // Você pode baixar T3- T19 como documentos do Word usando os links abaixo e T20 como um PDF.

T3. FICHA DE VERIFICAÇÃO DE VEÍCULOS

T4. DIÁRIO DE BORDO

T5. RELATÓRIO DE ANOMALIAS PARA O OPERADOR DE VEÍCULO
VERIFICAÇÃO DIÁRA

T6. AUTORIZAÇÃO DE TRANSPORTE

T7. PLANO DE MOVIMENTOS PARA O PERÍODO

T8. PROGRAMA DOS TRANSPORTES PARA O PERÍODO

T9. PROGRAMA SEMANAL DE UTILIZAÇÃO DOS TRANSPORTES – SEMANA DE

T10. RELATÓRIO PERIÓDICO DOS TRANSPORTES (tabela)

T11. RELATÓRIO PERIÓDICO DOS TRANSPORTES (narrativa)

T12. INVENTÁRIO DE VEÍCULOS

T13. FICHA DE INFORMAÇÃO DO VEÍCULO

T14. RELATÓRIO DE ACIDENTE INCIDENTE

T15. RELATÓRIO DE SEGUIMENTO DE ACIDENTE INCIDENTE

T16. PROGRAMA DE REVISAO DE VEICULOS PARA 12 MESE

T17. FORMULÁRIO PARA O AVALIADOR PARA  AVALIAÇÃO DE OPERADORES DE VEÍCULO

T18. REGISTO DO OPERADOR DE VEÍCULO

T19. SUMÁRIO DE MANUTENÇÃO DE VEÍCULO

T20. Gestão de Transportes: Um Auto-guião para Gestores de Transportes Locais de Serviços de Saúde Pública