The challenges of controlling TB in a mobile population

Reporting from a practicum in southern Africa.

Miriam E. Reda, MD, MPH 2013'

Tuberculosis (TB) disease is as old as history. Throughout time, the disease went from death sentence to, with the discovery of the causing organism by Robert Koch and extensive experiments, vaccinations theories and cures, that by the 20^th century it was considered a curable disease en route to elimination. However, the age of optimism was short lived as the HIV epidemic emerged in the late 20^th century and TB resurged in more extensive, aggressive and resistant forms. The concomitant burden of TB and HIV has since been top on the health agenda of international organization, medical conferences, donor societies, philanthropists, affected countries and the civil society.

  

Lesotho is one of the countries with very high burden of co-infection currently being supported by ICAP at Columbia University. A small country in southern Africa with the world’s third highest HIV prevalence at 23% and the fifth highest incidence of TB in the world,  Lesotho bears this double challenge.

In addition, with a very limited employment opportunities for men in Lesotho, the South African mining sector represents a prospect for many Basotho men to cross the borders and work on making a better living to support their families. However, this opportunity comes with substantial occupational hazards for acquiring TB.  Miners work in closed poorly ventilated mine shafts with prolonged exposure to silica dust and are exposed to the social consequences of living away from their families for extended period of time. The combination of all these different factors leads to a disproportionately high disease burden among miners with TB incidence in gold mines in South Africa being the highest in the world and in Lesotho 10 % of TB patient and 25% of MDR-TB patients are either current miners or ex-miners.

TB REACH care supporter performing TB screening for a miner and his wife at TEBA Maseru 

This troubling situation was addressed by the South African Development Committee (SADC) in its August 2012 Declaration aiming at the elimination of TB in the Region through improving practices of environmental, health and safety standards of the mining sector in the region.

Less than a year after this declaration, ICAP, in collaboration with the Lesotho Ministry of Health (MOH) and The Employment Bureau if Africa (TEBA), worked extensively on the design and implementation of the TB REACH project which targets 26,000 miners and their families through establishing TB clinics at TEBA sites to provide TB education, counseling, on-site prompt diagnosis and same day treatment initiation with close follow up and contact tracing. The project is innovative in its nature since it is able to catch the highly mobile population of miners through establishing points of care at TEBA where miners report regularly to get their deferred payments, offering services over the weekend and making use of the latest advancement in TB diagnosis with onsite GeneXpert machines.

 

TB REACH laboratory technician running sputum samples on the GeneXpert machine at TEBA Maseru

I had the opportunity to contribute to this project in Lesotho as my practicum for completing my Masters in Public Health graduation requirements. My experience in Lesotho and with TB REACH has been highly interesting and enriching.

Despite the fact that Lesotho is a small country with various challenges, it is full of very friendly people. I was overwhelmed by the kindness I was welcomed with to the country and by the approachable and pleasant way people interacted with. Moreover, Lesotho offers breathtaking sceneries; gorgeous mountains and some parts of Lesotho are a very concrete example of rural villages with rocky roads, basic lifestyle, poor access to transportation and scarce health clinics all of which make the provision of medical services extremely challenging. I had to chance to visit some of the most remote health clinics abundantly mentioned in public health textbooks.

As for setting up the TB REACH project, my experience was vastly educational and fulfilling on various levels. Initially, I was involved in drafting, revising and finalizing the nurses’ and health care workers’ training curricula. It was a challenging task taking the WHO guidelines and trying to contextualize them to suit Lesotho’s National guidelines and regulations however through discussions with several clinical advisors I was able to further understand the process and I learned greatly on the mechanisms of integrating both the medical and public health aspects of one disease.

Then, I was heavily involved in delivering the actual training which was a very exciting experience as I was able to interact with the nurses, understand their perspective about patients’ management, explore their creativity in resource limited settings and touch the difference in their knowledge by the end of the training. After this training I realized that capacity building is a fascinating area in public health that I plan on developing further as it is a process of mutual exchange of information, knowledge and skills.

TB REACH launching with Dr. Wafaa El-Sadr and ICAP staff is Lesotho, TEBA Country Representative Mr. Kikini Kikini and WHO Country Representative Prof. Mufunda

Moreover, I was involved helping establish Monitoring and Evaluation tools and indicators, procurement of medical supplies for clinics, supervision and mentorship of clinic’s staff and creation of educational material that would convey comprehensive yet simple, understandable messages to miners. Despite learning extensively about all these aspects of a project throughout my courses at school, the actual realities of adequately implementing the theory on the ground with heavy stakeholder involvement are worth hundreds of hours of classroom experience. A few hours spent with the people and the communities addressed can prove to be the best way to learn how to design and implement a successful intervention.

The TB Reach project was launched by the Lesotho Minister of Health and Dr. Wafaa El-Sadr in late July and is currently running in three districts in Lesotho. Moreover this project represents the first step towards a more holistic approach of the TB/HIV co-infection among miners and in Lesotho in general as ICAP will continue working on expanding services to integrate the inseparable TB and HIV services in accordance with its overall goals and mission.

Top picture: Dr. Wafaa El-Sadr with the Lesotho Minister of Health Dr. Pinkie Manamolela

Bottom right: Ribbon cutting during TB REACH launching by Dr. Wafaa El-Sadr, Dr. Pinkie Manamolela (Minister of Health) and Mr. Kikini Kikini

Bottom left: ICAP Lesotho Country Director Ms. Blanche Pitt (right), ICAP global director Dr. Wafaa El-Sadr (middle) and ICAP Lesotho Technical Director Dr. Koen Frederix (left)

Mariam E. Reda, MD

MPH Candidate, Mailman School of Public Health

Working with Communities to Strengthen Their Resilience

This year’s food crisis in the Sahel, a thin strip of land below the Sahara, marks the third time this decade that the region has suffered a food shortage. Chad and Niger, the two countries that traditionally have food shortages, were joined this year by Mali, Mauritania, Burkina Faso, Senegal, Gambia, Cameroon and northern Nigeria. According to Save the Children and OxFam, over 18 million people in the Sahel are affected by hunger, and upwards of one million children are at risk of severe malnutrition.

The shortage did not come as a surprise; forecasting technology allows aid organizations to predict and plan for famines in advance. Therefore, the fact that famines happened in both 2005 and 2010 is rightfully frustrating to aid organizations, and leaves them wondering what can be done to better prevent or mitigate the cyclical food crises in the Sahel.

Map of countries and their food vulnerability

It is out of this frustration that aid agencies are recognizing the need to provide humanitarian aid with the intent of helping the long-term prospects of a community or state. The idea that programming should help people overcome shocks is referred to as resilience.

Resilience programming has been recognized as a step towards helping communities reduce their vulnerabilities so that when a major shock, such as a food crisis, political upheaval, or natural disaster occurs, there is less of an impact on the community. Or, if there is an impact, the community is able to return to their baseline level more quickly than without the aid programs. For example, negative coping skills, such as selling assets, would be less prevalent in a family that is resilient versus a family that is not. Moreover, systems should be resilient, meaning that a health center’s resources and staff should not be debilitated during a crisis. A resilient health center would be prepared for an increased patient load by training staff or having a supply chain that can react quickly to fluctuations in times of crisis.

As an intern at UNICEF’s West/Central Africa Regional Office this summer, I helped UNICEF gather information and plan for resilience-focused programs. Because the level of resilience of a community is determined by a number of factors, UNICEF is approaching resilience by looking at how their sectors are interacting and the best way to link their humanitarian aid with their development work.

In order to support this goal, I met with Section heads to gather information about how they see resilience fitting into their programs. I spoke with Country Offices to find out what they knew about the concept and whether or not the office had begun considering resilience as a framework when planning programs. I met with other UN agencies in order to learn about the coordinated approach to resilience, and met with other organizations to find out about their work. I helped create two monitoring tools to assess the progress towards implementation of resilience programming. Most important, I identified programming that was already promoting resilience, and identified areas where resilience-based programming could be increased in the Sahel.

Measuring the impact of resilience programming is difficult since so many factors can influence a person or community’s level of resilience, but I hope some operational research will take place to assess the impact of resilience programming. Research in both Palestine and Kenya by Alinovi et al. provides a comprehensive look at how to measure resilience to specific shocks. Columbia’s Sandro Galea used census data in the Gulf region to measure expected levels of resilience in communities impacted by Katrina.

Although the Sahel faces many challenges, I am hopeful about the future of the region. As a Peace Corps volunteer in Cameroon, I saw the daily challenges the population faces, but also saw populations that had inherent safety networks that provided resilience. Therefore, I believe that the combination of the natural evolution of existing safety nets coupled with smarter, more strategic aid from the international community will result in disasters that are less debilitating to communities in the Sahel.

Abigail Greenleaf
MPH Candidate, Mailman School of Public Health

Allowing female CHEWs to ride gender-friendly motorbikes in Jigawa State, Northern Nigeria: a critical step towards better maternal and child health

A gender-friendly motorbike

Nigeria has a disproportionate burden of global maternal mortality burden. About 342,900 women worldwide died from causes related to pregnancy and childbirth in 2008. Three out of five of these deaths occurred in sub-Saharan Africa, and Nigeria alone had an estimated 50,000 maternal deaths thus constituting one of the highest maternal mortality ratios (MMR) in the world. The situation is dire in northern Nigeria, where MMR is estimated to be significantly higher than the national average with recent estimates for the north exceeding 1,000 per, 100,000 live births compared to MMR estimates for the southern region below 300 per 100,000 live births.

Between 2007 and 2008, a Partnership for Reviving Routine Immunization in Northern Nigeria (PRRINN); and the Maternal, Newborn and Child Health (MNCH) Program targeting four states in northern Nigeria (Jigawa, Katsina, Yobe, and Zamfara), was established with co-funding from the Department for International Development of the United Kingdom and the Government of Norway in response to dire health status of women and children.

With the support of the operations research unit for PRRINN-MNCH Program, Jigawa state consequently decided to pilot an adaptation of the Navrongo Community-Based Health Planning Service strategy in Ghana to bring services to especially remote communities. This decision is convergent with the position of the Nigerian Association of Health Workers. The association has recognized the need to ensure that the health system focuses on deploying community health workers to provide basic health services in the communities.

A study was designed to explore the feasibility and outcome of community-based health extension workers (CHEWs) providing essential MNCH services within remote communities in Jigawa State. If the pilot in one Local Government Area in Jigawa showed the feasibility and effectiveness of this model, it can be expanded to other areas in Jigawa, if not to other states facing the same constraints on effective access and utilization of primary health care services. In this way, Jigawa will answer the call by the Nigerian Association of Health Workers, and be able to provide national leadership in systematically introducing innovations to the primary health care system and its effective and efficient use of available resources that appear to be key to making substantive progress towards the attainment of MDGs 4 and 5.

The pilot was conducted in the rural and remote communities of Kadawawa and Takalafiya, with a population of 20-25,000 people each. In each community the CHEWs sought to engage 5,000 women of childbearing age, with a focus on the 1,000 pregnant women and the 1,000 who had children under age 1.

Deploying a CHEW to work and live in a community is one of the interventions that have generally been known to work effectively in many settings. However, deploying such an intervention in a rural setting of Jigawa State and assessing the health system challenges and the capacity to respond to them was one of the key objectives of the pilot study.

While the study generally demonstrated an increase in the uptake of MNCH due to the availability of CHEWs, transport for making home visits especially during the rainy season was one of the challenges experienced during the study. A number of home visits could not be made due to the difficult terrain. Most of these problems were reported to the health administration and efforts to resolve these were made within the limits of the health administration.

Successes and challenges from the pilot study were shared with stakeholders in order to plan effectively for the scale-up. One critical action was the support of the operations research team for the study which made intensive advocacy visits to senior health officials on some of the challenges encountered. The Gunduma Health System Board in Jigawa State, inter alia, obtained approval from the State Assembly to employ more female CHEWs towards the end of 2011. At the time of the study, the Gunduma Health Systems Board had budgeted for more CHEWs recruitment for 2012 and apparently recruitment of female CHEWs will become regular and stabilize.

With respect to transportation, an advocacy visit was made to the traditional ruler, the Emir of Dutse in August 2011, who gave consent to allow female CHEWs to ride motorbikes to implement home visits. The Emir consented to the purchase and deployment of gender-friendly motorbikes in order to address this challenge. Such consent was critical since women riding motorbikes is considered by others within the community and northern Nigeria in general as contrary to sociocultural and religious beliefs. By the first quarter of 2012, 20 motorbikes were purchased and female CHEWs will be trained to ride the motorbikes and use them during the scale-up phase of the intervention. While addressing the MNCH challenges in northern Nigeria is not a here and now matter, allowing female CHEWs to ride motorbikes is a milestone in efforts to provide integrated MNCH services at the doorsteps of the community and this will increase access and utilization of MNCH services in rural areas.

Gender-friendly motorcycles have a step-through space which makes it easier for them to mount the motorcycle than the 'male' motorcycles which have a gas/fuel tank in the middle. Gender friendly motorcycles have a gas/fuel tank under the seat.


Henry V. Doctor
Associate Research Scientist, Population & Family Health
Operations Research Advisor, PRRINN-MNCH Program, Nigeria

Losing sight of invisible women: Behind the maternal mortality statistic

Transport for women with obstetric complications
in the Democratic Republic of Congo

Observers of global public health are rightly encouraged by new figures on the extent of maternal mortality in the world.  Both the data of the University of Washington’s Institute of Health Metrics and Evaluation and new data from the United Nations show that the stubborn figure of over 500,000 maternal deaths per year that had been cited for so long may finally be replaced by the still alarming but encouraging figure of about 350,000 annual deaths.  The new data arrived in time to generate encouragement at the September 2011 session on the Millennium Development Goals.

While the new data represent an achievement that should be both celebrated and studied in more detail, optimism around these figures must continue to be tempered by the reality that women in most of sub-Saharan Africa and probably the poorest women in most countries did not enjoy the gains represented by the new data.  As an obstetrician from Chad, one of the poorest countries in the world, I see these new figures with a mixture of optimism and continued concern about how the world understands the phenomenon of maternal death and injury.

I have been privileged to observe maternal health services in a number of African countries for over three decades.  When I graduated from secondary school in 1970, there were two Chadian medical doctors in the country, neither of them focused on maternal health.  The common saying “a pregnant women is a woman who has one foot in the tomb” was illustrated only too graphically for all Chadians, including myself, as I watched relatives and other women of my acquaintance die from complications of childbirth.

I wish that I could say the situation has greatly improved in Chad and many African countries.  As the new data show, maternal death is entrenched at high levels in a number of countries.  As WHO has noted, in some countries HIV is a barrier to reducing maternal death, but in other countries the intransigence of maternal mortality reflects the difficulty of women’s struggles against many kinds of subordination.

I wonder whether the global policy-makers who will be poring over the new statistics understand the circumstances that add up to maternal death in my country and too many others.  When I worked briefly in Ethiopia, for example, I was struck to find there what we also see in Chad – that there are remote areas where it is well known to everyone that rural women die waiting alongside roads, hoping to find a car that can bring them to a maternity hospital.  Too often, their active labor does not come on the market days that may be the only time when a vehicle may come by.  Naturally, it is not the better-off women who have this problem.  Somehow the many women, especially rural women, who do have it, are practically invisible.

But women are so subjugated that in some places, even the better-off ones are constrained by gender-based subordination as they struggle to save their own lives.  As a practicing obstetrician in one of Chad’s main hospitals, I remember dealing with a woman who was related to a high-level official, so not among the most marginalized of my patients in social terms.  She was suffering in obstructed labor from a breech presentation of the fetus, indicating the urgent need for delivery by caesarean section.

But in her ethnic group, it was a strongly held view that “real women” should not deliver babies by caesarean section.  She feared that a caesarean would cause her husband to reject her and take other women as wives.  In the hours that I had to spend talking to her and her husband, we came close to seeing her add to the mortality statistics.  This is the situation of even the better connected women in my country.

In my current position in RAISE, a program affiliated with Columbia University that works to bring reproductive health services to war zones and other emergency settings, I have seen how women are once again the most vulnerable to the worst effects of political instability and insecurity.  Though I had witnessed the subordination of women in so many communities in Africa, it has been deeply shocking to me to see the health effects of the use of rape as a weapon of war in Congo.

When communities are threatened by violent soldiers or rebels, somehow society tolerates a situation where men stay at home to avoid insecurity, but women are sent to work on the crops or fetch water or fuel.  I have met so many women in that situation – women who were raped and gang-raped with horrible life-long injuries simply because only women do the chores that sustain the household.

I was honored to be invited to observe the activities of the health system in Honduras that have led to improvements in maternal health outcomes in that small country.  Honduras is better off than Chad in per-capita income, but it still faces very severe resource constraints for health services.  With the limited resources at their disposal, health officials and service-providers in Honduras assessed the maternal death situation and realized that the risk of death was highest among low-income rural women, including those in remote mountain areas.

Making it a political priority to solve this problem led officials and communities to work together to ensure that women could find transportation to get to health facilities and that those facilities would have the basic services needed to prevent the vast majority of maternal deaths.  This experience for me was both moving and maddening.  Making a difference in the statistics should not be so hard for Africa, but women just don’t count for much.

A lifetime of advocacy for government attention to the relatively simple measures that need to be taken to reduce needless deaths and disability linked to childbirth among Chadian women makes me concerned that the message of the new maternal mortality data will be that the victory is won and we can rest on our laurels.  Rather, in my country and many of its neighbors, we must urgently seek ways to re-energize a focus on maternal death that is based on women’s right not to die as well as the right of all women to comprehensive reproductive health services.

In the aftermath of the Millennium Development Goals discussions, every leader who praises the countries that have reduced maternal mortality must also be concerned about places where the lack of progress is link to the continued atrocity of treating women as less than human.  Maternal mortality should always be spoken of as a symptom of the more pernicious pathology of failing to give political priority to women’s rights, humanity and dignity.  

- Grace Kodindo, MD, Assistant Clinical Professor of Population and Family Health

Public Health in the 21st Century

At the beginning of the 21st century, key public health issues and challenges have taken center stage on the global scene.  Ranging from arsenic in drinking water to asthma among children and adults; from the re-emergence of cholera, to increasing rates of various forms of cancer; from HIV and AIDS to MDR-TB, malaria; from the crises faced by displaced or refugee populations to the new challenges that have emerged for reproductive health and rights; from the experience of public health emergencies as the result of disasters such as tsunamis, and catastrophic storms to the growing specter of potential global pandemics such as those linked to H5N1.  The expansion of serious public health problems, increasingly taking shape on a global scale, has been one of the defining features of recent history.

Like most aspects of contemporary life, this range of key public health problems has been increasingly impacted by processes associated with globalization.  The issues that confront us have been, and are, being shaped by evolving processes such as the growth of inequalities between the rich and the poor, the globalization of trade and commerce, new patterns of travel and migration, as well as a significant reduction in available resources for the development and sustainability of public health infrastructures.

The social, cultural, economic and political transformations associated with globalization have increasingly intersected with the growing range of environmental threats produced by industrialization, epidemics of newly-emerging infectious diseases, and the rapid increase of chronic diseases linked to changing lifestyles.

The new public health challenges of the 21st century have taken place within the context of a rapidly changing political and institutional landscape. In recent decades the field that was initially described as international health involving sovereign states has increasingly been re-conceptualized as global health within the global system. 

This change represents far more than a simple shift in language.  It stems from a fundamental transformation in the nature of health threats and in the kinds of solutions that must be posed to them.  It recognizes that many of the most serious health threats facing the world community today reach beyond the sovereign borders of nation-states and require the attention not only of governments but also of a range of non-state institutions and actors.

The Routledge International Handbook on Global Public Health, edited by Richard Parker and Marni Sommer, addresses both the emerging issues and conceptualizations of the notion of global health, expanding upon and highlighting critical priorities in this rapidly evolving field.  This comprehensive handbook is intended to provide an overview for students, practitioners, researchers, and policy makers working in or concerned with public health around the globe.

The book includes ten sections, ranging from Structural Inequalities and Global Public Health, to Ecological Transformation and Environmental Health in the Global System, Global Access to Essential Medicines, Global Mental Health, and Health Systems, Health Capacity and the Politics of Global Health, and brings together leading authors from across the world to reflect on past, present, and future approaches to understanding and promoting global public health. 

Maintaining an Audacious Hope

I’m an undergraduate student at Columbia, who completed the Fundamentals of Global Health class offered by faculty at the Mailman School. This confirmed my interest in the field of global health and I was therefore delighted when, last semester, I had the opportunity to study abroad in Kenya.

The program, which focused on health and development, taught us a lot about East African culture and current events, and how different health and development organizations operate within that context.

One issue that struck me regularly through my time in Kenya was the disconnect between government and the day-to-day realities faced by many people. For example, Kibera, the largest slum in East Africa, is in Nairobi, the capital. In fact, Kibera may be the largest slum in Sub-Saharan Africa, but slum populations tend to be hard to count. Estimates for Kibera range from 200,000 to 500,000 people. One group estimated 1,000,000. However, the Kenyan government does not recognize Kibera as a human settlement and marks it as forest on official maps.

This leaves hundreds of thousands of people without rubbish collection, electricity, or access to clean water that the government is supposed to provide. The fact that three Kenyan officials summoned to the International Criminal Court in The Hague to face charges of crimes against humanity during the widespread violence following the last elections continued to hold positions as government ministers during my stay also jarred with me.

That being said, it was a fascinating time to be in Kenya, because things are seemingly beginning to change. A new Constitution was passed last year, paving the way for a highly functional and beneficial government when it is fully implemented. The uprisings in the Arab world are encouraging Kenyans to believe that that they too have the power to hold their government accountable, and people are beginning to find their voice and call for an end to corruption. Kenyans are also beginning to unify as a nation, instead of each identifying first as the tribe of which they are ethnically and culturally a part. Everyone seems tired of the problems and, aware of the underlying causes, are ready to work to make things better.

Change comes slowly however. Many services, especially in the health sector, remain significantly supported by bilateral funding or foreign NGOs. Though there is talk about sustainability and a time when programs will be entirely run and funded by Kenyans, most people suggested to our study abroad group that this would not be anytime soon. Problems of governance, a lack of natural resources, limited infrastructure, and high disease burden are obstacles that are not going to be easily or quickly overcome.

Buses in Kenya are often decorated, and many of them have signs on the front or back. The bus shown here was one of my favorites. Using the name of the book by then-Senator Obama, this sign is indicative of the phenomenon of Kenyan identification with our president. It is also indicative of the hope that so many Kenyans have in the face of their continuing challenges.

- Devon Welsh
Student, Columbia University

Providing pregnant women access to emergency care in northern Nigeria

Drivers demonstrating how they transport a woman
(with a scarf) in labor into their car.

Nigerian women have a 1 in 23 lifetime risk of maternal death, and the country's maternal mortality ratio is the 9th highest in the world. With roughly 50% of Nigerians living in rural areas, cost and lack of physical access are two of the major barriers to Nigerian women having access to maternal health care.

The northern region is particularly burdened. As it is more rural, with lower education rates and certain cultural practices, women in the north tend to have less access antenatal care and are less likely to give birth in health facilities than in southern regions.

A user of the Emergency Transport
System (ETS)

Loosing a mother during childbirth is a reality for many in northern Nigeria, and it doesn't just effect individual families. Maternal deaths deeply impact communities who often feel (and, in reality, are) helpless to stop them. I worked for two months with the Partnership for Reviving Routine Immunizations in Northern Nigeria – Maternal, Child and Newborn Health (PRRINN-MNCH), based in northern Nigeria, and saw firsthand how they are working with local communities to break down some of these barriers.

In the communities in Zamfara state where I was living, increasing access to maternal health is incredibly complex. Not only does it require access to cars and passable roads, but the cars must work and have fuel, families must know where to find the drivers if the need them (which may require a phone), communities must be educated on when you need to go to the health facility and why, and the health facilities must be staffed, with the drugs and tools necessary to deliver a child.

And these are just a handful of the barriers I saw.

Through a variety of access programs, PRRINN-MNCH is working to break down some of these barriers. Two years ago, it launched the Emergency Transport System (ETS) program in the 4 states where it works. Using commercial drivers who volunteer their services, ETS provides pregnant women with emergency transportation to a health facility when they need it. Many women who have used ETS thus far, if not most, were suffering from excessive bleeding or were already unconscious when the ETS driver was called.

While their children did not usually survive, without ETS these women would not have either.
Calling a commercial driver would have been out of financial reach. Commercial drivers often charge extra to transport women in emergency situations. Combined with the hospital fees, these costs can make a family choose between food and basic survival and going to the hospital. In describing what he liked about the program, one community leader stated, "We are helping ourselves."

Despite these successes, a big question remains: Without financial incentives for drivers, health facility staff and community volunteers, is ETS sustainable?

Ambulances do exist, but a functioning ambulance system in Zamfara is far off. It's clear that finding an alternative is imperative to improving maternal health outcomes, and ETS has been the best alternative in the locations where it operates. Yet, ETS drivers often use their own money for fuel and loose commercial customers when transporting a woman. Their work is inspiring and admirable and they are undeniably proud to be volunteers and ETS drivers, helping their communities. Speaking with them, most of them said they do not want anything in return for the services they provide. They are helping their communities and believe they will be thanked in the afterlife for their work.

Focus group of women who used ETS

However, even with all of this they still need to provide for their families. How long will it be until the financial burden on them is too much? At what point will mothers be left to die?


PRRINN-MNCH isn't willing to wait to find out. In a few months, a series of incentives will be piloted for ETS drivers, health facility staff and community volunteers. The goal is to understand whether they work, amidst fear that providing monetary incentives, however small, will alter the altruistic spirit of the program. If drivers are seen as gaining personally from helping women, will they lose the sense of pride they have in helping the community? If so, will the program become less effective? These answers will help improve the ETS program in northern Nigeria and provide a model to improve global maternal health outcomes.

- Laura Baringer, MPH/MPA '12, Population and Family Health

August 31, 2011