For over twenty years, Andrea Coleman has focused on solving a seemingly simple, key component of rural healthcare delivery: on-the-ground transportation. Through a series of partnerships with government institutions, Andrea has designed new ways of bringing health workers to where patients are, built local expertise and supply chains for transport and maintenance, and dramatically improved healthcare reliability. Her work is driving transport up the government agenda in Africa and beyond, removing a crucial barrier for effective development as a whole.
La idea nueva
Andrea Coleman founded Riders for Health in 1989 along with Barry Coleman, and American motorcycle racer Randy Mamola, to transform the delivery of rural healthcare across the developing world and dramatically increase health services’ ability to access the most remote patients. Having spent her life riding, racing and surrounded by motorcycles, Andrea knew that the were the perfect to provide reliable rural travel even in the absence of paved roads. However health systems still rely on travel by foot, some bicycles or in vehicles unsuited for the terrain. Andrea and Barry saw that weak operational infrastructure was a key limiting factor on any efforts and resources aimed at improving rural health. They therefore developed an innovative model to mobilize health workers, and put appropriate transportation and vehicle maintenance systems in place across entire regions. By focusing on this simple but ignored link, Andrea is changing how the healthcare system operates by inputting a crucial lever: reliability. In turn, more reliable public health provision allows local communities to re-gain their trust in government services and more fully take advantage of modern medical care.
Rather than expect sick patients to travel hours or days to reach centralized hospitals and clinics, Andrea and Barry’s model revolves around health providers taking full responsibility to deliver healthcare to where people are. In partnership with existing health providers and government ministries, Riders therefore manages motorcycles, ambulances, and the vehicles used in the delivery of health and lab samples. Riders for Health has built networks of locally-run rural maintenance workshops through a “hub and spokes” model, which in turn creates a crucial supply chain of spare parts, trained technicians and tools into rural areas, benefitting the transport and commerce sectors as a whole. Finally, Riders trains existing health workers on safe motorcycle driving and how to do daily, preventative maintenance. In this way, Riders for Health operates on a “zero-breakdown premise”, ensuring that the chain in health care delivery is never broken by failing vehicles. Once this transportation bottleneck is addressed, the effectiveness of all existing resources are maximized and improved– be they hospitals, laboratories, health workers, or on-the-ground delivery of medicine following telemedicine consultations.
Riders for Health is enabling health workers to serve up to six times more rural inhabitants than before, currently reaching 14 million people in seven countries: The Gambia, Nigeria, Zimbabwe, Zambia, Kenya, Lesotho, and Malawi. Andrea’s practice has affected policy, and been replicated as far as Indonesia. At the broadest level, Andrea’s work is demonstrating the power of transport for development. By working in partnership with local governments and ensuring they contribute to costs, Riders for Health is combatting donor dependency, demonstrating that a sustainable path for development is possible based on public-private partnerships, bringing transportation up the government agenda, and holding governments responsible for the health of every citizen in every geography.
1 billion people around the world do not have physical access to a hospital, clinic or doctor of any kind. Some 400 million of them live in Sub-Saharan Africa. With 60% of women giving birth without any medical supervision, Africa has some of the highest maternal mortality rates in the world: The World Health Organisation (WHO) estimate that 11,400 women per 100,000 live births in Malawi die from preventable childbirth complications.
Healthcare provision decreases the farther away one lives from cities. UN figures suggest 62% of people living in Africa are in rural communities, of which only 20-30% live within 2 kilometers of any road. Public transport systems are scarce and hospitals are far out of reach for many, with people having to walk for up to two days to see a doctor – a journey they might not survive. In addition, there is a lack of doctors and trained health care workers. In some areas, more than 10,000 people rely on just two doctors. Compounding this problem is a lack of infrastructure to get these rare human resources where they are needed: to patients in the last mile. Only 7% of all roads in Africa are paved, making the majority of roads challenging terrain and depending on seasons inaccessible for most means of transportation.
Extensive resources have been ploughed into Africa’s healthcare system over the past forty years. Efforts have been made to increase the number of health care workers, but a series of factors including low government funding means Africa has only 2.3 health workers per 1,000 populations, compared to 4.3 in South East Asia and 25 in the USA. Poor working conditions and hot, long journeys also decrease the talent pool and efficacy of each health worker. Large steps have been made to train local community members as health workers, but their impact is limited by being cut off from the necessary medical supplies and ongoing training support. To meet the health-related Millennium Development Goals alone, it is estimated one million more health care workers are needed in Africa, almost doubling the number of these workers currently operating worldwide. Telemedicine promises to improve rates of diagnosis and effective health monitoring, but there are limits to what can be achieved digitally without physical access to medical resources, vaccines and professionals. Aid donations contribute to buying drugs and vaccines, but without effective distribution infrastructure, USAID drugs worth millions remain stuck in warehouses. Health systems, in other words, are only as good as the links between their facilities and the patients they are meant to serve.
Effective transportation, however, slips down the government agenda when resources are so scarce. As many African governments, formed within the last forty years, struggle with big issues such as corruption, instability and lack of resources, they may lack capacity to professionalize transportation and some public services. A number of non-profit organizations have provided bicycles to patients, but their reach is limited and excludes those who are too sick to ride a bike. Yet others put their hopes into road building – an extremely cost-intensive task: in Zimbabwe alone, only 18,300 square kilometers are served by roads, compared to a total size of 390,000 square kilometers. At the government level, a shortage of qualified mechanics and transport managers has meant investing in vehicles is not a priority and inappropriate procurement decisions have been made for government fleets. Ambulances break down due to a lack of maintenance and the inability to be fixed. Spare parts and tools are only available in capital cities and lack a supply chain to reach the rural areas where breakdowns occur. Transportation of drugs and health care workers therefore all too often grind to a halt unnecessarily. These daunting gaps in the transport system mean NGOs, alternative health care providers and governments have steered away from mobilizing health workers, and rural communities are left struggling to cope with only sporadic availability of healthcare or supplies.
Andrea envisions a world in which healthcare can truly reach anyone, anywhere. By addressing the crucial, yet still neglected, area of transport for development, Andrea’s aim is to set a new standard for public health care delivery across the African continent and beyond. Over twenty years, her strategy, with that of co-founder Barry, has gone through a number of phases: first, proving that zero-breakdown health vehicle systems are possible, then brokering influential relationships with relevant Ministries, and ultimately running the model sustainably through local leadership, breaking the cycle of donor dependency.
Riders for Health’s work began with proving that motorcycles and other vehicle fleets could dramatically improve healthcare services to rural areas in a low-cost way. Riders’ work touched Uganda, Lesotho, the Gambia, Zimbabwe and Nigeria within ten years of founding, providing a combination of training in driving and maintenance, along with providing motorcycle vehicles, tools and parts on a subsidized basis. Gradually, the difficulties of implementing rural transport at scale became clear, and a hub and spoke model was developed to build an entire supply chain of tools, parts, fuel and newly-trained local technicians in rural areas for the first time. In this way vehicles could be fixed and maintained where they are based, instead of being taken to a central location, meaning that minimal off-road time is necessary. To prove the model’s effectiveness at scale, Riders built their own fleet of 47 motorbikes in Lesotho that helped healthcare workers deliver their services from 1991 to 1996 without a single breakdown, multiplying by three the number of villages a single public health employee was able to reach.
However from her background in business, Andrea knew that this model would not be able to scale and transform the healthcare system unless not only donors, but public health providers themselves gained real value – and would be willing to pay for the service. Andrea therefore raised the issue of health transportation across Africa, and used her careful impact measurements to gain buy-in. Riders worked with the Gambian government to open their accounting books and expose the hidden costs their budget was incurring already in health vehicles: a figure that no central team had been monitoring specifically. Finally, the Gambian Ministry of Health agreed to paying a stable, non-profit cost-per-kilometer fee to Riders, for managing and maintaining government-owned vehicles and providing related training on daily upkeep and preventative maintenance. This marked a historic turning point, as the first instance of a government in Africa outsourcing a dimension of public health provision to the citizen or private sector.
In 2009, Riders was able to prove to a number of governments that outsourcing health care delivery to Riders, a non-profit social enterprise, would be cost effective and translate into dramatically improved health outcomes. Andrea therefore brought Riders’ public-private partnership to the next level, fully outsourcing the transport delivery component of The Gambia’s healthcare system across the country to Riders for Health. Andrea, along with her team in The Gambia, led by Therese Drammeh, pioneered an arrangement between Riders, Africa-based GT Bank, the Skoll Foundation, and the Gambian Ministry of Health. The unique public-private partnership saw Riders secure a loan of $3.5 million to purchase its own vehicle fleet of over 140 vehicles and make long-term strategic investment. These vehicles are then managed by Riders and leased to the Ministry of Health on a cost-per-km basis. The number of villages a health worker in the Gambia can reach has now tripled, national immunization campaigns have been delivered, and the cancellation of outreach clinics for maternal health were halted. In 2012, The Gambia signed a new five-year contract. By employing Riders to take care of their transportation needs, the Ministry is free to focus on providing health care: for the first time, medical care will be able to meet any Gambian in need.
Partnerships, since rolled out to a number of countries, have allowed the health system to operate fleets at the lowest possible cost for the longest possible time, even in difficult road conditions. In some countries, such as Lesotho, Riders’ model is now entirely self-financing. Other countries still rely on some charitable subsidies, but Andrea’s priority is to make them sustainable, proving the benefits for governments to steer away from donor dependency. Riders currently manages 1,400 motorcycles, ambulances and other four-wheeled vehicles. Discussions are under way for expansions into several countries, and Riders’ goal is to reach 25 million people by 2017. Andrea is working with the Gates Foundation and Stanford University to measure the wider impacts on the system that occur as a secondary impact of Rider’s transportation systems, including effects on national health policy, mindsets, efficiency, geographic reach and economic effects. Already, Riders has achieved transformative results on rural healthcare, catalyzing the efficiency of existing health resources: turnaround time in delivering medical test results more than halved; governments have built new nursing schools; and the availability of vaccines has improved. With health ministers attributing up to 75% of recent improvements in health services to Riders’ work, Andrea has changed the conversation about transport for development.
Ultimately, Andrea’s mission is to build local capacity for public health services to provide the best possible service to their citizens. A large part of her work, therefore, involves changing mindsets and building human capacity, not just technology and infrastructure. Riders have established a training school called the International Academy of Vehicle Management with branches in Kenya and Zimbabwe, promoting local and youth employment. Andrea is seizing on this opportunity of building a new employment market for skilled technicians across Africa, to combat gender stereotypes. Many of the mechanics Riders trains in the apprenticeship program are women: it is a job with a low entry barrier, assists with female independence and esteem, and is compatible with family life. Riders has an explicit remit to build sustainable local expertise for transportation: all in-country management is conducted by local nationals, and less than 8% of all staff are international. Whenever Riders scales into a new country, locally-based teams from neighboring countries are responsible for sharing skills and setting up the new program, rather than the head office in the UK which is primarily responsible for international policy, funding structures and long-term strategy. In the widest sense, by increasing public health reliability Riders’ work is promoting public trust and accountability for government services. The impact of Riders’ true partnerships with government ministries also spreads beyond healthcare: Riders insists on transparency and accountability, and is embedding a culture of efficiency into the heart of government institutions.
Andrea was born in the outskirts of London in the UK. Her attendance at school was patchy and traditional education failed to spark her interest, but from early on she was passionate about anything to do with engines. She was also determined on being financially independent, and embarked in entrepreneurial activities from her high school years including doing paper rounds, redeeming cola bottles for money, a parcel delivery service and a window cleaning business.
As an adult, Coleman did a four-year stint in business management with Chelsea Football Club, a job that helped to support her weekend trips to motorcycle races, her ultimate passion. She enjoyed a five-year spell as a professional motorcycle rider, and worked as public relations manager for motorcycle champion Randy Mamola, working together to raise funds for charitable work. However, in 1979 Andrea’s husband unexpectedly died in a motorcycle crash, after which Andrea worked passionately for years to make the sport safer and more dignified. She eventually married Barry, a lawyer, journalist, and fellow motorcycle enthusiast, and together visited Somalia at the age of 40 with a corps of volunteers. Here, Andrea’s experience, skills and interests finally came together in what would be her life calling. Andrea and Barry realized that people in rural communities in Africa didn’t have healthcare because there was no transport infrastructure. They were shocked to see a graveyard of barely-used motorcycles that had been abandoned because no one knew how to maintain or repair them; only 5 out of 80 donated motorcycles provided by Save The Children were working after just five years due to disrepair.
So in 1989, Andrea and Barry set up Riders for Health to focus on training mechanics to keep motorcycles in rural Africa running, providing the means for health workers and resources to reach the people who needed them. Andrea never intended to run a charity – she was unaware that raising grant funding was even an option – but was motivated to do whatever she could with her skills and experience for this new mission. She ran many parts of the organization like a business. To earn income for Riders’ costs, they put on events in the motorcycle community - persuading the racing stars to give up 1-2 days a year to attend the events, with all proceeds going to Riders for Health. This link to the professional industry is still a hallmark of Riders’ fundraising and partnerships, but they now also have wider grant and corporate partnerships, earn sustainable income by charging for services, and design innovative social finance packages. Andrea has worked tirelessly to highlight the issue of transport in global health, working with bilateral donors, global institutions and philanthropists to secure the investment and funding to put systems in place, and is now seen as a global expert.