By Dr. Anthony Olagunju & Chibuike Alagboso (Lead Writers)
The Federal Medical Centre (FMC) Gawu in Niger State serves as a Tuberculosis (TB) treatment centre for patients in the zone under the CHALLENGE TB program. The Koninklijke Nederlandse Chemische Vereniging (KNCV) TB foundation, the professional association of chemists, life scientists and process technologists in the Netherlands, led the program between 2014–2019 with support from the United States Agency for International Development (USAID). For FMC Gawu to effectively deliver its responsibilities to patients, it must carry out laboratory investigations to diagnose cases before commencing treatment and also monitor treatment progress for patients. However, achieving this in record time in Niger State with its difficult terrain and large land mass can be quite daunting. It is even more difficult for patients living in rural areas.
About 48.84% of Nigeria’s population live in rural locations. The rural landscape in Nigeria is characterised by poor road networks and inadequate healthcare facilities. These limit accessibility to qualitative healthcare services, forcing rural dwellers to spend more time and money transporting themselves to urban areas where desirable heath services are readily available.
The barriers presented by transportation as a result of cost and distance have been reported as major social determinants of health seeking behaviour for rural dwellers in Nigeria. Riders for Health (Riders) contributes to strengthening health systems by bringing healthcare services closer to people through innovative transport solutions, bridging the gap between healthcare providers and patients, and saving transportation expenses for patients. One of the ways Riders achieves this is through its Sample Transportation (ST) program.
Since commencing operations in Nigeria in 1999, Riders has become a credible point of reference for medical transport and logistics. The organisation has collaborated with government and several international development partners for the control and management of public health diseases such as HIV/AIDS, malaria, tuberculosis, and recently, coronavirus.
Prior to the commencement of the program, facilities that had needed to send samples to distant laboratories handled it on their own and this meant more expenses for patients. This was the case at the FMC in Gawu for instance, according to Ms Salamatu Abdulkadir who heads the Tuberculosis treatment unit. “We were the ones transporting the samples all the way to Suleja without a proper transport system”.
The Riders ST program is a specialised courier service aimed at increasing laboratory access for the diagnosis and monitoring of HIV, tuberculosis, and other diseases of public health importance. Leveraging its corporate expertise in automobile management, Riders deploys 2-wheeled and 4-wheeled vehicles to transport samples from local community health centres to designated laboratories and return results in a coordinated, safe and timely manner. This way, Riders travels the distance for patients, encouraging their adherence to treatment and boosting their confidence in the health systems.
Riders initiated the first integrated sample transportation in Nigeria in 2016 through a contractual partnership with Clinton Health Access Initiative (CHAI). This was piloted in the Federal Capital Territory (FCT) and later extended to Kaduna State after a successful pilot. Over the past five years, Riders has facilitated sample transportation in 30 out of the 36 states in the country and the FCT.
Strengthening healthcare delivery through logistics
Since the beginning of its sample transportation programme in Nigeria, Riders has transported over a million samples and helped more than one million people living with HIV (PLHIV) access health monitoring and care services without any financial burden. Presently, with coverage in 20 states under the USAID-funded National Integrated Specimen Referral Network, Riders ST programme is run by a team of 182 couriers, 18 State Coordinators, and 8 management staff. Riders specialised sample transportation fleet comprises 18 cars and 187 motorcycles.
Health workers working in the different locations where they have initiated the sample transportation say it has made their work easier and this rubs off on the patients they are managing too.
Ms. Abdulkadir said the sample transportation service has helped improve the turnaround time for tuberculosis samples sent for diagnosis. This means that positive cases are promptly placed on treatment. “We were the ones transporting the samples all the way to Suleja without proper a transport system but now with the new intervention, everything is fine, free and moving well. Our results take maximum of two days to come back. My patients can now get treated on time,” Abdulkadir, who serves as the Directly Observed Treatment Short-course (DOTS) centre focal person in her hospital said.
For Clementina Ibio who works at the Uyo Police Hospital, it’s the turn-around time that endeared her to the service. “The courier responds promptly, and this has also helped in easy monitoring and following of my positive clients”, Ibio said.
Aishatu Tanko who works with the Dije Bala Clinic in Suleja, Niger State pointed out that the sample courier service makes same-day delivery possible . “Before now we used to send patients to General Hospital for GeneXpert, but now we collect their samples and send the courier and our results get back in just a day,” she said.
By providing seamless laboratory sample transportation and fast delivery of test results, beneficiaries say the organisation is strengthening health systems across the country. Dr Grace Osemwenkha of New Bussa Hospital in Niger State said they now give patients definite time to get their result. She shared an example of a courier picking up a patient’s sample for transport on a Tuesday and the patient picking up their results two days later. This was impossible in the past.
Beyond pickup and delivery
The Riders sample transportation program adopts an all-inclusive and comprehensive approach to maintaining quality throughout the logistics chain of sample pickup, transportation and result delivery. Couriers are trained to maintain international best practices in the transport of samples, as well as be ambassadors of the program..
The comprehensive training conducted for couriers cover the range of safe handling and transportation of infectious biological substances (Category B UN3373), defensive riding and vehicular maintenance. The couriers are also trained to identify possible symptoms and create awareness for free HIV and tuberculosis screening and treatment in their communities. In their own way, the couriers are heroes without capes who save lives with their advocacy and service.
Mr Yahaya Yakubu, a resident of Kibiya Local Government in Kano State accessed tuberculosis diagnosis and care after he came in contact with one of Rider’s couriers, Zaharaddeen Dikko, during a commute. “He was sitting next to me in the bus. I noticed that he was coughing frequently and sweating profusely. So I asked what was wrong with him,’ says Dikko. Yakubu told him he had been disgnosed with pneumonia at a hospital he visited. Sceptical about the disgnosis, Dikko pressed further, asking if they collected his sputum for a laboratory test. Yakubu said they didn’t so Dikko convinced him to visit the DOTS centre at Tiga Hospital to have his sample collected for testing. Dikko emphasised that it was free so as not to discourage him. At the facility, the staff collected Yakubu’s sputum sample which Dikko transported to Alnoury GeneXpert site. Yakubu tested positive for Mycobacterium tuberculosis (MTB), the bacteria that causes Tuberculosis and was immediately placed on treatment.
Mr Bala Musa, a Lagos resident benefitted from the experience of his neighbour, Olufemi Babatunde, who works as a courier for Riders for Health. “Bala had been coughing for a while, lost so much weight and complained he could no longer sleep well at night because of the cough,” Babatunde said. As they discussed his symptoms, Babatunde found out that Musa had not been to the hospital, he only visited a pharmacy and was told he had pneumonia which would clear eventually.
”I asked him if he has heard about tuberculosis and the free testing and treatment programme. I took him to Orile-Agege General Hospital where his sputum sample was collected, and I transported it to Sango Primary Health Centre GeneXpert laboratory. The result showed MTB detected, RIF resistance not detected which means he had Tuberculosis. They placed him on treatment. I am happy he looks better now and has gained some weight,” Babatunde said.
Musa remains grateful for Babatunde’s timely intervention. “Help me to thank Mr Olufemi — that man that uses a red power bike. He took me for test and medicine. I am okay now and nearly done with my medication,” he said.
It’s never an easy sail
Riders for Health continues to remain at the frontlines of health transport and logistics in Nigeria. The Sample Transport programme ensures a win-win situation for healthcare service providers and users in Nigeria. Although this does not come without its challenges, it however provides opportunities to learn and improve.
For instance, the inadequancy of functional molecular laboratories necessitates frequent inter-state movement of samples, thereby, imposing a burden on sample transportation resources. Presently, the couriers bear the inconvenience of travelling long distances for sample delivery, sometimes spending up to 48 hours on the road. Even though it is a difficult task, they do this because they share the Riders vision for health equity. Given Nigeria’s population growth trend, the Rider’s team believes that people would be better served if there is a functional molecular lab in each state.
The inefficient patient management and sample documentation at health facilities which cause delays in the pick-up schedule for sample transport couriers are other challenges. This is managed by calling each facility ahead of the scheduled pick-up time to confirm that samples are ready for collection. “If this issue is to be permanently solved, health facility management should be restructured to allow automated patient registration and clinic appointments,” says Kayode Ajayi, Country Director, Riders for Health Nigeria.
There is also the recurrent issue of intra-ethnic clashes and the associated insecurity challenges which hinder sample transportation operations. Sometimes, the organisation is unable to secure exemption passes from security agencies to allow the couriers conduct their assigned activities.
Lastly, the current system of paper documentation is time consuming and gives room for data entry errors. Digitisation of the sample transportation workflow is ongoing although at a slow pace. Digital processes like allocating barcodes to samples so they can be scanned will produce easier, quicker and possibly error-free documentation.
Despite the state’s difficult terrain and large land mass, Riders has successfully executed the sample transportation program in Niger state, providing seamless laboratory sample transportation and fast delivery of test results to patients in FMC Gawu and other rural areas. If effectively implemented, this program can be taken beyond places that Riders has worked and replicated across the country, one health facility at a time.