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 Mobile Health Units in Resource-­‐Poor Settings: Review of the Literature Laura Hanson Boston University School of Public Health March 2012 Introduction Mobile Health Units (MHUs) have long served as an important adjunct to health services in areas with poor security or poor access, as with rural conflict zones and dispersed and/or geographically isolated populations. Renewed emphasis on the primary health care approach and high demand for basic services in rural and hard-­‐to-­‐reach areas has driven the need for alternative methods of basic health service delivery such as MHUs. Existing literature reviews have focused on MHUs operating in specific contexts,1 services, and populations.2 There does not, however, appear to be a descriptive review focusing on the use of MHUs for primary health care delivery to communities living in resource-­‐poor, developing country contexts. This review of published and grey literature provides a brief assessment of utilization of MHUs in rural, resource-­‐poor settings and provides insight into how international organizations and governments have found new ways to leverage MHUs in serving such populations with primary health care services. An analysis of trends and observations will address the following areas: • models of service delivery • services provided • routing, scheduling, and general operations • staffing arrangements • sponsor and funding arrangements • costs and charges • integration and linkages with health systems • evidence of outcomes Methodology A web-­‐based search was conducted using PUBMED, Science Direct, Web of Science, Google Scholar, Google and the Center for Health Market Innovations web directory. Keyword combinations included: mobile health clinic, mobile health unit, mobile hospital, wellness clinic, rural, rural health, primary health care, curative, preventative, treatment, screening, developing country, resource-­‐poor, and low-­‐income. The search was restricted to English language articles and literature made available between 1970 and 2012. While MHUs are used among rural and/or underserved populations in developed nations, this literature and online search was targeted more specifically toward programs operating in rural and developing country contexts. The range of services provided by MHUs is quite extensive; therefore, the search focused on those providing preventative and curative primary health care. One-­‐time expeditions or yearly medical mission projects were also included in the review. Importantly, this review is not exhaustive or all-­‐inclusive of the current initiatives to provide services through MHUs, as many such efforts are locally focused, operate on a small scale, and are less likely to report their activities and internal evaluations for public view. Of the organizations found in the search, 25 are described Table 1. Background The central purpose of an MHU is to improve access to health services -­‐ whether basic or advanced -­‐ that are otherwise inaccessible to the target population.1 In contrast to a health camp, which typically involves the transportation of clinical personnel and equipment to a fixed site, MHUs most commonly take the form of a self-­‐contained vehicle. This vehicle is typically equipped with skilled personnel, equipment and medical supplies, and is able to assess and treat patients at a distance from a fixed health facility. MHUs are most commonly employed on a temporary basis such as before the opening of a more permanent health facility, in settings where health services are absent or dysfunctional, or in emergency relief settings. The International Committee of the Red Cross (ICRC) which presented guidelines for the deployment of MHUs in emergency relief settings, asserts that MHUs are “a strategy (which is sometimes effective but rarely has lasting effects) to be used as a last resort to reach population groups cut off from health services.”1 Yet the use of MHUs extends well beyond emergency relief; there is a diversity of services being provided, including promotive,3 preventative,4 curative, even palliative5 care depending on population need and access to services. MHU programs most commonly target specific groups such as homeless6, displaced,7 marginalized8 or indigenous sub-­‐populations,9 inner-­‐city youth,10 migrant farm workers,11 nomadic herders,12 or industry employees.13 Some target specific age or gender categories such as the elderly,14 pregnant women and children,15 female sex workers,16 or male truck drivers.17 MHUs may also provide services to the general population, particularly when the main service offered is primary health care. Models of Service Delivery using MHUs MHUs can take many forms, depending on the terrain and services being provided. Most operate out of the back of a simple pickup truck, or an adapted van, bus, or recreational vehicle. A few reach target populations using boats,8 trains,18 bicycles,12 motorbikes19 etc. Health By Motorbike funded a pilot program, which uses a motorbike, equipped with cooler bags for basic medications and vaccines. Carrying a nurse or trained clinician, the bike travels out from a fixed health center for outreach three days a week.20 A few organizations are using more than one means of delivering services. CHAT/NCT, which works with scattered, nomadic populations in the Laikipia region of Kenya uses an integrated model, including trucks, bicycles or foot travel to nearby communities; it even employs camel convoys in areas without a road network.12 Some MHUs use vehicles to transport supplies and equipment but set up and assess patients under fold-­‐out tents21 or out of community buildings such as churches and schools.22 To save time, a nurse or outreach worker will often take medical histories, blood pressure and vital signs outside of the MHU before the patient is seen by a physician.23 In order to increase awareness of and demand for the clinical services provided, MHUs will often advertise the clinic times and locations through loudspeaker announcements, banners, pamphlets, and door-­‐to-­‐door visits by volunteers or auxiliary health workers.24 The Spectrum of Service Delivery Using MHUs Vertical Programs MHUs have long been a favored strategy for vertical programs such as family planning,25 mobile surgical teams,26 dental27 and ophthalmological clinics,28 or immunization campaigns.29 Some hold service-­‐specific health camps out of the same unit, adapted for particular medical missions. The Lifeline Express, for example, is an adapted hospital train created in 1991 by the Impact India Foundation and has been replicated in China and elsewhere. The train travels to rural areas and uses volunteer surgeons and specialized medical personnel to deliver high-­‐intensity eye and ear clinics for disabled individuals. Between 1991 and 2010, the hospital train had completed 120 projects, providing corrective surgeries for over 600,000 Indians. 18 The literature also suggests that MHUs can be an effective avenue for disease screening (such as cervical cancer,30 or infectious diseases31) as well as for health promotion and preventative activities, depending on the relative burden of disease.4 These disease or service-­‐specific programs tend to report successful outcomes due to their high volume, low-­‐cost per patient approach. This is most often achieved when MHUs operate in an area where there is high demand for a service or procedure which can be administered relatively quickly using the same or similar set up and equipment.32 27 For example, a PEPFAR funded mobile male circumcision clinic, launched in 2011 through the government of Uganda, plans to reach 4.2 million men in 5 years. The van is positioned in identified ‘hard-­‐to-­‐reach’ areas until it has satisfied the demand for circumcision before moving on to another region.33 There is a large body of evidence to suggest that mobile HIV testing units are a successful strategy in reaching individuals in the earlier stages of HIV infection34 and those who are high-­‐
risk but not being served by traditional STD/HIV health clinics.35 There is reasonable concern, however, that referral for facility-­‐based care HIV care, while feasible, is often ineffective.34 None of the MHUs found in the literature provided ARV treatment for HIV/AIDS, but rather, referred patients to a fixed facility for treatment. Often, an organization’s vertical approach shifts towards more general preventative and health promotion activities. Other projects may begin with primary care and slowly expand to include additional services such as dental health, family planning, or palliative care. SALUD Family clinics, which work in rural parts of Colorado, USA, operate in areas known to be gathering places for Mexican migrant populations, setting up outside of grocery stores and farm camps. While the mobile clinic initially provided only primary health care, it expanded to include mental health and dental health services after conducting a health needs assessment.36 Primary Health Care Approach Services provided by MHUs delivering primary health care vary greatly depending on the capacity of the clinic and ability to refer patients to a fixed facility for treatment. Some focus on both disease screening and treatment of a selected number of high burden diseases. A MHU program run by GIAI in rural Malawi, focuses activities on HIV testing, treatment and referral, sputum collection for TB screening, diagnosis and treatment of malaria, STIs and other opportunistic infections, as well as pre-­‐natal care.22 In an effort to reach a larger population with health education and HIV testing, many MHUs focus efforts on screening for diseases such as HIV, tuberculosis, diabetes, and hypertension, and then refer patients elsewhere for curative treatment.13 Far fewer of the MHUs found in the literature were providing comprehensive primary care to the general population; most take a more vertical approach, focusing on HIV/AIDS care or reproductive health. An exception to this vertical orientation is the Mister Sister Mobile Primary Healthcare Clinics, operated by PharmAccess Namibia. The offer family planning, pregnancy tests and routine ante-­‐ and post-­‐natal care; immunizations; well child care and monitoring; screening for TB symptoms, VCT for HIV; and treatment of routine communicable disease. These MHU’s also provide testing, referral and follow-­‐up on chronic diseases such as hypertension, asthma, diabetes, and arthritis.37 Some MHUs provide primary health care along with more advanced services such as outpatient surgery8 or specialized medical camps.38 Medical Camps India Foundation operates a MHU which travels to villages in a 50 kilometer radius, providing basic primary health care and health education. One a month, it holds eye and dental clinics using specialists brought in from surrounding areas.36 Most of the MHU programs offering primary health care provide heath education; this includes information on HIV transmission or basic health issues such as nutrition, sanitation and safe motherhood. Fewer of the vertical programs seemed to include a health education component. Routing, Scheduling and General Operations Most MHUs operate within a defined region or number of districts.36 Others are more flexible and operate in certain areas based on requests from sponsoring organizations18 of from regional CBOs, NGOs, government ministries or community leaders that identify communities lacking essential services.12 Operating on a fixed schedule was the dominant model found in the search. Most MHUs visited the same locations on the same days of the week, allowing patients to anticipate their arrival and hours of operation.36 The duration of site visits for primary care clinics was usually one day, while surgical or specialized care clinics could stay in one place for several weeks.39 The number of sites visited or frequency of visits per site were not usually reported by MHU programs. MHUs providing services to industry and farm workers generally visit worksites or hold evening hours 11 to accommodate beneficiaries and minimize any disruptions in workplace operations.13 Alternatively, health units can target mobile populations that don’t work at a fixed location. North Star Alliance operates small Roadside Wellness Centres, which are fixed clinics built into re-­‐purposed shipping containers. The centers are strategically set up on major transport routes across the African continent, specifically targeting male truck drivers with health services. The units provide VTC for HIV, screening and treatment for TB, malaria, hypertension and diabetes. Other risks specific to the truck driver lifestyle are addressed, including poor nutrition, lack of exercise and substance abuse.17 The majority of MHUs identified in the search operate out of, or have a close affiliation with, a fixed health center40 or outreach camp,12 rather than operating independently of existing health facilities.41 Such units use the fixed base to replenish stock or store medicines and other equipment overnight.20 MHUs affiliated with a fixed health center were more likely to have functioning referral networks and may have provided a wider range of services thanks to linkages to sites with more specialized equipment and health professionals.38 There was no conclusive evidence found in the literature, however, that MHUs affiliated with fixed site clinics are more or less effective than an independent unit providing similar services. In a few cases, MHUs split their time between serving communities in the field and working in close proximity to a fixed health center to supplement the center’s services.39 42 When given the opportunity, some MHUs participate in local emergency relief efforts, health fairs, blood drives, and heath education campaigns.43 Some programs engaged patients with ‘health talks,44 music and theater dramas, or dental health videos36 during waiting times. In areas of high demand for medical services, MHUs often benefit from using triage procedures,45 sometimes recruiting community members to identify the most severe cases. Expedicionários da Saúde, a mobile surgery clinic trains ‘Indigenous Health Agents’ to identify surgical cases to be served by the NGO and to carry out the triage process, transportation and accommodation of patients and postoperative follow-­‐up.21 Several of the MHUs found in the search provided or arranged emergency transport to hospitals for severely ill patients.9 Staffing Depending on the level of care and types of services provided, MHUs may require either specialized or multidisciplinary teams. Most of the MHUs found in the search consist of, at minimum, a multi-­‐purpose driver, one nurse, and sometimes a physician. Paramedics, nurse midwives, dental hygienists, pharmacists, lab technicians, health educators, psychologist, general surgeons, and additional support staff are sometimes, but less often included. Many of the primary care MHUs found in the search used nurses as the highest-­‐level caregiver. Inclusion of a physician depends on the capacity of the unit, what services were being provided and whether volunteers were frequently used. In one case, a pharmacist-­‐conducted wellness clinic provided disease screening in rural areas.46 Some MHUs maintain a fixed staff, others have a small number of fixed staff and recruit doctors on a rotational basis from satellite hospitals or higher health facilities9 or supplement with government paid nurses.41 Others attract foreign medically trained staff for short or long term stays. The Brazilian NGO, Expedicionários da Saúde, has a staff that consists predominantly of volunteer doctors who travel to Brazil to provide specialized surgical procedures to indigenous populations living in remote areas. The project is filling in service gaps in Indigenous Health Care Districts (DSEI), set up by the federal government, which are challenged to attract skilled health professionals to serve in these remote areas.21 A few projects operate almost entirely with foreign volunteer support, both for clinical staff and outreach workers.8 Alternatively, some MHUs rely on locally recruited staff and volunteers to conduct outreach clinics,24 serving as community health workers and HIV/AIDS counselors.12 Sponsors and Funding Arrangements Most MHU operations found in the research are operated by faith based47 and charity organizations48 and are heavily dependent on institutional grants and private donor contributions. Some of the worksite focused MHUs receive substantial support from other industry stakeholders.13 A few MHUs are funded and managed by private corporations. Mondi Group, an international paper and packaging company has partnered with the South African government and local NGOs to provide employees and families living in remote communities with two MHUs which provide fee primary health care, VCT for HIV, immunizations, and treatment for children under five.41 There are also examples of for-­‐profit and social business ventures15 operating MHUs. Over a seven year period, Siemens, a German health care technology company, provided a fleet of 18 mobile clinics to underserved regions of India. The company has reported US$3 million in revenues and a profit of more than 5 percent for Siemens. The company is able to showcase its expertise in healthcare technology because the mobile clinics are fitted out with Siemens equipment including ultrasound, X-­‐ray, and mammography machines. One Indian state has since bought one of the clinics and is currently providing primary healthcare and diagnostic services.15 A World Bank funded project in northern India, targeting remote tribal populations, took a public-­‐private approach by introducing six MHUs and contracted with NGOs to run them. The units provided basic treatment for common illnesses, first aid, family planning, and maternal and child care and also used its network of local partners to provide emergency transportation for pregnant women to health facilities for obstetric care.9 One MHU project found in the review, the Mama-­‐Toto mobile motorcycle clinic, cited using an outside income generating activity to help cover costs. The motorcycle travels to a different community for outreach clinics 3 days a week. On days when the motorcycle is not in use, it is rented out, subsidizing the cost of medications and gas. Some services are provided free, for others program charges small fee. Those who cannot pay are given free care.20 Costs and Service Charges Many of the implementing organizations documented in the literature stressed the high expense of operating an MHU.49 The mostly commonly reported costs or sources of financial stress included initial investment in purchasing, adapting and maintaining vehicles44 as well as the cost of equipment and medicines.21 Many of the MHUs found in an online search do not appear to survive for long. Of those that provided reasons for project failure or suspension, organizations suggested high costs of operation,24 unreliable medicine supply chains, and unrealistic requirements imposed by government and non-­‐government entities.44 MHU’s offering specific services in a vertical program were more likely to report project outcomes as ‘cost-­‐effective’ when compared to similar services provided at a fixed facility.42 A comparative cost study of mobile and fixed clinic services in South Africa observed that 1) Cost comparisons between mobile units and fixed centers are difficult, as MHUs tend to have shorter consultation hours (due to packing and travel time) but often see more patients per day than some fixed centers offering similar services, and 2) Depending on patient load, consultation time per patient at MHUs tend to be shorter than at a fixed site.50 Some studies suggest that MHUs are more expensive than fixed facilities in delivering services, such as family planning.51 However there does not appear to be much cost-­‐analysis in the published literature comparing general primary care services offered through MHUs compared to fixed clinics. There is some evidence however, that MHUs can deliver care at costs comparable to fixed facility outpatient visits 52 and can reduce the number of hospitalizations and emergency visits among some populations.53 MHUs operating in industrialized nations such as the United States, Canada and Australia generally received funding from government grants and private foundations. In a few examples, these MHUs charged fees on a sliding scale based on income level, required a co-­‐pay and/or accepted private insurance.8 Aside from PharmAccess Namibia, the review did not identify any MHU’s that were specifically linked to a pre-­‐payment or insurance plan. The vast majority of identified MHUs operating in low income or developing countries provide services and treatment free of charge. Of the MHUs that did request payment, patients were charged nominal rates for certain medications, but none of the non-­‐profit MHUs claimed to be sustained through patient revenue. For example, CHAT charges a token rate of 20 Kenyan shillings to cover medical treatment and other services but individuals or groups that have no money can pay with milk or other food items.12 Fees may differ depending on type of patient. The Lifebuoy Friendship Hospital, a ‘floating hospital’ adapted from an oil barge provides primary and secondary medical care to riverbank communities in Bangladesh. A registration fee is charged for first time visitors (female visitors, BDT 5 and males BDT 10) and a lower rate is charged for follow-­‐up visits, (BDT 3 and BDT 5 for females and males).8 Linkages to National Health Systems A few of the MHUs found in the search have been implemented in conjunction with the national MOH13 or are somewhat integrated into the national health system54 and receive support from local governments or the MOH through provision of medicines and medical supplies,12 or supervision of activities by district health staff.23 Conversely, MHU teams may play a role in recruitment and supervision of Community Health Workers who also work in target areas.12 Some MHUs have ambitions to transfer the projects to local governments or ministries of health.44 In the case of the World Bank funded program in India, a local state government plans to take over an MHU in the district where the project was first introduced. In two other districts, the National Rural Health Missions has built the capacity to manage the public-­‐private contracts with the NGOs to continue running the MHUs and will include the mobile clinic program in an integrated state-­‐tribal development plan.9 Evidence of Outcomes Few of the MHUs found in the search provide any sort of report on program impact, apart from dentistry, eye and surgical clinics.28 Outcomes that are reported most commonly refer to the number of beneficiaries served, the number of clinics or outreach clinics held, and more rarely -­‐ the related costs of operation in terms of cost per patient. None of the MHUs found in this search compared their cost per patient expenses with that of a local or affiliated fixed clinic providing comparable services. Similarly, none of the MHUs found in this search provided information on level of use or strength of referral networks. On the other hand, MHUs often demonstrated success in reaching populations that would otherwise not have sought VCT or disease screening.55 By observation, MHUs tend to be popular with beneficiaries, particularly for women and children’s services9 due to their flexibility of location and services provided. However, MHUs may not be an adequate substitute for a functional primary care center. In a patient satisfaction study conducted in rural Saudi Arabia, 51% of MHU beneficiaries reported also using services at a primary health center, a 56-­‐minute trip away due to poor roads and limited available transportation. 62.5% viewed the MHU service as of lower quality in comparison to fixed site clinics. Although the MHU visited the village once every week, 90.9% of the users did not feel that they could depend on the mobile clinics to meet all of their routine or emergency care needs.54 Importantly, several projects noted that their activities were helping to raise awareness about certain health issues such as HIV and disability. By helping to increase public demand for certain services, the rural poor were more likely to put pressure on local health systems to invest in basic or improved services.18 21 Additional activities carried out by MHU teams surrounding disease prevention can have an important impact on public health. In 2010, The Mama-­‐Toto mobile motorcycle clinic trained 300 women in basic health care through summer health camps held in three villages, distributed 900 mosquito nets, and conducted 500 Malaria Rapid Tests, which decreased misdiagnosis and over treatment of malaria. Follow-­‐up research showed that of the families that reported receiving treatment for malaria multiple times, only 1 in 3,000 reported contracting malaria between May 2010 and 2011.20 Discussion The existing literature indicates that MHUs are a highly flexible means of outreach to those who might not otherwise attend a fixed health center due to geographical, economic, or social barriers. By addressing these population-­‐specific needs and barriers, MHU can successfully deliver essential, as well as specialized health services. Interestingly, very few clinics discussed in the published and peer reviewed literature have provided sustained services to the general population through a primary health care approach. Instead, most have taken a vertical approach targeting specific groups or gaps with a limited set of services, often those not available at basic primary care facilities. The online search for this paper suggests that MHUs in use today are pursuing an integrated model of primary health care, but these efforts are not yet analyzed in the evaluation literature. There are relatively few publications addressing the actual operation of MHUs in resource-­‐poor settings; the available research is mostly descriptive -­‐ covering number of beneficiaries given treatment, services provided and perhaps patient perceptions and satisfaction of services. However, little detail is provided on clinic financing, day-­‐to-­‐day operations, or outcomes. Comparisons with fixed site alternatives are therefore very difficult. This lack of outcome data also points towards the need for stronger data collection systems on MHU’s, as well as a need for better indicators of program impact when assessing service utilization, increased access, and clinical outcomes. There are a small number of publicly available evaluation reports and cost-­‐effectiveness studies involving MHUs. Implementing organizations may generate such reports and evaluations, but they are not being shared in the published literature. There is a clear need for learning to be shared, particularly in cases of outstanding success as well as project failure. The sustainability of MHUs has long been a topic of debate. Many of MHUs identified in this search appear to have survived only a few years. The underlying cause of failure is rarely described. Some attribute project failure to a decrease in demand, but more often to inadequate funding and high operating expenses. The vast majority of MHU’s identified that are still operating do not operate independently but rather, under the umbrella of another organization, usually a fixed health center, which may be a factor in long-­‐term sustainability. References
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