It’s not news that the health care systems in many parts of Africa are sorely lacking: There are great needs for more doctors, more medicine and more medical equipment. But a hidden hole in the system for many years has been vehicular: The ambulances, trucks and motorcycles that were meant to help practitioners get aid to their patients were, quite simply, falling apart. And even if you have the medicine people need, it does them no good if you can’t reach them.
Andrea Coleman, co-founder of Riders for Health, recognized that problem, and made solving it her mission. For the work that her organization has accomplished, Riders for Health was recently honored with Wharton’s 2015 Lipman Family Prize. Anne Greenhalgh, deputy director of the Wharton Leadership Program, spoke with Coleman about what Riders for Health does, how it works and the challenges of providing health care on a continent where good-quality roads are often harder to come by than good doctors.
An edited transcript of the conversations appears below:
Anne Greenhalgh: Could you begin and tell us a little bit about your organization and the kind of social impact you’ve had?
Andrea Coleman: Riders for Health is an organization we started 25 years ago. And we started it because we became aware that vehicles were being sent to Africa — ambulances, motorcycles and other vehicles — but nobody was training local people to maintain them or run and manage [them] — all the very basic things that have to be done to keep a vehicle going.
We realized that what that meant was that vehicles — very expensive vehicles — were breaking quickly and easily, which meant a waste of the money, a waste of the vehicle and a waste of lives, because people weren’t being reached with the health care that those vehicles were meant to take to them.
And, of course, Africa is 86% rural. It’s a rural continent. So, once those hard roads finish, there’s no infrastructure. Actually, there are no roads, but the vehicles aren’t working either. Even if you had all of the roads in the world, you still wouldn’t be getting to those people who desperately need the health care.
We decided that that was something we could address and really make a change to. You can spend a lot of money on developing drugs or training health workers, but if they can’t get to the people who really need it, you’re wasting time and lives.
Greenhalgh: What’s the vision of your organization in a nutshell?
Coleman: The vision of the organization is that no one should die of easily preventable and curable disease simply because they can’t be reached with the health care that’s available.
Greenhalgh: Can you talk about the values underpinning the organization?
Coleman: We are very certain that it must be local people who are trained with the skills that they need, to work with the [a nation’s] Ministry of Health and to make sure that it’s the country’s strategy — not our strategy — and that it’s local people who are building the skills and delivering the impact.
Greenhalgh: How do you do that? Through partnerships, I’m sure, but tell us a little bit about those partnerships.
Coleman: Well, the primary partnership is with the Ministry of Health. … [We] explain to them if you outsource the vehicle management to us, it takes the burden away from you. But it also means that you don’t have to worry about those issues. You can think about what the health workers are going to do, and what your health strategy is, and what your budget is.
That partnership is the primary one and the critical one. Then from there onward, it’s building the skills of the staff and bringing in other partners — other NGOs also need their vehicles maintained. But obviously, the primary one is with the Ministry. But then, of course we’ve got our external stakeholders, people who support us. And those are very important partnerships.
“The vision of the organization is that no one should die of easily preventable and curable disease simply because they can’t be reached with the health care that’s available.”
Greenhalgh: These partnerships run both at the national level and also locally?
Coleman: Yes. The partnership, in terms of permission, if you like, is with the ministry. But then at the next level you’re really working very closely with the provincial and the district ministries. Then you have your technicians, your mechanics, working very closely with the health workers. So, it’s the health workers who need the mobility to reach their rural communities. And it’s the mechanic that has the relationship with the health workers to enable them to be predictable and reliable in reaching their rural communities.
Greenhalgh: Really there are two critical aspects to what you do. One is the management of the vehicles, but also the maintenance of those vehicles as well. When we talk about vehicles, say a little more about what vehicles those are?
Coleman: Well, there are three kinds of vehicles that are very important in rural access. Motorcycles [are] one. And that’s for outreach. That’s for health workers to be able to reach their communities with health education, with vaccines, with all the things that prevent people from becoming sick. For example, for monitoring nutrition levels: Is there malnutrition in this community? How many women are pregnant? At what stage are they? Making sure the prenatal care is taken very, very seriously.
And then the next level is trucking vehicles — vehicles that can take goods and larger numbers of people for say, a mass clinic for immunization, or pre-imposed natal care. Next [are] ambulances that are used to move people in emergencies. Women in obstructed labor can’t walk, of course, and they often die in the village. And there just aren’t ambulances available. And sometimes there’s no fuel or there’s no driver.
So, the logistical part of it is something that we take very seriously. We think about the journey planning — how you make sure those journeys are efficient and they are actually addressing the health needs of the communities.
Greenhalgh: In terms of percentages, what [percentages] would you say of the fleet [are] motorcycles versus ambulances and so on?
Coleman: There are many more motorcycles, because that [preventive health care mission] is so critical, rather than leaving it until it turns into a disease or even an outbreak. So there are many more motorcycles, because if you picture the geography, you’re really looking at large amounts of people in the city. Down at the provincial level, in the larger towns, the logistics aren’t so difficult. But once you get past provincial down to district, there are villages that people don’t even know where they are. There are millions of people living in rural communities, and there are no roads to them. There are animal tracks and human tracks. But actually navigating that to those large communities is pretty tricky.
Greenhalgh: Do you own any of the vehicles, or do you just manage the infrastructure?
Coleman: There are two financial models with that. We can either manage the vehicles that the ministry already owns. We call that transport resource management. And that’s making sure that they are viable vehicles and fit the purpose.
“A health worker doesn’t have to ride into a major town maybe 500 miles away to get the vehicle serviced. We’re taking the service station to them.”
We’ve also done a model where we buy the vehicles. We’ve borrowed money, which has been underpinned by very philanthropic organizations to guarantee it. But nevertheless, then the ministry has to pay us for the running of the vehicles and pay back the capital costs. But of course, it’s up to us to negotiate a very low interest rate in that case.
But what your question really hits home at, is that having the vehicles that are already there run well and managed properly is one thing. But having enough vehicles to reach all the areas that need to be reached is another issue. So, having some control — enabling the ministry to have control about the number of vehicles, whether they’ve got enough and also manage their budget. And that’s the beauty of knowing exactly what the running cost is — because the ministry can spend as much on having vehicles that are not running as having vehicles that are running, simply because the capital cost is wasting away in a car park somewhere.
Greenhalgh: In terms of proportion, I’m imaging that most of the vehicles are owned by the ministry.
Coleman: Yes. Most of the vehicles we run are owned by ministries, but at least a third of them are owned by Riders for Health, but leased on a full service lease basis to the ministry.
Greenhalgh: How many vehicles are we talking about?
Coleman: We’re running 1,600 vehicles at the moment. So, it’s pretty big. In eight countries — our newest is Liberia, as a result of the Ebola crisis. At least two-thirds of those are motorcycles for outreach. And then there are ambulances, and what we call trekking vehicles.
Greenhalgh: And I’ve read that the reach is 12 million people, 13, 14 million? Is that right?
Coleman: Yes, 14 million people we’re reaching — enabling health care to reach 14 million people at this stage.
Greenhalgh: That’s really quite, quite remarkable. So, part of the equation is the fleet. The other side of the equation is the maintenance of that fleet. Could you talk a little bit about how you do that?
Coleman: Yes. I’m delighted you asked the question about the maintenance because I think people talk too often about fixing a vehicle. They think of maintenance as something that’s broken, let’s fix it. We don’t allow the vehicles to break because if a small part in an engine breaks, it could destroy the rest of the engine. I’m not saying it always does, but needless to say, that’s a risk we don’t want to take.
So, in terms of keeping the economics of the service at the right level, we make sure that if a manufacturer’s part — if they recommend changing it at 8,000 kilometers we’ll change it at 6,000. And the health worker is trained to do his or her daily maintenance. She will make sure the chain on the motorcycle has the right tension, check that there’s enough air in tires and no stones in the tires that will cause punctures. He or she will make sure that all of the nuts and bolts are on tight, because if you’re out in the rural area and a nut and bolt falls off, [there’s] nowhere to get another one. And you could be eaten by a lion, or anything could happen to you.
Those things are real risks in rural areas. But worse than that, of course, worse than anything, is that you’re not getting to the communities to deal with health care.
“People think of this ‘greasy hands’ part of health care as not really being relevant. But actually it is critical.”
The way in which we do this is, in the capital city in the countries in which we work, the parts will come in for the vehicles. And so stores management is a very critical part of what we do. We make sure the stores are kept very well, and that the workshops are very clean and very well-systematized. The health worker will do his or her daily maintenance, and on a monthly basis, our technician will ride out to those motorcycles out in the rural communities and do the next module, whatever it is. That could include hanging the tires or making sure that all the brake cables are changed — whatever is the next part of the [vehicle maintenance] plan.
And that means that a health worker doesn’t have to ride into a major town maybe 500 miles away to get the vehicle serviced. We’re taking the service station to them, however rural and however remote those vehicles are.
It’s a very systematized infrastructure issue. And then we have to think about the fuel, because in those remote areas, there’s no fuel. We have to make sure that we have fuel stores in strategic places to enable them to have constant fuel supplies, which, of course, in crisis moments is very difficult because fuel is always under pressure at crisis times.
Greenhalgh: How do you go about training health care professionals to do the kind of maintenance that’s required?
Coleman: It’s wonderful to see. I’m always thrilled when I watch this process. In the very first instance, we had a highly trained person to train two or three people in our first country. That was Lesotho. And the same people, two or three people, in The Gambia, our second country. And now those people are the training professionals. Those initial people trained in West Africa and Southern Africa are the specialists in training. And the levels of training are riding and driving. That’s critical to preserving an engine and a vehicle — how you ride and drive. And to make sure that yes, the vehicle is well-preserved, but also that they’re not driving carelessly.
The number of road accidents on the African continent is very high. We make sure that that’s done, that everybody who is on a motorcycle wears gloves and proper protective clothing and a helmet. There’s no riding around in a pair of sandals and no helmet. We take that very seriously.
And then, we train the health workers to do their daily maintenance. I know this sounds unlikely, but it’s true. We’ve actually found a way to ensure that somebody who has never ridden a motorcycle can ride without any fear of falling, and [from] there, to brake and stop within 10 minutes. And once you’ve got that down, the rest is easy, because there are a lot more complications about riding in very remote, tough countryside, but just getting that initial confidence is so important.
[It’s] the same with cars and ambulances and so on. But they have to be highly trained. And then their daily maintenance, they’re trained in that routine. That’s a very important piece of their work. People think of this “greasy hands” part of health care as not really being relevant. But actually it is critical. That boring kind of maintenance and greasy hands — this is actually critical to the health system. Where would we be without logistics in the developed world?
Greenhalgh: Now you have a sort of a “train the trainers” model. Would that be fair to say?
Coleman: Yes, yes, we do.
Greenhalgh: And how many trainers do you have?
Coleman: We have some specialist trainers who will go from country to country to do training. But we also have in-country trainers who do refresher courses and make sure that everybody is up to standard. And they will go around and supervise, and make sure that there is no carelessness creeping in.
Greenhalgh: I would be remiss if I didn’t ask you a little bit about your personal journey to Riders for Health. How did you get into this business?
Coleman: Well, my husband, Barry Coleman — we are co-founders. And we have different backgrounds, but where we are the same is that we’re both motorcyclists. My background in motorcycling comes from the fact that all my family, right from the early part of the last century, were motorcyclists — and racing motorcyclists, in fact. And my father was a development engineer, so was my brother. And on my mother’s side, too, it’s the same background. And I used to race motorcycles myself.
My husband, Barry, has a much more dignified background. He’s trained as a lawyer and a journalist. He wrote for The Guardian newspaper in the U.K. But he’s also a motorcyclist. So, when we saw this issue, Barry looked at that and said, “That’s got to be solved.” And I said, “That’s got to be solved.” So, from our different standpoints, we both focused on that. And we wonder how we risked — at that time, our three children were young, really young — and I was 42, I think, and Barry was 43. And we kind of took the risk of starting this organization, giving up everything we were doing in terms of income and just focused on this because we thought if we’re not going to do it, nobody’s going to do this.
So, that’s how we started. And fortunately, we were able to keep the roof over our children’s heads and not starve everyone to death. But it was a big risk, but nevertheless worth every second.
Greenhalgh: Didn’t you also get some important help from an, at the time, rather famous motorcycle racer as well?
Coleman: That’s right…. Randy Mamola has been a person I’ve worked very closely with over many years. I used to do his public relations and other management. And so, he and another famous motorcyclist, also from California … we said, “How are we going to raise the money to do this?” And we decided that we had to make all these famous stars in motorcycle racing do what we need them to do just for one day a year. They’re all amazing people. They’ve got this competitive focus.
So, they helped us with the core funding that enabled us to prove the concept. Without those two guys from California, we wouldn’t be sitting here today.
Greenhalgh: Speaking of funding, the Lipman Family Prize comes with an unrestricted cash award of $125,000. How do you see that award helping you further your vision of the organization?
“You can spend a lot of money on developing drugs or training health workers, but if they can’t get to the people who really need it, you’re wasting time and lives.”
Coleman: Well, this is a very important award to us. And the prestige of it, of course, is immense. But the money is really critical at this time because, as I said earlier, we’re at a really important transition point at this moment. And really what’s happened is that now is the time to really build the leadership in the Africa programs, and to make sure that in the future, Riders for Health is an African organization, and not one that has to be generated from the U.K. The leadership and the expertise is outstanding, but we have to make sure that it’s transitioned properly, and this is going to be what’s going to help us to do that transition — to take it from an entity that’s driven, if you like, from the U.K., to one that is solely driven by our amazing staff in Africa.
Greenhalgh: Do you have thoughts about how to do that? You’re really talking about succession I think.
Coleman: Yes. This is definitely about succession. And I think that Barry and I both came to realize some time ago that we’re not going to live forever…. We think that not only should we be thinking about how to hand over to leadership in the way that the organization looks now, but how to make sure we’re handing over that leadership to the African continent. And to think about our outstanding staff there — how they think about succession as well in their own countries.
Our new work in Liberia has really shown us what skills and expertise we have in those programs. Building teams from The Gambia, Zambia and Zimbabwe have really put in place the new Liberia program in a country that isn’t their own. And that shows the capacity that there already is. But there are a lot of functions that we still do in the U.K. that really need to be built in. That’s our next step. And that’s where the money from the Lipman Prize is so critical and so welcome.