The project made transport services more accessible to the majority of women in the community with an increase in the number of women attending ANC services for all the four visits. Most mothers tended to use the motor cycles rather than the bicycles. This was probably because the motor cycle boda-boda were more comfortable and they could move longer distances than the bicycles. Indeed previous studies have shown that motorcycles are preferred even though they tend to be more expensive. This increased availability and use of transport services could be attributed to two factors; a) the reduced cost of transport (the mothers didn’t have to pay any money), and b) easier accessibility to the transporters. Because of the financial incentives, the transporters were very active in mobilizing mothers to attend services through either their cell phones or physically reaching prospective clients.
The increased access to services that was noted in this study shows that lack of transport was a major contributing factor to non use of health facilities by women especially the poor. According to previous research the poorest segments of the population tended not to use motorcycle boda-boda because they could not afford it . Initiatives that can help to reduce the cost of transport could therefore go a long way in increasing access to health services by the poor. However, this requires government interventions such as reducing license fees and other forms of levies and streamlining the registration processes, to allow more providers to obtain the required license. This would allow more entrants into the field, with the creation of more competition, and perhaps a lowering of the transport charges and eventually more affordable services.
Economic gains achieved by those engaged with the project have been recorded. Given that most of the transporters are generally school drop outs that have difficulty finding regular employment, the project acted as an opportunity to boost their income. Similar studies have shown that income earned through these boda-boda services provide benefits not only to the transport provider and his immediate family but also to dependants [6, 7, 10]. Other beneficiaries include groups that provide complementary services such as those who repair motorcycles, or who provide fuel. Developments in this sector can therefore provide economic gains beyond the increased income for the transport provider.
This kind of transport has, however, been associated with some risks. These include thefts of motorcycles at night, at times even accompanied by loss of life, accidents stemming from reckless or drunk riding or simply poor riding skills . However, in this study accidents did not seem to be a major problem, partly perhaps because the transport providers had signed a contract which indicated that irresponsible behavior could lead to termination of the contract. There are laws that require that riders have licenses, wear helmets and go to a training school where they can be taught how to ride. However, these regulations have often not been enforced . The associations for the providers could provide some help in ensuring that these laws are enforced. However, it has been reported that these associations are often informal and so they tend to play more of a voluntary role and therefore find it difficult to enforce such laws. According to Bloom et al , compliance with rules may be affected by the legitimacy of the body trying to enforce the rules. The establishment of franchises in this sector could also help to promote ethical behavior in terms of compliance with the transport laws and regulations. Bishai and colleagues found that franchising provides more incentives for local entrepreneurship . A franchise could encourage provision of safe efficient transport services. This could promote the development of trust in reputable providers, leading to an increase in their client base. Hence eventually such arrangements could benefit both the providers and the clients whose safety would be more assured. Regarding the insecurity associated with night travel, the local governing authorities could play a more significant role in ensuring that riders and mothers are safe at night through enhancing local security that can curtail the activities of robbers.
In considering whether this initiative can be scaled up, two important issues warrant discussion; a) the capacity to run the scheme, and b) the cost of running the scheme. Proper running of the scheme requires that there is a clear system for paying the providers. This payment needs to be done regularly and frequently because these transporters handle small sums of money and therefore need the money for running costs. This problem is likely to be magnified in the early stages of the scheme when there is a lot of suspicion. After trust has been gained then payments can be made monthly. To reduce transaction costs, the use of mobile phones for making payments could be explored. However, such systems are usually available in the more urban areas and almost nonexistent in the rural, primarily because there is no business in the rural areas. Lastly, a system for identifying fraud also needs to be set up. Fraud is a common problem with voucher programs. The voucher agency has to ensure that the vouchers have special security features that cannot be forged easily. A mechanism for confirming that services have been supplied will also be necessary before the transport providers are paid.
The second main issue is the cost of the project and therefore concerns of sustainability. In a resource poor country, the government may have difficulties meeting the financial requirements, and donors get fatigued over time. It is therefore necessary to think of ways of mobilizing the community to contribute to the running of the programme. One option could include the creation of a community mobilization fund perhaps through community insurance schemes. Families could then be encouraged to make periodic contributions that would cater for the transport needs of the mother and the newborn. This insurance scheme would then liaise with local transport providers and discuss pricing and service arrangements.
Ownership of the project could also affect its sustainability. It was conceived by a research team from outside the district. However, the study was implemented in close collaboration with the district health team. Regular meetings were held with stakeholders at district level to discuss the implementation of the study and to address the challenges that arose, including soliciting for ways of sustaining the project beyond the study phase.
In conclusion, the project has shown that it is possible to utilize locally available transport systems that are responsive to the different local and rural contexts. Such low cost intermediate transport systems (bicycles and motorcycles) can reduce the challenges paused by geographical inaccessibility and poor transport networks. Secondly, they are effective in increasing institutional attendances for maternal services and hence can lead to improvements in maternal and child health. An effort should be made to identify ways of reducing the cost of transport by encouraging more investment in the sector, with the hope of increasing competition and hence reduction of user charges. However, care must be taken to ensure that there is enforcement of laws that will ensure the safety of passengers and the transport providers themselves.