This is a documentation about the referral transport ambulance system set up by the government of Madhya Pradesh and UNICEF in India. From 2013 to 2016, this system has allowed the successful transport of over 4 million women and children to health institutions in the state of Madhya Pradesh alone.

Written by Tanya Bhandari in collaboration with the UNICEF India country office

Guddi is standing outside the community health centre with her 9-month-old baby and a reluctant toddler who is hiding behind her. The nurse who is showing us around tells us that he fears coming in since he associates it with getting a vaccine. The nurse offers him a sweet, and he forgets about all his anxieties. In the open courtyard of the health centre, a driver cleans a van that looks like an ambulance. He waves at us and we go over.

This vehicle is a Janani Express, and the driver – Pintu Bhaiya – has been operating it for over four years. It is part of a government program that provides emergency transport services to patients living in rural areas. Its main goal is to ensure timely healthcare for pregnant women and infants.

Reducing the Maternal Mortality Rate
In 2008, the state of Madhya Pradesh in India had the highest neonatal mortality rate and the fourth highest maternal mortality rate in the country. The Government of India and the state government have been committed to reducing these numbers for several years. They identified the need to address the three-delay model – three groups of factors which delay women from accessing the maternal health care they need:

To address the second delay, many states under National Health Mission have now set up transport systems like the Janani Express in Madhya Pradesh. The program follows a public-private partnership model with fleet of contracted private vehicles and a centrally located 24 x 7 call centre to coordinate the vehicles. The vehicles are hired locally for a specific period to fulfill the duties of bringing pregnant women to health facilities.

How does it work?
1. A beneficiary (pregnant mother, mother or child needing a check-up) contacts the call centre via the phone number for their district.
2. The call centre takes down the beneficiary’s information and contacts the driver for the local Janani Express vehicle.
3. The driver is given the locations for pick-up and drop off – and has the contact information of the beneficiary.
4. Once the driver has dropped the beneficiary off, they contact the call centre.
5. The call centre records all this data digitally and closes the trip in the system once the call from the driver is received.Sub-Health Centres
Another intervention that complements the transport system was to upgrade existing sub heath centers for 24 x 7 delivery services. These centres were set up to reduce the distance and travel time needed from remote villages as existing centers were limited in numbers and located primarily at district and block levels.

The sub health center where we are standing is among dozens of other sub health centers set up by the government of Madhya Pradesh with technical support of UNICEF in the district of Shivpuri. The centre is a small village-level institution that acts as a safe haven for pregnant mothers and their children to get information, checkups, vaccinations and delivery.

At a sub-health centre, Sister Nazma, an Auxiliary Nurse Midwife (ANM) shows us the receiving room, holding room, labour room and her living quarters. ANM’s are regarded as multi-purpose workers and are mentored on a monthly basis by a gynecologist, a pediatrician and a staff nurse from a higher-level facility – a process set up through the help of UNICEF. The nurses are linked to the community with the help local women who are Accredited Social Health Activists (ASHA). The ASHA is trained to act as a health educator and promoter in her own community and in most cases, is also the person who contacts the call centre on behalf of the beneficiary.

Call Centres
The communication hubs between the drivers, beneficiaries and the health centres are call centres set up in each district hospital. The call centre at the Shivpuri District Hospital is a simple room with a computer, a few phones, a printer, some logbooks and one operator around the clock. The operator, Mukesh Sharma tells us that this model of the call centre is replicated across all 51 districts in the state.

Each day, operators like Mukesh Sharma input large amounts of data about the beneficiaries of the Janani Express system. One beneficiary’s information takes about 3-4 minutes to fill out digitally and the platform has predictive text for filling in common information like the name of a district or hospital. The platform also makes it easy for him to generate visual representations of this data in many permutations.

Once the beneficiary has completed the use of this service, the call center operator reaches out to them again for feedback. They ask questions like: Did the ASHA travel with the patient? Was money taken for transport? Were you provided with free food at the hospital? Did you spend any money out of pocket, and if so, for what?

The granularity of data being collected almost in real time at district level is incredible and when looked at from a state level gives a robust understanding of the system. Three key parties monitor this data on a monthly basis in order to advocate for change where it is needed – the call center operator, the Chief Medical Health Officer (CMHO) of the district and the UNICEF supported district consultant.

Constant feedback loops
Call Center Operator: Mukesh shows on the online monitoring system, how many calls were missed in his district during the week. For him, monitoring the number of calls coming in, tracking the call conversion rate, kilometers travelled by each vehicle and closing of trips are some of the key data points to observe. The call centre operator is the one who cross checks the logs provided by the driver, keeping the system in check.

Chief Medical Health Officer/Government Official: Most of this data is analysed by the government on a monthly basis. Through this system, they can track where ambulances are not reaching on time, where cases are often missed, releasing payments to the vehicle contractors etc. These policy makers can use the data to track decisions made for increasing the number of vehicles in certain pockets with the technical support of UNICEF.

In the district of Mandla, district consultant Manish Agarwal was able to identify silent villages – villages which were not making calls to the centers at all. By comparing the calls coming in, to the list of villages as per the census, they were able to locate pockets where the referral transport system was not functional. Using this information the number of vehicles in these pockets were increased, home visits from ASHA’s were further encouraged and sub-health centres were strengthened. These constant feedback loops of data analysis and advocacy for change are the primary reason for the success of this scheme.

Scale
With the technical support and catalytic funding from UNICEF this service was piloted in two districts of Guna and Shivpuri in 2007-08 and rapidly scaled up to all districts in the state of Madhya Pradesh by 2012.

Dr. Gagan Gupta, Health Specialist at UNICEF who was behind the conceptualization of this model and was involved right from the pilot to the statewide scale-up of the system says – “The success of this model resulted from the fact that there was a strong need on the ground and we provided a workable solution to address that need. Also, integrating the entire cost in the National Health Mission budget and getting the buy-in at the highest level in the government ensured scale up with desired pace and quality”

Several other factors played a key role in the success of this system like the involvement of the state technical team right from the pilot stage which helped in generating knowledge and creating a sense of ownership. The robust data management system allowed for not only internal accountability but also clear indicators that could facilitate timely advocacy

UNICEF provided continued support, not only in the conceptualization, advocacy and initial pilot phase but also in working closely with state team during scale up. This included support for planning, budgeting, standardization of designs and systems, staff training, development of real time monitoring system and data analysis and feedback. There were also Regular visits by field coordinators and UNICEF staff to health centres, call centres and on-going mentoring of the field staff to ensure quality of services.

Looking Forward
While this transport system doesn’t solve all the problems faced in rural maternal health, it helps alleviate one of the bigger issues of access to institutional care.

Nearly 8 out of 10 women in Madhya Pradesh are now giving birth in institutions, which is a big shift from 2007 when every second woman was delivering at home. More than half the women utilizing these services are from marginalized groups like schedule castes or schedule tribes, groups where access to institutional care is a major barrier. Nearly half of the pregnant women were transported after sunset and before sunrise, a period where public transport services in rural areas are the most compromised.

“Over the last ten years, Madhya Pradesh has reported an increase in the institutional deliveries from 26% as per the National Family Health Survey (NFHS-3, 2005-06) to 80.8% in NFHS-4 (2015-16). Improving the access of pregnant women for institutional delivery was a key factor in contributing to this success. This was made possible with the technical support of UNICEF piloting the referral transport Janani Express call centers in Guna and Shivpuri districts in 2008-09. This enabled the government of Madhya Pradesh to address the second stage delays responsible for maternal deaths in the state and based on the learnings in the pilot districts, the state scaled-up the model to all 51 districts. The comprehensive model of vehicles linked to the call center and monitoring of the Janani Express transport through the online software was a cost-effective model developed to reach the underserved populations of Madhya Pradesh. The state is now integrating the call centers with the Advance and Basic Life support vehicles for providing emergency services in the state, named as Deendayal 108 ambulance services.”

– Dr. Archana Mishra, Deputy Director Maternal Health, National Health Mission


I visited several health centres and district hospitals to learn about this system. I spoke to a lot of people at different levels, and the one thing I found in common was how strong willed they were to make a difference in the world. Towards the end of the conversations, I made sure I asked – ‘how does it make you feel to do this kind of work’.

Pintu Bhaiya’s face lights up in this surprised sort of shyness and he stares into his log book. “I transport a pregnant woman 20 kilometers to the hospital at 2 a.m., and when I am dropping her back a few days later she has a small healthy baby. She would have given birth at home if it was not for this vehicle and anything could have happened. Of course it makes me feel good, I have a sense of purpose for my community.”

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