Episode Transcript
*This transcript was compiled using automated software — spelling and punctuation errors are possible.
Jason: Hello Molly, and welcome to the Crisis Response Podcast, how’s everything going?
Molly: Hi! It’s going well, thank you.
Jason: You are the director of MotoMeds in Haiti. Could you share with us what MotoMeds is, what it does, how it all works?
Molly: MotoMeds is a pediatric nighttime telemedicine and medication delivery service. It’s currently operating in two cities in Haiti, and the idea is to bridge the gap in access to pre-emergency treatment for children at nighttime.
When we talk about pre-emergency treatment, that would be for common childhood illnesses like acute respiratory infection, diarrhea, other infections like ear or urinary tract infections. All of these have well-established, cost-effective treatments, but those need to be administered early. So in countries with low resources that don’t have great healthcare systems, there is a gap in access to these types of treatment once the clinics are closed for the day.
Most of those clinics close in the afternoon, around two o’clock or four o’clock, and if you need care after those times your only options are emergency care or waiting until the morning. Young children are vulnerable to illness progression during these times, so for some children if they wait until the next morning they now have an emergent illness which is something you always want to prevent.
But when you are in one of these resource limited settings that may not have emergency care or it could be prohibitively expensive, then it becomes more urgent to eliminate or to prevent these emergencies from happening in the first place by stopping common illnesses from becoming emergent ones.
So that is the idea for MotoMeds, and how it actually works in practice is that we have a call center that’s open at nighttime. So in Haiti it opens at six o’clock pm and it closes at five o’clock am. It’s staffed by nurses or nurse practitioners, and they receive incoming calls from families with sick children. They use a set of guidelines and a standard operating procedure that our team has built to assess each child and then generate a treatment plan.
Most treatment plans involve a medication delivery, so we use Trek Medics Beacon system to dispatch delivery drivers. They come to the office, pick up a backpack full of supplies, and then they navigate to the home of the sick child and they deliver the medications. We use a tablet to transfer instructions on how to administer the medication or how to take the treatment. In some cases, some children who have say moderate illness, we will also send a provider, so we will send a nurse to their house to perform an exam to make sure that the child can be treated at home. If not, they will escalate care and refer them to the hospital.
We can transfer patients to the hospital as well, but we don’t take on care when it reaches that level.
Jason: This sounds like a really useful service, I mean, anyone with children can relate that children tend to get sick at night, and like you’re saying, common illnesses can progress and become a lot worse if they’re not taken care of right away. This all sounds very novel and understandable. One thing that strikes me so much about MotoMeds is the area that you’re working in and specifically, the topography. Can you talk a bit about Gressier, Haiti, and the community that you are serving?
Molly: Gressier is a small city along the highway that opens up into more rural mountainous areas. We also work in Les Cayes which is a more urban setting.
But in Gressier there’s no street lights, there’s very few paved roads, there’s no address system. So we rely on the local knowledge of the delivery drivers and they have done an incredible job and almost always find the location that they’re going to, which the only exception being sometimes when we lose contact with the family because cell service is not great in these areas. Families have limited access to electricity, so their phones sometimes will lose battery charge and so we don’t get the full address from them.
But other than that the delivery drivers have been able to find houses like on the side of mountains with no, like I said, no address system. Usually they use local landmarks, and then just their knowledge from all their work as motorcycle taxi drivers. So during the day they drive kids to school, they drive women to the market, they drive people to work, so they just know the neighborhoods well.
Jason: These are motorcycle drivers, wow, so how did you find these drivers? How did you find and recruit the nurses, the nurse practitioners? Were you able to find them from the community or did you have to go outside?
Molly: Before we launched MotoMeds we did a needs assessment. We interviewed families in the area to ask them about their healthcare options and their healthcare needs. So we had a nurse researcher head up that project, a local Haitian nurse researcher who had worked for the University of Florida previously. She had a preferred motorcycle taxi driver for getting to and from work or for sending someone out to get lunch or things for her. So we used him to recruit the other motorcycle drivers and we had a couple meetings with them before we hired anybody.
And we also wanted to get their feedback on the idea and whether they’d be willing to go out at night. There’s not a lot happening in Haiti at night. Most people — because there’s not electricity — it gets dark, and they go to sleep. So we weren’t sure of people’s comfort about going out at night or their willingness to go out at night. So we held meetings with groups of motorcycle drivers, and we asked them about their concerns. And from that group almost everyone decided to continue.
So that’s how we got out first pool of motorcycle drivers. And then when we expanded to our satellite delivery area in Les Cayes, we did a similar method with a trusted contact who I think worked for the Red Cross previously, as a volunteer, and he recruited a pool of motorcycle drivers for us.
Jason: You mentioned that they’re hired. How are they compensated? Is it per delivery or do you have them on a retainer of some kind? How does that work?
Molly: So the original idea was to have a pool of motorcycle drivers that work every night and that we would broadcast a need, and whoever responded first – similar to like the Uber model – would get the job and they would come to the office, pick up the items, and go deliver the service. But in those original meetings the drivers wanted to share the work evenly. They didn’t like the idea of like the first person to respond to get all the work.
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So what we decided to do, which actually ended up working out well, was at the beginning stages we wanted to limit the number of things that could go wrong. So we decided to each night pay a small retainer to two of the drivers to make sure that they would remain available, that they were not traveling far away or out drinking or something, so they’re basically on call as we would say. Then, depending on the needs of the night, we might use one or we might use both, or we might use them both multiple times. Then they just switch every day, it’s two new drivers who are on the retainer, and we pay them by the trips that they take.
Jason: That sounds like it works out quite well then. Here is a question I hear a lot, and that’s that we have people willing, but how do we make sure that they stay willing. It looks like you’ve found a nice solution to that and a solution that came from them as well, that they actively participated in making, so that’s really impressive.
What about your nurses? How did that recruitment happen?
Molly: We advertised the position around to local NGOs and clinics, and then interviewed those that were interested.
Sometimes it’s hard to read resumes in Haiti. Often times the universities, you may not recognize the names, you’re not sure if they’re reputable or not because the schools that they went to are not regulated very well. It’s hard to get a feel for that so we ended up hiring most of the nurses who had job experience. Solid job experience working for a known entity, be it an NGO or a clinic or a hospital.
I also contacted people to act as references for them to make sure that everything was as it appeared on paper. Then we did a pretest just to get their baseline knowledge, because we were combining research with providing care and that is not as common for some of these employees, they are not as familiar with research and consent and data collection.
Then finally, asking them about their willingness to work at night and willingness to drive around on motorcycles, that was part of the interview process as well.
Jason: How did that go over? Because the nurses are predominantly women and the motorcycle drivers are predominantly men, and obviously the risks for traveling at night are higher for women than they are for men, but there are also risks for the men as well. Can you talk about what kind of risks they were concerned about and how you dealt with those?
Molly: So the drivers were mostly concerned about being on the road by themselves because there’s the possibility of having like a flat tire or your motorcycle breaks down and you’re stuck by yourself. Because as I said before, there’s not a lot happening at night, so there’s not a lot of resources to turn to if something happens.
They were also concerned about potentially being robbed at night. And interestingly, they were concerned about hitting animals on the motorcycle in the dark which would obviously cause an accident.
So we ended up using a buddy system so most deliveries are done by two motorcycles together, depending on the time, situation and the location, which was definitely a good solution to make them feel more comfortable.
The nurses were more concerned about getting wet in the rain, I’d honestly say that was their biggest concern. I think for them, they knew they would always be with the driver, whereas the drivers sometimes will be on their own and that’s more of a risk.
Plus the nurses, most of them at least are from the area where we’re working so a lot of them are already familiar with the drivers, which I think helped them feel more comfortable going out at night with them.
Jason: That makes sense. So you’ve recruited drivers, you’ve recruited nurses, you have the technology set up so that you can take calls in and then you can dispatch the drivers and/or the nurses, so you are ready to go. Now it’s time to promote this to the community and raise awareness, what did that entail?
Molly: That was the biggest unknown before we got started is how much do you have to promote it or how little do you want to promote it? Because when we first started we had done a lot of role playing, we had tried to practice you know, receiving calls from community members, but we were not actually sure how it would play out. So we didn’t want to be overwhelmed with calls at the beginning because that could have led to disaster.
So we started with very limited publicity. We contacted a number of participants in the first study that we conducted. We contacted all of them and said we would be opening the service and when the start date was and what the phone number was. We also did a handful of announcements at local churches, but not too many. Then we told our staff they could advertise to their networks, like their neighbors and family members.
We did get a call the first night from all of that, but that was the only call for the entire first week. So we quickly realized that we needed to increase the advertising, so then we started going to more churches, to soccer games and schools, we handed out flyers and put up signs that all increased our population’s awareness of the service and that increased our call volume.
In the end it took us about a month to get to steady calls coming in. So then later on when we expanded to our first satellite location in Les Cayes we knew right away that we could handle plenty of calls and could get it up and running faster.
Jason: That’s something we always talk about with organizations that are getting started is that it’s much better to start small and grow than it is to start way too big and then have to scale back. Because when you start scaling back very quickly off the bat, people are going to notice and they’re going to lose faith in the service you provide. It’s a lot easier to scale up than it is to scale back.
So of the areas that you mentioned advertising, one of them that I think I noticed wasn’t mentioned was you weren’t doing a lot of advertising in other health clinics, right? Or at hospitals?
Molly: We actually did, sorry, I missed that one. We did advertise at a couple local clinics.
One of the aspects of our model is that we don’t want to be in competition with daytime providers. So sometimes people say like, “why are you only open at nighttime?” But here in Haiti it’s like 40% of healthcare that is provided by the government, and so the rest is either by NGOs or private healthcare providers, and so that’s what they do for a living and we didn’t want to take away from their business by offering daytime service.
MotoMeds isn’t free, but it’s definitely subsidized, so we didn’t want people to delay seeking care for clinical reasons, but also we didn’t want people to not frequent their regular providers that cost money to instead use MotoMeds at night for free. So we don’t compete with daytime providers and I think for that reason, the daytime providers were happy to put up signs for us or to hand out flyers and to advertise with us.
Jason: That’s a really interesting balance that you are meeting there.
So for anyone who has paid attention to the news over the past couple years, Haiti has experienced its fair share of disruption in the day to day life, both politically, socially, and in terms of security.
One of the things that’s amazed me over the years about MotoMeds is that you’ve never stopped providing services. I’m wondering if you could talk a little bit about that, both about the challenges that you’ve faced and how you’ve dealt with them. Because, you know, we’re reading in the newspapers that after that abduction of the seventeen missionaries I think it was, that all the NGOs closed up shop, and understandably so, they packed up and left Haiti for fear of safety. But MotoMeds continues to operate, how has that been possible?
Molly: I’ve got two responses to that. First is when you talk about like a lot of NGOs packing up and leaving Haiti, that’s true, but we are almost entirely run by Haitians. So it’s not a problem for us if there are no foreigners on the ground in Haiti to help run the program.
I would say the one thing that our team struggles with a little bit is troubleshooting technology problems, so when the internet’s not working well or like a router or a speaker or a phone goes down, sometimes that can be hard for them to fix on their own.
But in terms of staffing and management of the staff and in general employee conduct, everything is run by our local team and they do a great job of that.
In terms of how we are able to operate amongst the political and social problems in Haiti, when we launched MotoMeds, that first like two months was during a period of protest where there were lots of roadblocks along the roads and burning tires and things. Sometimes those were manned by people with guns, not wanting society to function normally because they wanted to make a point to the government that they were unhappy with the way things were going. But what’s interesting is that like that all stopped when it got dark. At nighttime, the fires and things went out and the people went home. So the roads were open at night.
At first we were a little hesitant because we weren’t sure if that was dangerous or not. But once we realized that there was no one out then it felt fine to continue operating and doing nurse visits and deliveries at nighttime.
Now I do have to say that this current month has been a little bit difficult. What’s happening now is there’s like a gang that’s blocking the fuel terminal. They are blocking the delivery trucks from accessing fuel at the terminal to distribute throughout the country. So the cell phone towers that all run on diesel are running out of gas, which means some of the cell towers are going out. Since people need to have cell service to contact our call center, that causes problems. We have backup power at the call center but they don’t necessarily have that at their homes. So if this doesn’t clear up and those towers can’t get diesel then things could get really difficult.
Jason: You’d hope that the gangs that are blocking the terminals need cell tower to communicate with each other as well, so maybe they can carve out some exceptions. But I would think the local telecom providers are probably engaged in those conversations, who knows, but those are certainly big challenges that you’re dealing with.
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Now another thing that happened was the earthquake in 2021 near Les Cayes
When you launched that satellite program, what was the need that you recognized that caused you to want to launch a satellite program? Because it took you a fair amount of time to get set up in Gressier, but I was paying attention, and you were able to launch the satellite program very quickly.
Molly: Yes, so the need we saw was right after that earthquake, you’re correct, there was a lot of emergency responders and field hospitals and folks ready to respond to trauma. All things you’d expect with an earthquake, and they were only intended to be in the area for a short period of time, maybe two months.
So we went out there and did, let’s call it a superficial needs assessment. I wasn’t totally sure there was a place for us, but we realized a lot of the healthcare infrastructure was damaged. Things were not collapsed but they weren’t safe to be occupied for the time being. So there was definitely diminishment of healthcare access, especially the basic healthcare access because these are your general clinics that were closed down due to damage.
That meant to us that there was a need for MotoMeds at the time, an increased need in fact. So it happened quick, we had already developed the standard operating procedures and clinical guidelines and dispatch networks. So it was really a matter of recruiting and training employees, which we did same as before through trusted contacts.
In the end we did training one week, we launched the next week, kind of a supervised launch, did that for about two weeks and then they were ready to operate on their own.
Jason: What kind of numbers were you seeing in the new location compared to Gressier?
Molly: So Les Cayes is the third biggest city in Haiti, so we had to delineate a delivery zone when we decided to launch there, because we couldn’t send the motorcycle drivers an hour or more away where they are less familiar with the areas.
So we sectioned off the more urban areas of Les Cayes, which had a population around 80,000. We were getting an average of maybe three calls a night versus the one a night average in Gressier.
We did have a bit of a problem responding to some of the camps that had been set up for survivors who had lost their homes. What would happen is someone would call the service, like either a nurse or a driver would show up with medications, and because it’s a densely packed area, our driver showing up would mean everyone there started to want to use the service and we just didn’t have capacity for that.
So that didn’t work so well, and those camps were probably not the right target population for how we were able to operate.
Jason: Right, that makes sense. So you’ve not got these two programs running, has the government taken any notice of what you’re doing?
Molly: I would say there’s people within the government who have noticed. Because we’re operating within the umbrella of research, we have our research studies approved by the National Bioethics Committee, which works with the Ministry of Population and Health. So they are aware of our work and support our work.
We also have a partnership with the State College of Medicine. So the Dean of the College of Medicine and others there support our work and have put us in contact with Haitian physicians who are co-investigators in Haiti.
Then locally in Gressier, the government clinics are aware of our work. We’ve advertised with them, but I wouldn’t say they’re in a position to integrate MotoMeds into their services at the moment, which would long-term be great if they could.
Jason: So what’s the plan for MotoMeds moving forward, what the future looks like or what are the aspirations that you’re going for?
Molly: We’ve spent five years building MotoMeds and I guess the immediate goal is to create a system that could be handed off to other organizations or governments to implement.
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One of the biggest steps to getting there is to digitize our clinical guidelines. So our clinical decision support right now is all on paper. It’s just a lot to learn and I think if it was digitized it would be easier to follow as well as easier to transfer to new locations, new providers, new organizations.
Then the second thing is to try to see how exportable MotoMeds is, or the MotoMeds model is, to other settings. For instance, right now we are about to launch MotoMeds in Ghana with the National Ambulance Service, in partnership with them. We hope to see how a different population responds, and it’ll be interesting because they have different issues, like malaria for example, which we don’t have in Haiti.
Jason: Fascinating. Well, I really love what you guys are doing. You and Dr. Eric Nelson have been at this for so long and it’s really showing impact which is great. Is there anything that you’d like to share that I haven’t hit on or that I’ve left out? And lessons learned or advice for other groups that are looking to start community response programs like you are doing?
Molly: I think involving the community is important. There’s no way we would’ve been able to build MotoMeds without the local drivers or the fact that our nurses are part of the community. This just wouldn’t have happened without that.
Jason: And you’ve been in Haiti for quite awhile, right? How long have you been there?
Molly: 11 years now.
Jason: That’s fantastic, really great. Well thank you so much, Molly. Really appreciate it, always a pleasure to catch up and I appreciate your time and look forward to getting updates from you and following MotoMeds journey in Ghana now too.
Molly: Always a pleasure, enjoy the rest of your day!
To learn more about MotoMeds, visit their website here.
To get in touch with Molly directly, email [email protected]
