Across the globe, life at the last mile is similar. Located far from urban centers, last mile communities are characterized by poverty, lack of access to basic services, insufficient infrastructure, and limited economic opportunity.
Health care at the last mile is often inadequate and inaccessible. Good health is an essential component of economic productivity, and provision of basic health care is imperative for support of productive communities. Deficient transportation infrastructure means that medical services and commodities readily available in urban health centers only reach rural health centers on a sporadic and unreliable schedule. Insufficient communication and technology systems limit vital communication between doctors and patients and prevent collection and recording of essential operations data needed to make informed rural health policy decisions.
Read on to learn more about last mile communities in different regions and to hear tales from the last mile.
Africa
Sub-Saharan Africa has 11 percent of the world’s population, bears 24 percent of the global burden of disease and has only 3 percent of the world’s total numbers of health workers according to the WHO. Sizeable rural populations, low levels of economic development, and high rates of HIV/AIDS infection exacerbate the challenges of providing rural health care in Africa.
Tackling the Challenge of Improving Health in Rural Malawi - meet Maxwell, a Health Surveillance Assistant »A Day in the Life of a Rural Medical Assistant and Nurse - Anderson and Egrina »
Challenges of Motherhood in Rural Malawi - Agnes, Ellen, and Joyce »
Asia
Asia has experienced rapid economic development over the past few decades. However, poverty remains a significant problem, mostly a rural problem. According to the Asian Development Bank, many governments in Asia spend less than $10 per person per year on health care, and high levels of out-of-pocket expenditures have pushed millions of people below the poverty line. Globally, only Sub-Saharan Africa has lower health indicators than South Asia, but South Asia’s indicators for malnutrition and births attended by skilled health staff are the worst in the world. Infectious diseases are the major health challenge in Asia, but emerging diseases such as HIV/AIDS as well as preventable diseases such as diabetes and cancers are growing in prevalence as well.
Latin America and the Caribbean
Access to health care services has increased dramatically in Latin America and the Caribbean over the past decades. However, the most vulnerable populations such as indigenous peoples, low income groups, and rural populations still suffer from lack of access to public health services. Latin America is faced with acute socioeconomic inequality, and at least 125 million residents do not have access to health services.
In rural Malawi, Health Surveillance Assistants (HSA) are the first line of defense against poor health associated with rural poverty. As an HSA, Maxwell is responsible for providing basic health services to families in four villages. He delivers immunizations, teaches the importance of sanitation and hygiene, and encourages sick patients to go to the health center.
Life is hard for the families Maxwell works with. Most people are subsistence farmers with six to eight children and hunger is common during parts of the year. Women have to walk as much as two miles to get water, life expectancy is 42, the malaria rate for children under five is over 100%, and 43% of the population has no sanitation facilities.
Maxwell’s efforts are generally appreciated by the community, which calls him the “village doctor.” Unfortunately, some people, including Maxwell himself, do not always follow his advice. For example, though Maxwell teaches the importance of sleeping under a mosquito net, his family’s net was patched so much it fell apart and his son caught malaria. A persistent lack of resources and opportunities prevents Maxwell and the families he serves from adopting the simple measures necessary to ensure good health.
Anderson and Egrina are the health professionals at the Kwitanda Health Center who serve a population of more than 21,000. Community needs are great and poverty and the rural environment contribute to many health issues. Patients have to walk or bicycle up to 19 kilometers for medical attention at the health center. The health center lacks running water and electricity and can provide only the most basic services to patients with illnesses that include malaria, meningitis, dysentery, and infections, among others.
When Anderson arrives at 7:30 AM to start his day, the lines are already very long. Anderson sees between 300 and 500 patients each day and must diagnose the patients, fill their prescriptions, and refer people to the District hospital when needed. In order to attend to all the patients, Anderson works without taking breaks, allowing no more than a few minutes to talk with and evaluate each patient.
Egrina sees patients who come to the health center for prenatal care, family planning, and HIV/AIDs counseling and testing. She advises women to go to the District hospital for their delivery but knows that many women will not be able to travel to the hospital in time.
Both Egrina and Anderson are making sacrifices to live in rural Malawi and serve the Malawi people. They remain far from their families and the amenities of city life so they can provide care to rural people in desperate need.
Agnes, Ellen, and Joyce are from three rural villages in Malawi, where motherhood is hard. Ellen recently gave birth to her first child. When she went into labor, she began walking the 13 kilometers to the health center where they could transport her to the nearest hospital. 
However, she did not make it and instead gave birth on the side of the walking path. For her two children, Joyce used a Traditional Birth Attendant (TBA). TBA’s are discouraged by the government because they do not have the training to prevent mother to child HIV transmission. When asked why they did not hire a bicycle taxi to take them to the hospital, each woman said “I don’t have the money.”
Each woman wakes before sunrise to collect water, gather firewood, tend the fields and care for her children. Collecting water alone can take 3-4 hours because each woman must walk between two and three kilometers each way for a bucket of water. The women survive on Nsima, the staple grain of Malawi that they grow themselves. Food is plentiful during harvest, but when stocks run low later in the year, their families may have nothing to eat. 
Malaria affects nearly every family in the women’s villages. They have no money to purchase a mosquito net and as a consequence, each woman reported that she had suffered from malaria within the last two months and their children suffered from the disease frequently as well.
