Drones to the Rescue: A literary study of Unmanned Aerial Systems within healthcare

THESIS

Department of Social and Economic Geography

Drones to the Rescue

A literary study of Unmanned Aerial Systems within healthcare

Lisbet Ersson and Emma Olsson

Course: 2KU039: Thesis STS - Social and Economic Geography, 15 hp Semester: Spring 2020

Supervisor: John Östh

Course coordinator: Cecilia Bygdell

ABSTRACT

Ersson, L., Olsson, E. Drones to the rescue. ​Uppsatser Kulturgeografiska institutionen​, Uppsala university.

This thesis addresses the subject of drone deliveries within healthcare to examine whether unmanned aerial vehicles can contribute with increased accessibility to medical supply. An overview of the advancements made in the field since its introduction in health care, is first presented in the report. Through a literary review on the subject, dimensions have been identified as significant for determining the possibly increased accessibility to medical equipment that the unmanned aerial system provides, and thus the utility of the system. This thesis further evaluates the system out of an accessibility perspective, which aims to meet theoretical criteria established by previous researchers in the accessibility field, and thereby adopt a holistic approach to the subject. It is concluded that the dimensions are dependent on characteristics of the geographical location and should be considered when discussing drones in medicine. However, knowledge and evaluations are lacking from regions that have implemented such a system, which contributes to uncertainties for how drone deliveries work in practice.

Keywords: Drone deliveries, Unmanned Aerial Vehicles, Unmanned Aerial System, UAV, UAS, health care, medical drone deliveries.

Supervisor: John Östh.

TABLE OF CONTENT

ACRONYMS 3

1. INTRODUCTION 4

1.1 Purpose 5

1.2 Research questions 5

1.3 Delimitation 5

1.4 Previous research 5

2. BACKGROUND 8

2.1 Unmanned Aircraft Vehicles 8

2.2 Drones in Medicine 9

3. THEORY 13

3.1 Accessibility 13

4. METHOD 15

4.1 Method Choice 15

4.2 The Literary Review 16

4.3 Interview 16

5. RESULTS 18

5.1 Accessibility 18

6. DISCUSSION 24

6.1 Dimensions of accessibility 24

7. CONCLUSIONS 28

7.1 Further studies 28

REFERENCES 30

Interview 31

Websites 31

APPENDIX 1 34

APPENDIX 2 35

ACRONYMS

UAV Unmanned Aerial Vehicle

UAS Unmanned Aerial System

AED Automated External Defibrillator

EMS Emergency Medical Services

MSF Médecins Sans Frontières

1. INTRODUCTION

Unmanned aerial vehicles (UAVs), commonly known as drones, were originally created for military operations but have in recent years undergone a transition into civil use ​(Ling and Draghic, 2019 ​)​. As mobility is considered a major obstacle to good health care in remote areas, especially in developing regions, UAVs are considered a promising solution to achieve the global goal of universal health care for all (McCall, 2019). Laksham (2019) has identified four possible categories of drone use within healthcare: transport of blood, medicine and biologicals;

medical emergencies and disaster relief; organ transplantation; and surveillance in difficult areas.

Africa is leapfrogging the progress of unmanned aerial systems (UASs) in healthcare. Rwanda leads the way as the first country in the world to implement a nation wide UAS, and advancements are made towards a similar system in Ghana ​(​Simmons, 2016​; ​Asiedu, 2019)​.

Some research has been presented on the subject of UAVs in healthcare that identifies both potential benefits and restrictions on the system’s effectiveness. However, there are big gaps in research regarding the already implemented systems which contributes to uncertainties in the discussion about the potential of the technology. Before making evaluations of current systems, however, it is relevant and interesting to review current research for potential obstacles, and address the role of the context in which the technology is being implemented to add a social perspective to the discourse. This will hopefully contribute to an understanding of which aspects should be addressed in the evaluations of the current systems and also what perspectives that need to be included in the examination of the system to gain a holistic understanding for the system in society.

The drone technology has been tested in various projects throughout the world. Previous literary reviews have focused on the general potential of the technology, and concluded that there is great potential in the UAV technology to increase access to medical aid ​(Bhatt et al., 2018;

Rosser et al., 2018) ​. The researchers also identified obstacles for implementing such a system, which included safety and regulations. ​The environments where the UAVs are operating in, differ around the globe and therefore the prerequisites will depend on the geographical location and its characteristics. Different types of UAVs can be seen in Appendix 1, e.g. fixed-wing, hoverable and hybrid drones. They have different range, payload and flexibility, and are dependent on various kinds of distribution hubs and technical assistance. Previous work has quantitatively examined general difficulties for drones in medicine, but an evaluation of the system where the social perspective is more integrated has not yet been presented. This thesis will contribute with new perspectives by including the geographical context of the technology.

The hope is to further analyze what role the social environment plays, and through that

contribute to a more holistic understanding of drone technology in medicine. The thesis will

examine whether the potential in drone technology is universal or differ depending on

geographical context and to what extent, as well as what implications that may arise for future

development in the area.

Since the potential of drones in healthcare is related to increased access to medical equipment, this thesis will evaluate its potential and obstacles when implemented into healthcare out of an accessibility perspective. Dimensions that have been identified through a geographical lens as crucial when determining whether the UAS will increase accessibility to medical supply in different contexts, will be presented. By addressing the subject from an accessibility perspective with a holistic approach, this thesis aims to contribute with perspectives lacking in current research on UASs in medical use.

1.1 Purpose

The purpose of this paper is, through a literary review, examine if and how the implementation of an unmanned aerial system can contribute to further accessibility to medical supplies, and whether the potential of the system differs depending on the geographical context.

1.2 Research questions

To reach the aim of the thesis, the following questions will be answered:

- What dimensions can be identified from current research, as significant for how much the accessibility to medical equipment changes when implementing an UAS?

- Are these dimensions universal or dependent on the geographical context?

1.3 Delimitation

UAS in the medical field can potentially be used for several purposes, in this study we will focus on the transportation of different types of medical supply, which constitutes three of the four identified categories by Laksham (2019). That is the transportation of blood, vaccines and biologicals; organ transportation; disaster relief and emergency settings will be of focus in the analysis of the report, while surveillance will not. Disaster and emergency settings will only be addressed in the way that materials, such as defibrillators, can be transported. It will not take food and water into account. The geographical locations evaluated in the report have been selected by relevance. Which resulted in locations where the technology has been used or received attention in research or in media.

1.4 Previous research

There are few implemented UASs to date in the world, which is reflected in the lack of

evaluations of the current systems. Since the introduction of drone use in civil application is

quite new, the need to identify possibilities and limitations for the technology to be integrated in

society becomes more apparent. Two literary reviews on the subject will be presented below,

both papers focus on the general advantages and disadvantages of implementing drones in

medicine, but take less account of the differences that different types of geographical context

constitutes. Both states examples of how literary reviews can be used, especially on subjects that are relatively new.

Systematic literary review on drones in medical application

In the article ​Surgical and Medical Applications of Drones: A Comprehensive Review ​(Rosser et al., 2018) the authors have, ​through a systematic literature review, sampled the scientific work on drones used for medical applications. The aim of the study was to present current and possible future applications for drones in the medical field. The literary review was completed on Elton B. Stephens Company Discovery Service, searching for subject terms as ​drones, UAV, unmanned aerial vehicles, UAS ​and ​unmanned aerial systems​. The literature selected for the article was based on relevance for the purpose of the study. The sources were arranged in a chronological schedule, relevant title names were sampled and then selected if they were considered applicable for the study. The material chosen for the study included academic journals, trade publications, electronic resources, news articles and magazines. The criteria set for the material was to be published in English and published at latest in April 2017. Besides the academic literature, nonacademic was used as well in an effort to capture recent information on drone technology.

After selecting the relevant material, the sources were categorized into subcategories depending on the type of application within the civilian sector. One category was ​medicine ​which was the focus in the review. An additional search was also performed to identify medical sources in case some was not found in the initial search. The subcategory ​medicine was then divided into three new categories consisting of ​Public Health and Medical Surveillance, Telemedicine ​and ​Drones as Medical Transport System. ​The result of the literary review consisted of the advancement made in each category ​. ​The paper presented drones as a potential improvement in all of the categories mentioned. ​Conclusions were that advancements in the medical field have been slower than other applicable fields of drone technology for civilian use. The authors meant that the research efforts need to be emphasized onto ​airspace integration, safety, response time, participation expansion, ​and privacy best practices​. Furthermore, Rosser el al. (2018) concluded that some efforts have already been made to speed up the process but more work is needed as the final goal is to enhance medical delivery over the world.

Comprehensive review of drones in telemedicine

In the paper ​Applications of Unmanned Aerial Vehicles (Drones) in Telemedicine Bhatt et al.

(2018) conducted a comprehensive literature review, in which they discuss the feasibility of

current UAV projects as well as limitations that needs to be addressed before the technique can

integrated on a larger scale in telemedicine. To search for relevant literature the databases

PubMed and Google Scholar were used, searching for terms such as ​unmanned aerial vehicles,

UAVs, and ​drones​. The search results were limited to English language studies, clinical trials and

review articles that addressed the search terms and clinical medicine were prioritised. The

sampled material was then divided into three groups; ​Prehospital Emergency Care, Expediting

Laboratory Diagnostic Testing ​and Surveillance. Current progress and projects in each of the subcategories were presented to identify the advantages and potential of the technology, as well as the limitations that need to be addressed for the technology to be integrated in medical use.

The authors believe that UAVs have a promising future in the medical field. Bhatt et al. (2018)

claims that if drones are used as a surveillance tool or to deliver important medical products, the

technique can increase the accessibility of care, especially in rural areas. However, before

integrating the technology there are limitations to consider such as ​FAA regulations​, ​privacy of

patient information ​, ​safety, computing errors, ​and ​costs​. Furthermore, the authors call for a

discussion focusing on examining the ethical, legal, environmental, and clinical issues connected

to the technology in telemedicine.

2. BACKGROUND

In this section a brief introduction to the technical functionality of drones is presented, this is to provide an understanding for the technical possibilities and obstacles for the drones. This is followed by an introduction to drone use in health care operations worldwide. This will contribute to an understanding of how the technology this far has been used globally in medicine.

2.1 Unmanned Aircraft Vehicles

The characteristics of the UAV directly affects the functionality of it and thereby determines what type of UAS that is suitable for a particular case. In the White Paper ​(Chris Wright et al., 2018) ​ some characteristics are presented:

- Vertical takeoff and landing capability ​: Fixed-wing UASs set requirements of landing capabilities, they typically require large open areas and starting/landing towers to enable landing and take off. Multi-rotor or multi-copter, which is hoverable UAVs, typically has vertical starting and landing capabilities, that makes the take-off and landing process easier. For two way deliveries landing at health facilities is necessary, which usually requires a hoverable drone if there are no landing capabilities out at the hospitals.

- Payload: The maximum cargo an UAV can carry depends on the drone type. How much energy it consumes sets requirements on battery capacity, which in turn may affect the weight of the drone.

- Range: The range that the UAV can fly is also dependent on the UAV type. The hovering UAV consumes greater energy. It tends to carry lighter cargo and the range is smaller than the fixed-wing.

- Costs: ​Costs are dependent on many factors, such as cost of each individual airframe, batteries/engines and other componentes, operator costs ​, insurance, how long individual components can last, maintenance requir ​ements, and cost of other base infrastructure.

The costs include fixed costs (which are not dependent on the number of flights) and variable (incurred per flight).

The characteristics of the UAV depend on which company provides them and the costs are

linked to the capabilities of the drone. Cost characteristics can vary across different UASs.

2.2 Drones in Medicine

Advancements in drone deliveries look different over the world. To gain insight into what has been achieved within the field, some examples of drone use are presented in the following sections.

Rwanda - the first country to implement a nation wide UAS

The first national scale healthcare UAS for delivering blood was implemented in Rwanda in 2016 ​(McCall, 2019)​. Zipline, a California-based company specialised in autonomous drone logistics and delivery systems, is providing the drone delivery system in Rwanda (McCall, 2019). In January 2019 the company had 19 of Rwanda's total 48 district hospitals connected to their service ​(Human Resources for Health Program, n.d.; McCall, 2019)​. Rwanda has undergone a transformation since the genocide in 1994. The economy has improved drastically and big steps have been made in health care ​(Binagwaho et al., 2014)​. The technical field has also advanced and the country is now covered to 95% with 4G internet ​(Tashobya, 2018)​. The ambitions are presented in the Rwandan Vision 2020 that highlights the importance of technological infrastructure in the goal of becoming a middle income country ​(Ministry of Finance and Economic Planning, 2000) ​)​. Rebuilding the health system was an important goal post genocide, and early approaches to rebuild the system were developed by Rwandans which was oriented towards access and accountability ​(Binagwaho et al., 2014)​. Known as ​the land of a thousand hills, ​Rwanda has a mountainous terrain. Even though efforts have been made to construct hospitals and health facilities, Ackerman and Koziol (2019) mean that the roads leading to them are still deficient. The roads are a real problem when transporting blood, due to the blood’s short shelf life and strict storage requirements. (Ackerman and Koziol, 2019).

Zipline’s technology comprises an autonomous fixed-wing style drone with a top speed of 128

km/h and a round trip range of 160 km, carrying up to 75 kg of cargo ​(McCall, 2019)​. An

illustration of Zipline’s drone type and system can be seen in Figure 2. The fixed wing drones

can carry relatively heavy loads, have a wider range and resists bad weather better than the

corresponding rotorcraft drone ​(Ackerman and Koziol, 2019; W. Rosen, 2017)​.

Figure 2. The drone is modular and consists of [1] the lightweight foam chassis, [2] the wings, [3] the battery unit. When scanning QR-codes [4] an automatic preflight test on the drone’s system is initiated.

The drone has two motors [5] and redundant ailerons [6] on the wings which helps the drone to maintain flight control. The drone’s cargo compartment [7] contains the package of blood until it is parachuted down to the delivery site. (Ackerman and Koziol, 2019)

The current service radius from a Rwandan distribution centre is 75 km ​(McCall, 2019)​. The two distribution centers are located in Muhanga and Kayonza, located on either side of Kigali (the capital of Rwanda) and can be seen in figure 3 ​(Ackerman and Koziol, 2019)​.

Figure 3. Distribution centers for Zipline’s drone service in Rwanda are marked in the picture, which

also shows its distribution routes. Illustration: Zipline, Source: ​ (Ackerman and Koziol, 2019) ​ ^.

Rwanda has an extremely unmet medical need, particularly regarding emergency blood supply, which motivated the Government to partner up with Zipline (McCall, 2019). The economics concerning the system is more uncertain than the technology. Zipline still receives subsidies from the Rwandan government for the hospitals to afford the service and the company still discloses the operational costs and how much they are paid by the government per delivery.

(Ackerman and Koziol, 2019) Zipline has admitted that the drone delivery system currently is more expensive than the standard system by road but claims that the system cut costs in emergencies ​(W. Rosen, 2017)​. As the company seeks to expand its business to other African countries as well as other parts of the world, costs and sustainability matters have become prominent on the agenda. By the end of 2018, the government in Ghana signed a four-year contract to deliver blood and other medical supplies by drone, worth approximately US 12.5 million dollars. The plan for Ghana is to have four fulfillment centers that make 100 to 150 deliveries per day. The Ghanaian government estimates the costs of each delivery to end up around 17 dollars. Both the minority party in the country’s parliament and the Ghana Health Service have criticized the contract for being too expensive, arguing to place the investments in other projects. ​(Ackerman and Koziol, 2019)

To overcome poor road infrastructure in Malawi and Papua New Guinea

Similar to other parts of Africa, HIV is a considerable problem that many people are suffering from in Malawi. Since the disease can be transmitted during pregnancy and breastfeeding, it is important to be able to test for it quickly as drug treatment can reduce the risk of transmission (Friedmann, 2019). The currently used transport system for test equipment is by motorbike. The road infrastructure is often poorly-maintained which result in high transport costs and delays in remote areas. These issues led up to a test program that Reuters reported on in 2016, in which drones are used to improve access to HIV testing for infants. UNICEF and the drone company Matternet believed that deliveries could be made more efficiently by air. Drones were seen as an alternative to increase the accessibility to HIV tests, and further reduce transportation costs. The Government of Malawi together with UNICEF launched an air corridor for UAV tests in June 2017 to evaluate the potential of the UAV technology for humanitarian use. (Reuters, 2016)

Similar to the Malawian case, Papua New Guinea’s Gulf Province serves as another example

where passability plays a big role. The mountainous landscape and dense terrain has meant low

road density which constitutes transportation difficulties. During large parts of the year the

weather conditions also complicates the passability in the region, e.g. hard winds complicates

travelling. Médecins Sans Frontières (2015) expressed that transportation and accessibility is a

problem for the tuberculosis programme in 2014. Both the assessment and treatment of patients

is complicated by the poor transportation. Of the total population, 85% lives in remote areas and

many residents live in diffuse communities spread over a few miles. Ensuring that the population

receives the necessary treatment and follow-up care is a challenge that an UAS could help

simplify. UAVs were trialled 2014, and the view of how to deliver, administrate and access patients has changed since. ​(MSF, 2015)

These two examples provide similar backstories to where UAVs have been considered a solution in cases where both regions suffered from poor infrastructure, a population with high rates of disease spreading and people living in remote areas.

Summary of other examples

In Vanuatu, located in the Pacific Ocean, a child received the first commercially delivered vaccine by drone in the world in December 2018 (Sidhu, 2018). Vanuatu’s Government has contracted the Australian drone company Swoop Aero, funded by UNICEF and the Australian Government, to complete a trial program for flying UAVs to the remote islands that Vanuatu consists of (Dziedzic, 2019). Matternet is a Silicon Valley based company which aims to provide poor regions with unusable roads with a network of UAV ​s (B​urrows, 2015). ​In August 2014, Matternet started an UAV program connecting remote Buthanese health-care clinics in the Himalayas. The program resulted in test results and medical supplies being transported in a matter of hours instead of days ​(Burrows, 2015). The same year, Matternet also provided Médecins Sans Frontières (MSF) with UAVs to help them with round-trip transporting of samples from patients in remote health centers to Kerema general hospital for testing and then transporting results as well as treatments back to the facilities.

In other parts of the world drone deliveries have gained attention as a solution of increasing

accessibility to medical equipment but rather in emergency settings. For example, a test project is

to be launched in June this year for testing delivering defibrillators for cardiac attack patients as

a supplement to regular emergency service in Sweden ​(Sveriges Radio - P4 Göteborg, 2020)​. In

Baltimore, Maryland, the first organ drone delivery was completed in 2019 and successfully

transplanted into a person. Time is essential for organ transplantation since the faster the organ is

transplanted into the patient, the higher the chance of survival. Organ transplantation requires

transporting the organ from the donor to the patient which can entail crossing a town or an entire

country. The usual transportation by motorcycle, helicopter and airplane have significant

limitations including high costs and timeinefficiancy. (Freeman, 2019)

3. THEORY

The purpose behind the UAS is to provide health care for all, in accordance with the Global Sustainable Goal number three - ensuring healthy lives and promoting well-being at all ages (United Nations, n.d.). By making it possible to transport medical equipment to places previously inaccessible or too remote for regular transport, UAVs can provide a faster transport method which can save lives. Hence the UAS provides a possibility of improving the accessibility to medical equipment in terms of both time and range. The drone technology is becoming more prominent as an option of overcoming difficulties with delivering medical products or aid, but its functionality and durability in society has not yet been examined. The system needs to be considered in regard to its utility but also its ability to be integrated in society, which contributes to the system’s resilience and sustainability. When deciding upon what utility the system contributes with in terms of accessibility, the theory on accessibility is more comprehensive than merely measuring efficiency in terms of time and costs. Geurs and Wee (2004) means that policy makers and researchers usually fail to fulfill all theoretical criteria when interpreting and operationalising the term accessibility. By using theories on accessibility, the potential of the UAS will be examined in order to understand what possibilities it provides and what obstacles to address in order for the system to be efficiently utilized.

3.1 Accessibility

Accessibility is determined by the distribution of potential destinations, the ease of reaching each destination, and the magnitude, quality, and character of the activities found there (Handy and Niemeier, 1997). Accessibility is widely discussed in literature and Geurs and Wee (2004) means that several transport policy options, including infrastructure building, aim to improve accessibility. Previous research in the medical drone delivery-field has focused on the quantitative measures of accessibility (Haidari et al., 2016; Claesson, 2013; ​Chris Wright et al., 2018 ​). Although these types of quantitative accessibility measures provide some indication of the utility and effectiveness of the drone delivery system, Geurs and Wee (2004) mean that it does not satisfy most of the theoretical criteria, since it tends to neglect land-use and individual components. According to Handy and Niemeier (1997), however, simple quantitative measures may be combined with qualitative evaluations to provide a more comprehensive understanding of the accessibility of a community than is possible with more complex quantitative measures alone. A broad definition of accessibility refers, not only to physical access to goods and services, but also the transport system itself in terms of its availability (including routing and scheduling), affordability, reliability and safety, as well as access to timetable information etc (Lucas et al., 2016) ​.

Geurs and Wee (2004) focuses on passenger transportation in their paper, in this thesis the

same components they identified as important when assessing accessibility for passengers, will

be applied on transportation of goods. In their article, Geurs and Wee mean that four components can be identified from the different definitions and practical measures of accessibility that are theoretically important in measuring accessibility. These four types of components are land-use, transportation, temporal and individual. The land-use component reflects the land-use system, which consists of the amount, quality and spatial distribution opportunities supplied at each destination. The transportation component describes the transport, which includes the amount of time, costs and effort of the system. The temporal component reflects the temporal constraints, i.e. the availability of opportunities at different times of the day. The individual component reflects the needs, abilities and opportunities of individuals. The characteristics of the individual may strongly influence the total aggregated accessibility.

Another aspect related to the individual component is the subject of social exclusion within transportation. The concept entails, as described by Lucas ​(2012)​, the interactions between the causal factors which are related to the individual (age, disability, gender) with failure of local services, such as a lack of available or inadequate public transport services and factors which lie with the national and/or global economy (restructuring of the labour market, cultural influences, migration and legislative frameworks). An important note to the subject of social exclusion in transportation, noted by Lucas, which is highly relevant for this thesis, is that the more mobile society becomes the more certain it is that groups are excluded from and/or disproportionately impacted by the system. Which indicates that an increased accessibility is most likely unequally distributed throughout society and an understanding for this distribution is important for the evaluation of the system.

The components presented in this section will be used to structure the analysis of the

material gathered in this report. The subject of social exclusion will also be used to contribute

with relevant aspects that should be considered when evaluating the UAS to ensure the

accessibility is increased ​for all.

4. METHOD

Previous research has focused on general possibilities and limitations of the technology. In this thesis, a literary review was performed to analyze how research so far has managed to include differences in geographical locations and what implications the geographical dimension adds to the possibilities and limitations for the drone technology to increase access to medical equipment. By adding a new perspective to the subject, this thesis contributes to the discussion on the subject of drones in medicine which has also been demanded by previous researchers Rosser et al ​. ​(2018)​ and Bhatt et al. ​(2018)​.

4.1 Method Choice

To answer the research questions, material was enquired through a narrative literary review. The material was gathered through convenience sampling, which according to Bryman ​ (2018, p. 243) is when the researcher chooses material that is available. As stated by Bryman ​ (2018, p. 245) ​ , snowball sampling is a subcategory of convenience sampling and was utilized to find relevant sources for this thesis. Snowball sampling is a type of chain sampling which means that a first reference is used to locate other sources. In practice, during the collection of material for this thesis, it means that the reference lists were screened to locate new relevant sources. Previous research by ​Rosser et al​. ​ (2018) Bhatt et al. ​ (2018) has been conducted through systematic literature reviews. This method circumvents disadvantages of narrative literary reviews, which according to ​ Eriksson Barajas et al. ​ (2013, pp. 26–27) ​ , in which the researcher risks becoming biased, since the researcher chooses the material itself. Systematic literature reviews are also replicable since the method is systematic and hence the author can account for how the searches were performed. Limitations with systematic literature reviews is the need of a sufficient amount of qualitative studies on the field to constitute a basis of a paper, and also some elements of the method which require time and resources - such as a panel of methodological and theoretical experts ​ (Bryman, 2018, p. 145; Eriksson Barajas et al., 2013) ​ .

Narrative literary review was chosen as a method in this thesis due to time constraints and

convenience. The purpose of a narrative literary review is to give a somewhat comprehensive

assessment of the subject and critical interpretation of the literature ​ (Bryman, 2018, p. 131) ​ . The

method is relatively convenient but has weaknesses such as them being random and difficult to

replicate and not being comprehensive enough ​ (ibid) ​ . The purpose of this thesis is to examine the

potential the drone technology has to increase accessibility to medical equipment and add a

geographical dimension to the subject, the narrative literary study was then considered sufficient

for the aim of the study.

4.2 Literature Review

When sampling material for the literature review, both academic and nonacademic sources were considered. Since the subject of drones in medicine is relatively new, more papers are added on the subject continuously. Therefore non peer-reviewed material was included in the search to attain the most recent information. When searching for UAV/drone related news and academic articles, key words such as ​UAV, unmanned aerial vehicles​, ​unmanned aerial systems, UAS, drone ​, ​health care ​and medicine were used to map out relevant information. Both English and Swedish material were considered and papers published up until March 2020 were included. The material was selected based on relevance to the topic. Both titles and abstracts were screened. To be considered relevant for the study, the papers had to be on the subject of drone transportation of medical goods. Quantitative as well as qualitative studies were desirable for the study to gain further insight to different types of studies. Databases used were Scopus, Google Scholar, Uppsala University Library’s database, and Wiley Online Library. The non peer reviewed material should not be considered as reliable as the peer reviewed, but was highly relevant for this thesis since it contributed with an understanding of the spread of the technology globally.

Many of the non peer reviewed sources were however retrieved from peer reviewed articles through snowball sampling which adds validity to the sources.

The material that fulfilled the criteria of relevance for the thesis were thoroughly read and examined to understand the already existing research in the field, and to understand which dimensions that are relevant to the subject of drones in medicine from an accessibility perspective. Whether the amount of sources is enough to provide sufficient support for a full evaluation of an UAS is unlikely. However, it should be considered sufficient to indicate the potential of the system, and also adequate to identify dimensions that could potentially be important for the system and its durability in society. This thesis aims to highlight factors identified from current literature, but also demand further research in the field to fully understand the utility of the system. The material of this report should therefore be considered sufficient for the purpose of it, as a first step of evaluating the system in a more holistic approach than has been conducted this far.

4.3 Interview

One interview was conducted for this thesis. The interview was used as an introduction to the

drone field rather than the basis of the thesis which explains the small sample. The information

gathered from the interview was mostly general knowledge about drones which was then

supported by the literature found and should be considered reliable. The interview was conducted

in October 2019 with Jan Björn. He is working at Flypulse, a Swedish based drone company, and

has previously been to Tanzania to perform tests of drone deliveries. His experiences from the

test flights as well as his knowledge of the drone field, such as technical aspects and

functionality of drones, were considered highly relevant for this thesis. The interview was

conducted in a semi-structured form following a predetermined interview guide. The questioning

in a semi-structured interview is based on Hay (s. 158), ordered but flexible. Follow-up questions

were based on the candidate’s answers where he was able to influence the topics discussed. The

interview was thereby to some extent shaped by the candidate's response. This method was

suitable since the interview was exploratory with the aim of obtaining new knowledge. Notes

from the interview can be found in Appendix 2.

5. RESULTS

This section will examine dimensions that have been identified as significant factors when determining the accessibility of the UAS. The evaluation of accessibility addresses the question of whether the UAS is beneficial to the alternative transportation method, i.e. road transportation.

5.1 Accessibility

Neal Sikka, an emergency medicine physician at George Washington University, explained that UAV research, to date, has pursued different agendas across various parts of the world due to local medical needs (McCall, 2019). Which means that depending on a region’s prerequisites and medical demand, different areas will be subjected to different types of UAV use. Through the literary review performed some dimensions have been identified as significant for determining the potential accessibility change. These are presented below.

Infrastructure

The improvements of accessibility to medical equipment when implementing an UAS depends on the condition of the alternative, already existing infrastructure. A region with well maintained road infrastructure, that reaches all regions in a country, has less incentive to look for an alternative solution for transportation compared to regions with poor road infrastructure. Haidari et al. (2016) has previously shown that road speed of traditional land vehicles was a major driver of cost savings from using UASs. The faster the traditional transportation method, the less time is gained by using an UAS. If assumed that well maintained roads lead to more passable roads and thus faster road speed, the research by Haidari et al. (2016) support the significance of infrastructure as a dimension which determines the utility of an UAS. Dr. Margaret Chan, the former Director-General of the World Health Organization has said: ​Just as mobile phones overcame the lack of landlines, the use of drones to deliver life-saving medical products can overcome the lack of road infrastructure seen in much of rural Africa ​(Chan, 2016). Such as the case of phones, mobiles offered a solution which did not require infrastructure and therefore landlines could be neglected. Similarly, Chan (2016) means that the UAS offer the same possibility for countries which do not have funds for large infrastructure investments as when mobile phones overcame the initial costs of landlines.

The connection between poor infrastructure, often in rural areas, and the possible

accessibility improvement that UASs can provide, is illustrated in cases where the technique has

been implemented and/or tested. The two countries to date with a national scale UAS, Rwanda

and Ghana, are both suffering from poor road infrastructure and drones were seen as a solution to

circumvent travelling by road (Ackerman and Koziol, 2019; Asiedu, 2019). The lack of

infrastructure is something that characterizes Africa and especially the Sub-Saharan region, since

road density has declined the last 20 years and being the only region in the world with a negative

progression ​according to the World Bank ​(van Leggelo-Padilla, 2017)​. The African

Development Bank wrote in their Economic Outlook Report 2018 that the insufficient stock of productive infrastructure in power, water, and transport services has been one of the key factors retarding industrialization in Africa (African Development Bank Group, 2018).

The increased access to medical supply in Rwanda and Ghana is related to the time saved, as drones provide a faster alternative than trucks or motorcycles. It takes minutes rather than hours, and since the lack of storage possibilities, on-demand solutions are favorable. Malawi and Papua New Guinea are examples of regions that have been subjected to drone delivery testing in which the lack, rather than low quality, of infrastructure was a significant factor for testing drone deliveries. Flying is the only transportation method accessible in these regions when weather conditions prevent transportation by sea and the lack of roads prevents the transportation of other vehicles. UASs is thus a solution that provides a transportation solution for regions with poor or inaccessible infrastructure, or areas that completely lack infrastructure.

Logistics Performance Index (LPI) is a tool used to measure the quality of trade and

transport-related infrastructure. The tool can be used to identify both opportunities and

challenges along the logistics supply chain for a country and the perspective it offers is both

domestic and international (The World Bank, n.d.). In figure 5 the LPI in different countries are

visualized in a world map. The United States, Canada, majority of Europe, China, South Africa

and Australia are performing well while the African continent in large parts has low scores in the

index. Drone delivery operations have gained interest globally but the goods category of interest

varies ​depending on the country. Countries focusing on deliveries of blood, vaccines and

biomaterial are to a large extent used in countries suffering from inferior infrastructure which is

seen in figure 5, e.g. Rwanda, Ghana and Vanuatu. While countries with relatively well

developed ​infrastructure, such as Sweden and the United States, are focusing on organ

transplantation and emergency aid, e.g. AED transport (Claesson et al., 2016). The access to

blood can possibly be increased by a more efficient blood supply chain, and the same for

vaccines, but organ transplantation and emergency aid provides additional difficulties as they

cannot be stored and thus are always on-demand goods. UASs were also found to have increased

the utility in rural settings compared to urban, according to Claesson et al. ​(2016)​, since regular

emergency services had longer response time in rural areas which increased the time saved by

drone delivery. This indicates that countries which can be considered to have good infrastructure,

such as Sweden that scored high in the LPI, still have use for UAVs but rather for emergency

transportation than goods shipping that belongs to a supply chain. Since all states are likely to

have at least some rural areas, which were identified to have prolonged EMS response time

according to Claesson et al (2016), thus drones provide a solution.

Figure 5. The Logistic Performance Index (LPI), a value of the quality of trade and transport-related infrastructure. Countries can score between 1 and 5 where 1 is low and 5 is high. In the figure dark color correlates to a high score and light color correlates to a low score ​ ^. ​ (The World Bank, n.d.)

Organ deliveries is another service where even quality infrastructure has difficulty performing as low transportation time as drone deliveries offer. Time is essential when transporting organs since a quick transplantation increases the chance of survival for the patient. The usual transportation by motorcycle, helicopter and airplane faces obstacles such as costly charters, slow commercial transportation, and small aircrafts with inconvenient schedules endangering the team, ​according to a surgeon in a transplantation team. He also stated that drone deliveries can cut time organ spends in transit by up to 70%. ​(Freeman, 2019) Even though the infrastructure is of good quality the emergency setting and long distances continues to constitute problems the regular transportation cannot efficiently overcome, but the drone can.

Furthermore, the type of UAV considered is depending on what kind of service the region demands. Fixed-wing drones have better performance in range and cargo capacity compared to its hoverable equivalent. In Rwanda, the fixed-wing drone is providing the region with blood, a big advantage is the range which contributes to cost efficiency compared to multirotor drones that need bigger batteries for the same range and cargo capacity. However, a study by Scalea et al. ​(2019) found fixed-wing drones to have more vibration, especially during landing and take-off, than the multirotor when transporting a sensitive organ, which could constitute an issue.

For defibrillator transportation Claesson et al. ​(2016) found that parachuting the AED was not an optimal landing solution since winddrift caused uncertainty about where the AED would land.

Latch-release from 3-4 meters or landing the drone were considered the best options, it increased

precision for delivery and reduced risk for hurting bystanders or damage the surrounding

environment. This implies multirotor drones as preferable for organ transportation and

emergency deliveries, since these drones are more flexible and precise in delivering, and are capable of landing which do not require a runway or a landing-installation.

Health care system

Another factor for determining to what degree an UAS would improve accessibility to healthcare, is the condition of the region’s health care system. An important factor for the utility of the UAS is, as identified by Write et al. ​(2018)​, the density of health facilities that can be accessed by the UAVs. Another factor that led to cost savings when using UAS according to Haidari et al. ​(2016) is how well equipped hospitals are with proper storage space as blood, vaccines and medicine often needs to be kept in certain environments within certain temperature intervals. One of the perks of a drone delivery system, highlighted by Björn (2019), is that similar to how an implementation of an UAS circumvents having to invest in infrastructure, the UAS provides an on-demand solution that does not require storage space for the medical equipment. The results presented by Wright et al. (2018) stated the advantage of a pooling inventory with on-demand deliveries for blood since it is short lived, difficult to predict demand and has strict storage requirements. The authors meant that blood groups with relatively predictable demand are possible to store at hospitals if cold storage is available, while rare blood types remain difficult to store due to varied demand. In well equipped hospitals where medical supply can be kept in required storage environments, on-demand solutions should not be considered as desirable. Since blood, vaccines and other medical material are sensitive to contamination and temperature, it is important that the facilities have capability of managing all requirements. Depending on the hospital’s capability of storing medical equipment, the need for an on-demand solution becomes more or less desirable. Thereby also the incentive for an UAS varies. By providing an alternative for regions where hospitals lack capability of storing medical equipment, UASs increase accessibility by providing an on-demand solution, which circumvents the need for storage space and reduces the transportation time compared to alternative transportation methods by road.

In the Rwandan case, drones were seen as preferable for on-demand delivery of blood. As previously stated, based on the purpose of the drone delivery system different UAV types are preferable. If two way deliveries are demanded, as in the case of performing tests, multicopter or hybrid drones should be considered the better alternative because of its superiority of lifting and landing capabilities. That means, depending on which products that are demanded by the hospitals and in the health care system, different types of drones should be considered. The demand can be affected by certain common and widespread diseases the region is suffering from.

In Malawi, similarly to other parts of Africa, HIV constitutes a big problem which can result in

high demand of HIV-tests and thus two way deliveries are required. In Rwanda, lacking blood

supply calls for on-demand solutions which only require one way deliveries. The choice of drone

type affects the capabilities of the drone system. Since fixed-wing drones typically have a wider

range but only manage one way deliveries and the multicopters typically draw more energy but

are more flexible, e.g. capable of two way deliveries, there is a trade-off between capabilities of the drone and range. If the healthcare system is in need of several different medical equipment that needs to be transported to hospitals in the country and the drone type therefore is multicopter (or possibly hybrid) the delivery range of the UAV will decrease. The costs of the system thereby increase by either upgrading the drones for better coverage (although this is likely to increase costs) or by expanding the number of hubs where the drones are loaded and sent out.

The environment at hospitals needs to be considered since secure space dedicated to drone deliveries is a possible security requirement. According to Björn ​ (2019) the landing procedure is often a technical difficulty for drones, as the drone needs to have functionality to navigate to a certain location, and further detect people, vehicles, buildings or other objects providing an obstacle when landing. Regulations and insurances sometimes require safe space for the drone to land in which according to Björn (2019) is about 50 meters in diameter. The fixed wing drones shoot out the parcel with a parachute but need to be able to drop it in a safe zone. Similarly, the hybrid/multicopter drone needs space for landing. For the UAS to deliver goods to the hospitals, there probably need to be dedicated space for goods delivery. It is possible there is no available space located in direct connection to the hospitals for that purpose. Then a place further from the hospital would have to be chosen which requires extra transportation from the drone delivery area to the hospital, which should be included in the evaluation of accessibility performance of the drone system.

Rosen ​(2017) writes in his article that the drones are capable of cutting the transportation

time from four hours to 15 minutes in Rwanda. On average the delivery time was reduced from

more than 2 hours to less than 30 minutes, based on previous analyses on small-fixed wing

UAVs for blood delivery in Rwanda and Tanzania ​(Wright et al., 2018)​. Rosen (2017) means

that Zipline’s impact in Rwanda is hard to quantify since the insufficient blood supply is not the

only factor inhibiting effective care. Other factors are a deficit of qualified personnel and

difficulty for patients to reach health facilities. The Sub-Saharan African region bears 24% of the

global burden of disease but is served only by 4% of the global health workforce. The health

graduate schools in the region face overwhelming financial, infrastructural, and personnel-related

constraints, limiting their ability to address the shortage. Between the years 1989 and 1997

Rwanda had the lowest life expectancy in the world, numbers that escalated after the genocide in

1994. Setbacks in the country were the broken economy and the healthcare system that took a

large hit. Health facilities were destroyed and the collapse of supply chains for drugs and

consumables was a big problem for the country for several years. ​(Binagwaho et al., 2014)

Furthermore, workforce setbacks were an issue within the healthcare system since many

clinicians fled or were killed (Binagwaho et al., 2013). Today, Rwanda still faces a lack of

specialists and similar to other countries in the region, do not have the health care capacity that is

required to support the administrative needs of each hospital (Binagwaho et al., 2014). Rwanda

has had strong economic growth and improvements in living standards. During the last decade,

the country has maintained its economic growth rates through important economic and structural reforms. ​(The World Bank, 2020)​.

Topography and environment

Another factor affecting the degree of accessibility that the UAS contribute with, is the terrain in the region in which it operates. In Vanuatu, a group of islands in the pacific, UNICEF conducted tests for vaccination deliveries. Drones were flown t ​o Cook’s Bay, a remote community on Erromango island. It is only accessible by foot or small local boats and does not have any electricity ​(Sid​hu, 2018)​. A hybrid drone was used to overcome the difficulties to reach the area and a nurse at place vaccinated 13 children and five pregnant women. In this case drones offer an obvious advantage to reach the area faster than through the (un)existing infrastructure. In Rwanda, a country called ​the land of a thousand hills​, drones offer a solution to reach the country’s hospitals faster. The configuration of the geographical location and its characteristics may directly indicate some profit that can be gained from the UAS. The more difficult the terrain is to cross, the better alternative transportation through airspace becomes.

The topography and environment is also linked to the preferred drone type. Björn (2019) described in his interview how the fixed wing drones are less capable of redirecting and do not have the same capability to shift height level as the hybrids/multicopters. With a mountainous topography, or in urban areas with high buildings, the drones need to be able to navigate around the obstacles. The passability also needs to sustain throughout the year. For drones in health care, that need to handle varying weather, temperature and sight conditions, e.g. night, day and fog.

Zipline’s drones for example, are capable of resisting most weather while airborne, however the

launching is more sensitive to weather changes which sometimes pause the activity . If the winds

are too strong and drain too much battery from the Zipline drones, they turn back to the

distribution centers. ​(Ackerman and Koziol, 2019)

6. DISCUSSION

This section will analyse how the above presented dimensions are connected to the literature on accessibility. The discussion investigates to what degree the UAS fulfills the theoretical criteria.

6.1 Dimensions of accessibility

The dimensions presented above have been identified as significant for determining to what degree an implemented UAS would increase access to medical supply. Various types of geographical locations are affected by these dimensions in different ways. That in turn determines the extent to which a region will benefit from the implementation of a drone system into health care, in terms of accessibility to medical equipment. In this section the advancements in the field is connected to the theoretical framework on accessibility.

Transportation component

From previous research and simulations regarding efficiency of UAS (Claesson et al. ​(2016)​, Haidari et al. ​(2016) and Wright et al. ​(2018)​) supports the claim of the UAS as beneficial in terms of time and cost. The gained experience from the operating nation wide system in Rwanda, according to Zipline, is that their business was still not more cost efficient than the standard transportation method by road as of 2017 ​(W. Rosen, 2017)​. However, it still seems to have reduced the transportation time of the equipment to health facilities. These two aspects, time and cost of the system, is connected to the transportation component presented by Geurs and Wee (2004) which should be considered when determining the accessibility of a system. While the time aspect has a rather unambiguous result since previous research by Claesson et al. ​(2016) and witnesses of implemented systems in Rwanda ​(Ackerman and Koziol, 2019) and Ghana ​(Asiedu, 2019) ​, as well as from tests in developing countries ​(MSF, 2015; Reuters, 2016)​, all refers to the UAV deliveries as time saving compared to the alternative. Thus the UAS should be considered to increase accessibility in terms of decreased delivery time. When it comes to the cost of the service, the question becomes more complex. From previous research and simulations by Haidari (2016) and Wright (2018) the expected outcome was for the system to operate at a lower cost than the former, however the experiences in Rwanda and Ghana indicates the reverse - the costs per delivery seem to have increased. It should be noted that the information regarding data of costs are too inconclusive to fully evaluate the aspect. There is a gap between research/simulations and evaluation of the actual systems in use, hence more information is necessary to properly understand the economical aspect of an UAS.

It should further be recognized that when investing in an UAS, some incentives are lost to

maintain road infrastructure, which has more functionality than medical equipment

transportation. The possible increase in access to medical supply, could indirectly reduce the

accessibility of transport to other important societal functions (e.g. shops, school, work), as the

investments allocated to the drone delivery system could have been used for other societal functions, such as road maintenance. This correlates with the statement of Wright et al. (2019) - that upgrading land transport always should be selected when possible and offering substantial benefits since the risk is lower and it is easier to implement. It also relates to the subject of social exclusion which Lucas (2012) described as unequal access to transportation. An investment in drone deliveries means that other types of infrastructure are not receiving funds and might be downgraded in priority in favor of the UAS. It is possible and even likely that the utility from such investments will be disproportionately distributed and that certain groups in society will be disfavored, for example groups in rural areas where infrastructure for human transportation is vital. As stated by Lucas, an understanding for how the distribution of accessibility is changed by a transportation system, is important for understanding its consequences.

The risk of reducing access to other functions, as well as the exclusion of certain societal groups, should be addressed as a potential effect and followed by discussions about which functions in society are most important to have access to. Access to medical equipment might come at the expense of other functions, which needs to be identified, evaluated and then decided whether the trade in accessibility is desirable. As stated by Handy and Niemeier (1997) qualitative evaluations can provide more comprehensive understanding of the accessibility than even complex quantitative measures. Qualitative measures, such as case studies, are highly relevant to identify the complex relations of the drone delivery infrastructure in society and the indirect effects of implementing such a system, such as social exclusion. Here, the matter of which conditions and characteristics the region possesses, again becomes relevant. The most vulnerable regions, where the drone delivery system has the potential of providing the most utility in terms of increased accessibility to medical equipment, are possibly the regions where the funds would have the most benefit in other important societal functions..

Land use component

The land use component is another of the four components that should be addressed in an accessibility evaluation according to Geurs and Wee (2004). For UASs the land component recognizes the spatial distribution of hubs, amount of hospitals connected to the system and the quality of the service. High density of health facilities was one factor identified by Wright et al.

(2018) which was found to be one of the prominent potentially value-adding factors. A relevant

question is whether the UAS system is capable of providing the service for all hospitals that are

in need of the service in the country. In Rwanda, about half of the hospitals in the country are

connected to the service, 19 out of the country’s 48 district hospitals were connected to the

service in 2019. Potential restrictions for the system to reach all hospitals are: topography, range

from the hubs, border crossing and safe space for the cargo to drop near the hospital. An analysis

of the distribution and quality of the service should be evaluated to ensure equal utility for all

hospitals connected to the service. The location of the service centers, which the drones originate

from, should be distributed to benefit all hospitals in need. The distribution and placement of the

centers could potentially be either intentionally or unintentionally excluding certain groups in society, for example discriminated minority groups. The distribution centers have a maximum range which could be used to undermine certain social groups, a risk more prominent in regions facing internal conflicts. Rwanda constitutes an interesting case study to examine the equality of the system since the country has implemented an UAS and has a long history of conflicts.

Temporal component

The temporal component is highly relevant for a system within healthcare since it needs to be accessible throughout the year. Also, as stated by Wright et al. (2018) another value adding factor for UASs is if roads are inaccessible or difficult to access large parts of the year. The increase in accessibility to medical equipment can vary over time which also should be considered. In Rwanda, Zipline’s fixed-wing drones are said to be more weather resistant than the multicopter equivalent. Their drones could resist most weather once airborne, but the takeoffs were sometimes paused due to weather changes. At high wind velocities, the energy consumption to overcome the wind resistance becomes too great for the drones, and they are redirected back to the hubs. Other drone types might be more or less weather resistant and possibly be subjected to other temporal restraints, such as difficulty to operate during night (i.e.

poorly lighted areas), which should also be considered. How resilient the system is against both weather and physical obstacles as other aerial vehicles, as well as legal administration, affects to what degree the system is accessible. Since the drones are not fully resistant to weather changes, the accessibility of the system decreases. The degree of resilience should also be addressed in the current system, as it should be able to indicate whether the UAS offers an improvement of the system compared to the alternative, in terms of accessibility.

Individual component

The last component is the individual which reflects the individual prerequisites and needs at

every hospital and health facility. This aspect reflects to what degree the system is flexible for

different needs and possibilities. For example, the need for medical equipment can differ

between hospitals in terms of amount and/or type of medical supply. Also, the possibilities for

receiving the cargo might differ between hospitals. This entails both having safe placement for

cargo delivery, in the case of fixed-winged drones, the delivery is executed through parachuting

the package and in multicopter case, safe landing space and having personnel in place with

knowledge of how to use the delivered equipment. In the Rwandan case, the system is flexible in

terms of being able to send different types of blood. The system inflexibility is for example the

fixed-wing drone’s inability of two way deliveries and hence complicates the process of

delivering other material than blood and vaccines that only requires one way deliveries. The

multicopter drone, with smaller range, is more flexible since it can start and land by itself and

therefore can deliver varieties of products to the hospitals. The multicopter should hence be

considered more flexible in adoption to individual hospital needs than the fixed-wing drones.

Although the multicopter requires safe spaces for landing, fixed-wing drones also require safe spaces to parachute the cargo to. The conditions at the hospitals are also likely to differ. Whether the level of accessibility will potentially increase, varies depending on the degree of quality the health facility already has. The accessibility to medical equipment might therefore increase a lot for some hospitals while for others accessibility remains the same. The aggregated accessibility change can be affected by these individual differences, therefore they should be identified and addressed when evaluating the system.

As stated by Lucas (2012), the accessibility distribution is likely to be disproportionate in the

region using the service, hence it is important to examine the individual characteristics of

hospitals with different prerequisites, e.g. located in rural versus urban locations, to understand

how the accessibility is changed and distributed in different areas. The individual component

highlights the importance of including individual differences in the analysis. This incorporates

what demands that are most crucial at different hospitals. At some hospitals the need for

medically trained personnel might be higher than the need for certain products. An increased

supply of products that drone systems can offer, might not even benefit the health care system if

there are no trained people that can use it. Therefore, it is crucial to understand the needs at

different hospitals in order to determine if a UAS is beneficial. Which types of medical

equipment is demanded at different hospitals should also be examined. If the demand varies and

the delivery system only can provide a maximum number of products, a discussion follows of

which types of products should be prioritised. Different products have varying requirements of

temperatures and transportation time. An ethical discussion could follow which examines

whether the most life crucial medicine or the one with highest demand should be considered

most important.