On the road. The
problem…the solution?
In a packed
room of students and professors, Dr. Charles Muchunguzi spoke on his work with motorcycle ambulances in Uganda. The project, funded by
UNICEF, aimed to decrease high maternal
and child mortality by facilitating access to local health centers. Motorcycle
ambulances would be a sustainable and efficient solution to target
transportation issues in hilly, poorly kept roads. They would transport
pregnant women to the closest health care center, mostly for the actual birth,
as well as others in case of medical emergency.
Traditional
ambulance maintenance costs, breakdowns and incompatibility with poor road
networks had led to misuse or nonuse in poor communities. In addition, the
motorcycle intervention had proved very successful in other countries like
India, as well as in eastern Uganda.
Despite
promising prospects on paper, development expansion is not simple. In the two
districts of western Uganda (Mbarara and Bushenyi), the pilot project largely
failed: the pregnant women did not use the ambulance. In the better-off Mbarara
district, only two women used it during a nine month period. In Bushenyi, the
communities showed mixed feelings about the ambulances; yet, without access to
alternative transportation, they did use it more.
Riding in
the “ambulance” felt anything but safe or reassuring to the women. If they had
used it, they would have lain in the back on a thin mattress across a hard
surface. The carriage of the ambulance would shuffle from side to side across
the turns, giving the sense that they would soon topple over. Indeed, the very community
health workerswho were asked to promote the intervention had experienced an
accident in the vehicle.
The women,
instead, chose to walk, ride a boda boda (normal motorcycle) or give birth at home just
as they had done before the project.
Encounter with the
ubiquitous roadblocks (not just metaphorically)
Dr.
Muchunguzi´s presentation gave the viewers a touching, if brief, encounter with
doing interventions on the ground. I cannot say how refreshing it was to hear
such a thoughtful, critical and honest presentation. It has not been often that
I have met someone so willing to expose the difficulties with a project that
meant so much to them. I felt truly honored to hear him speak.
For me, his
presentation had meaning far beyond the individual project. It showed how
projects set up by well-meaning organizations often do not work: he mentioned
latrines (built by the work bank but not used because of community taboos
against mixing feces of the young and the old) and bed nets (used for wedding dresses
and fishing nets).
Many of my
friends and colleagues who have done international work have come back with the
same sense of frustration: many interventions are done for communities with
little real impact in the long term.
Witnessing this frustration over and over can burn out the very people who wish to affect change. How could such an elegant idea as a motorcycle ambulance, which worked in so many other places, fail?
Rather than
being frustrated, Dr.Muchunguzi provided insight into how modifications might
be made in order to make the solution work. UNICEF is currently working on
redesigning the motorcycle ambulance; other ideas were provided by the
community focus groups post-intervention, such as making four wheel ambulances
(“does that then become a car?”) or subsidizing local cars. Also, communities
that had already organized and funded the infrastructure for the project (a
shed to put the motorcycle in, compensation for the driver), had much higher
acceptability.
Quality
Motorcycles
can be an elegant solution to an important problem, but only if people will use
them. Asking them if they want what you have is not good enough. As Dr.
Muchungunzi said, people are not stupid; they know what the developer wants
and, with money riding in the balance, they will give it to you. Even flimsy
motorcycle ambulances for free are better than nothing. Just as we might take a
free pen because it is there, it does not mean we will continue to write with
it if the ink is constantly drying up. Community buy-in to the purpose of the
intervention and real contribution to the design of projects cannot be seen as
ancillary to their success.
In the
villages where desire for motorcycle ambulances existed prior to the project,
the intervention worked much better. Community buy-in can be sought through
active consultation in focus groups throughout a project, as well as incorporating
appropriate and respectful care. For example, It is possible to incorporate cultural practices
like vertical birth in clinical settings.
Moreover, a
single intervention cannot stand alone. It is only a solution if the health care encountered in the health
post is of high quality and will really improve maternal mortality. It is only a
solution if the roads are good enough
for the motorcycle ambulances to get to people’s houses.
His talk,
to me, highlighted the importance of quality in planning interventions, quality
in community buy-in and engagement in the project and quality
in the services that are provided to people. While asking pregnant
women to lie on thin, hard mattresses in precarious vehicles might be deemed
cost efficient and sustainable, such a service may fail to respect their human
dignity.. Rather than accept this loss of dignity, many continueto give birth
in solitude or solidarity.
