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.
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.