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bicycle ambulances in rural Africa: mediocre aid?

10 January 2012

I must confess to being troubled by the increasing frequency of the donation of bicycles to be used as ambulances. In the 21st century, it is both sad and shocking that any people should be using bicycles as ambulances. By definition, ambulances are supposed to provide primary care and quick transport to hospitals to those in need of urgent medical care. They are supposed to have life-saving equipment on board, managed by trained para-medics that provide a first line of medical assistance before one can be transported to be seen by a medical professional…

If anyone outside Malawi wants to help the country, they should be told in no uncertain terms that Malawians need and deserve real ambulances. Bicycle ambulances do not belong to the 21st century, in Malawi or anywhere for that matter. It is as simple as that. Even an ox-drawn cart can make a better hospital ride than a bicycle in my view.

That was Boni Dulani, a recent Ph.D. in political science from Michigan State University, lamenting the acceptance of what he deems mediocre aid.

If you don’t know what a bicycle ambulance is, here is a short clip from a group in the UK:

I searched for any evaluations of the impact of bicycle ambulances (perhaps naively, I thought there must be evidence supporting the value and ubiquitous adoption of bicycle ambulances). I found only one article, and it evaluated the use of bicycle ambulances in Malawi. The research compared villages that had bicycle ambulances to villages with community transport plans to villages with no transport intervention for health. The outcome measured was the impact on obstetric care. Unfortunately for proponents of bicycle ambulances, the evidence is unsupportive. The conclusion from the study’s abstract read:

In this study we were unable to demonstrate any benefit for obstetric referral systems when [bicycle ambulances] and [community transport plans] were introduced. The dearth of international literature coupled with these findings highlight the need for further detailed studies prior to wide-scale adoption of transport schemes.

Providers of bicycle ambulances and aid agencies that have bought bicycle ambulances have only positive things to say. For example, even when confronted with the truth that bicycle ambulances were used very little if at all, VillageReach put a positive spin on it:

Of the three communities I visited, one community had used their bicycleambulance twice, another once, and the third had still not used theirs. While at first this seems like the bicycle ambulances are being underutilized, to me it reflected a real valuing of the bicycle ambulances;the communities were not allowing them to be abused and were reserving them for truly grave emergencies. This was a perfect (and heartening) example of real community buy-in, which at the end of the day is one of the few variables that can really support true sustainability.

Given the evidence, it’s hard not to agree with Boni’s original post. Though it sheds light in particular on bicycle ambulances, it also highlights a more general pattern of how aid agencies can not only fail to improve the situation for ordinary people in rural Africa, but also try to “help” in a way that is almost insulting. Yes, roads are bad in much of Malawi. Yes, the current fuel shortage in Malawi would certainly make it difficult for motor ambulances. Sure, vehicles are incredibly expensive to purchase and maintain. And, hiring paramedics or ambulance drivers will certainly cost more than getting some volunteer to pedal a bike around. But by giving some village a bicycle ambulance, are we simply saying they’re not worth that cost?

17 Comments leave one →
  1. 10 January 2012 9:11 am

    To answer your last question: no, we are not saying that they are not worth that cost. What we do say by providing bicycle ambulances, is that the extra cost of using motor ambulances is better used on other priorities (e.g. schools, or agriculture, or doctors/nurses, or….). I have no clue whether that is a correct decision (perhaps the money were better spent on motor ambulances), but seeing this as a judgement call about the worth of the people involved is not at all borne out by the facts.

  2. 10 January 2012 5:15 pm

    “Given the evidence, it’s hard not to agree with Boni’s original post. ” What evidence? Sounds like the jury is still out. I’m not seeing any facts here – just opinions. If you want to call for a serious study, great, but this dismissal of the practice just because of your impression – and never really talking about the substantial costs of maintaining automobiles and trucks, to the point of being entirely cost-prohibitive – is, IMO, quite unfair.

    • 10 January 2012 6:44 pm

      by “evidence”, I was referring to the one published peer-review article that evaluated bicycle ambulances — the link above to the PDF entitled: Are bicycle ambulances and community transport plans effective in strengthening obstetric referral systems in Southern Malawi. I have not spent much time researching this topic, but have yet to find any other studies that evaluated the impact of bicycle ambulances. I welcome any additional evidence you might have.

  3. 11 January 2012 2:06 pm

    The phrase “beggars can’t be choosers” comes to mind. Sure that is harsh. And sure bicycle ambulances are very mediocre. But the harsh reality is that Western aid polices and activities are always going to be made based on Western perceptions of what Africans should do, not on what Africans would like most or what is most effective (since we rarely know what that is anyway) . So certainly scrap the bike ambulances but I wouldn’t be very optimistic that whatever replaces them is going to be much better and it certainly isn’t going to be a flash new Land Cruiser ambulance. But maybe I’m just in a bad mood, spending all day in Mzuzu paying taxes will do that to you.

  4. 20 January 2012 11:35 am

    I am the co-founder and current excutive director of an organisation called Riders for Health. We began our work in 1989 just because we couldn’t see any reason why the many thousands of perfectly sensible vehicles (motorcycles and others) sent to Africa to deliver health care should not work just as well in, say, Malawi, as they do in Sweden or Maryland. It never crossed our minds to develop a bicycle ambulance because the world is not short of regular, motor-driven ambulances and, as it turns out, they work just fine in Africa. It wasn’t the heat or the flies that stopped them working. It was us, we humans. We couldn’t be bothered, as a species, to change the air filters and the oil filters and to adjust the chains and replace the sprockets — even though, we, as a species, knew perfectly well how to do it. We even had little books that showed us how.

    Many years ago, my little office overlooked the main street of a small town in the Midlands of England. A nice and clever young man from a nearby university called to say that he had designed and manufactured a bicycle ambulance that should be just perfect for Africa (where people were neglected and had no money) but for some reason it just wouldn’t catch on. We looked out of the window. There was a slight rise on the High Street, which is paved. I asked him if we were to park his ambulance at the bottom of the street and I were to lie on it, would he be prepared to ride it to the top. He would not, he said, because he would never make it. And then we thought about rural Africa with no paved roads — just sand, and some rocks and mud in the rainy season. He said he thought he might just go back to the drawing board.

    The bicycle ambulance, thought kindly meant by good people, is indeed mediocre. I have no idea what the ‘evidence’ is for its impact. It may well have saved some people. But that’s not the point. Africa needs proper, appropriate solutions not ‘solutions’ based on many, many years of failure on the part of the ‘development’ industry. Proper vehicles work fine in Africa provided they are in turn cared for. With that in mind anything makeshift or otherwise uncertain should make us ashamed, not proud of ourselves for ‘trying’.

    • 22 January 2012 11:45 am

      Barry, thanks so much for your comment. It was the first time I had learned about Riders for Health. I’m eager to learn more about the impact of your work (the photos of the vehicles posted on your website are awesome).

  5. 5 March 2012 5:46 am

    I suppose it depends on various factors on the usage of bike ambulances. It could be the terrain, the knowledge of riding bikes. It takes time to learn other transport vehicles and you need licences. Or maybe it could be numbers meaning more bikes mean more ambulances. If you are going to purchase a normal ambulance it needs money and more resources – human beings and not forgeting training. It takes time to train people. And we may also need professionals like nurses.

  6. 9 March 2012 4:29 pm

    After I initially left a comment I seem to have clicked the -Notify me when new comments are added- checkbox and from now on every time a comment is added I recieve 4 emails with the same comment. Perhaps there is a means you can remove me from that service? Many thanks!

  7. ken hargesheimer permalink
    4 September 2012 4:16 am

    Bicycle ambulances cannot replace motor ambulances. The thing that hinders their use is the mind set in people. A person must go to the hospital. No ambulance available. Is it better to use the BA or stay sick or die?

    The study shows hospital that have them do not use them. Why? No one knows they are available? It is easier to just let people stay sick or die?

  8. Robin Bolton permalink
    28 October 2012 2:53 pm

    Certainly the ideal would be to have a “Western”-style motorised ambulance service with all the “bells and whistles” throughout rural Africa, but the reality, surely is that the purchase cost of this type of ambulance and the attendant fuel costs would be prohibitive, not to speak of the impassible roads in many places. The provision of bicycle ambulances might better be seen as a “transition” phase. Our church, through the Canadian Anglican Church’s Primate’s World Relief and Development Fund is very enthusiastic about supporting the provision of these ambulances as a small step forward, despite the reservations of the “naysayers”.
    Having been a physician in Uganda and having to travel on difficult murram roads to more remote maternity centres and seeing some of the tragic outcomes of care denied or inaccessible because of travel constraints, I can appreciate the potential impact of bicycle ambulances. To my mind, these are an exciting evolution – but obviously not the ideal or final solution.

    (Dr.) Robin Bolton
    Sudbury, Ontario, Canada..

    • 25 January 2014 5:01 pm

      I so agree.
      If the reality is and there seems to be this reality, that motor transport is not available for emergencies Period. Yet, available is a method to deliver someone to a clinic or hospital for care, safely and timely relative to the alternative, then what? Boo Hoo it’s not good enough so i won’t use it?
      You say no to the bicycle ambulance because it is not the best there is?
      If the locals thought this up, would not the word spread? Really, What would you do, besides lobby for a motorized first response ambulance with trained crew while the possibility of saving lives exists right now. Sure it is not the best, but is doing nothing better?

  9. ben permalink
    23 November 2012 4:49 am

    Cost of bike ambulance $100 little too no maintenance costs.
    Cost of a real ambulance fully kited out and money for repairs and fuel $70,000

    Please come to Malawi and visit 100’s of villages across hundreds of miles of difficult to reach rural areas and tell them they are not getting a bike because you have decided the money would be better spend buying just ONE real ambulance which has no fuel in it, no spare parts are no long term finical plan to keeping it on the road and full of supplies.

    • 23 November 2012 4:09 pm

      While I agree that the costs associated with “real” ambulances are prohibitive, I think the figure of $100 that you quote for a bicycle ambulance is not current. Our church is providing funding for bicycle ambulances in Mozambique and the cost we have been quoted by our Canadian Anglican Primate’s World Relief and Development Fund (PWRDF) is actually around $600. Even that pales in comparison to the cost of a “real” ambulance. For goodness’ sake let’s do something to help out even if it’s not ideal or “state of the art”! At least it’s a step in the right direction.

  10. 15 January 2016 6:03 pm

    I have a feeling that most of the negative comments are from people who have never set foot in rural Africa. On a recent visit to a large town in Malawi we were unable to find a working air pump to pump up a flat tyre on a trailer, none of the garages had a working compressor and a hand pump would not give enough pressure. What hope of fuel and maintenance in a rural area? As for hills, I have seen 4 people pushing a bicycle loaded with water containers up a steep hill to get water to a village, so pushing a sock person on a bicycle-ambulance would certainly not be difficult. Do not knock low tech, in Africa it will always beat high-tech in the long run!

  11. 19 January 2016 4:19 pm

    It’s been a long time since I’ve seen postings on this site and it’s good to see that the debate continues. The evidence that has been presented by our Canadian Primate’s World Relief and Development Fund is that maternal mortality in Mozambique has been decreased by
    14 % in villages that utilize bicycle ambulances versus those that have no access to this support. Is that not significant?

    The naysayers continue to say that this system of transport is a mediocre response but what alternative do they have to offer? There is no way at present that these countries can afford a system of EMS vehicles that we in western countries have come to rely on. Baby steps are better than no steps at all, surely!

    Robin Bolton

    • 21 April 2016 10:48 am

      As the head of an organisation which continues to invest in the local manufacture of bicycle ambulances for rural communities, I am reasonably confident when I say the following:

      1. Gold standard RCT-type evidence about the impact of bicycle ambulances on health outcomes is still lacking – as it is for so many other public heath interventions in rural African settings.

      2. Across our projects (including Malawi, Zambia and Madagascar) we have seen that bicycle ambulances, ox and cart ambulances, canoe ambulances and stretchers provide a low cost, locally appropriate, community maintainable solution for getting literally thousands of emergency cases (primarily women in labour) to health facilities.

      3. On the contrary we have seen almost no examples of investment in ambulance services (be that vehicles, paramedics, equipment, call centres etc.) which could serve these extremely rural populations. Meanwhile we know that bicycle ambulances cost merely 1-2% of the price of a motorised ambulance, provide employment for local manufacturers, and can be maintained and operated at near minimal cost.

      4. We do have data to show that bicycle ambulances can be a serious means of getting patients to health facilities. Our data shows average distances of 10 – 15km, and maximum distances upwards of 42km one-way. Our data also shows that some bicycle ambulances have been running effectively for upwards of five years. Outside of the specific countries where people like Riders for Health work (see Barry’s comment above) we simply haven’t seen motorised ambulances consistently perform for anything close to that.

      5. We have feedback from multiple communities across multiple countries attesting to the dramatic impact which bicycle ambulances (and similar intermediate modes of transport) have had and (anecdotally) the prevented deaths attributed to their presence.

      In the spirit of transparency, I can share the following information for those who are interested in reading further:

      Click to access Filling-a-Gap-in-the-referral-system-in-Zambia-linking-communities-to-quality-maternal-healthcare.pdf

      Click to access webadmin

      Click to access 5-Transaid-Technical-Case-Study-Zambia-Bicycle-Ambulances.pdf

      Click to access 2-Transaid-Technical-Case-Study-new-bicycle-ambulancetrailer-design-in-malawi.pdf

      Click to access 4-Transaid-Technical-Case-Study-The-MchinjiMwami-bicycle-ambulance-project.pdf

      Click to access 22-Technical-Case-Study-IMTs-in-Madagascar-v5.pdf

      I hope this contribution has added to the discussion in a meaningful way. I also don’t mean this to sound like an either/or matter. Government’s should strengthen their fleet management practises to ensure that the health vehicles they do have are used as cost-effectively as possible in support of public health goals (Transaid has also done a substantial amount of work on health sector transport reform, information can be found on our website).

      Finally, does it hurt that fellow humans on this planet don’t have access to the same standard of services as perhaps we do? Yes, it does, frequently and deeply. But when we look at the resources available at this moment in time, and develop collaborative solutions with partners and communities on the ground in these countries, do I feel like we are making progress? Yes I do.

      Best regards,

      Gary Forster
      Chief Executive

      Transaid – transport for life, 137 Euston Road, London, NW1 2 AA.
      Tel +44 (0) 20 7387 8136, Fax +44 (0) 20 7387 2669
      Skype: gary.forster1

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      • Robin&/or Barbara Bolton permalink
        22 April 2016 9:21 pm

        Well said. While bicycle ambulances are not the ‘top -of-the line’ solution, they have abundantly proven their usefulness . Data from the Canadian Primate’s World Relief and Development Fund (PWRDF) have amply demonstrated their effectiveness in Mozambique and Burundi.

        Robin Bolton.

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