Medical emergencies: Why West Nilers prefer bodaboda over cars

________________

ARUA

Dilapidated roads, inadequate and under-equipped ambulances are part of the cocktail conspiring to compromise emergency response in the West Nile region.

For some of the region's residents, the promise of emergency services is a joke that has claimed lives and left families bereaved.

Complications due to pregnancy and childbirth and during the neonatal period remain the leading causes of maternal and newborn deaths in Uganda. Nevertheless, communities, especially those in hard-to-reach areas continue to experience delays in accessing health facilities promptly, putting at risk more mothers and their babies. 

Many of the delays are due to lack of transportation, lack of funds to pay for transport, poor road infrastructure and poor communication networks.

Improving referral systems, linkages between communities and facilities and timely transfer between the different levels of health facilities is a key priority for the Government.

According to the Twaweza sauti za wananchi report of 2023, only one out of 20 citizens is aware that a toll-free emergency services number exists; among them, less than half (2%) can name the correct number. Similarly, two out of 10 (19%) know of any ambulances that can be called to their area. The figure is a little higher in urban areas (23%) than rural (18%) generally.

Overall, 4% of Ugandans report ever having used an ambulance.

In Uganda, responding to emergencies in times of need is a crucial area that has often been overlooked and not given priority, especially when it comes to medical emergencies.

In West Nile, the situation has been worsened by a lack of standby ambulance services, poor road networks and ill-equipped ambulances which does not support live serving interventions for patients in transit. Many of the community members say they prefer to use bodabodas in times of medical emergencies as opposed to ambulances which are either unavailable or costly.

Bodabodas replace ambulance services

Hellen Ofezu, a tailor in Arua city who once lost a relative due to delays in accessing an ambulance said, she has resorted to use of bodabodas during emergencies.

Hellen Ofezu, a tailor in Arua City. (Photo by Robert Adiga)

“When you call for an ambulance, they give you a lot of excuses like lack of fuel and a mechanical challenge, among others. I, therefore, learnt my lesson and these days, we call for bodabodas if the patient can sit on them or we seek for assistance the neighbours who have vehicles,” Ofezu says.

Maracha district's Nyori village LC1 chairperson, Michael Andama, decried the poor roads in the village and said it is the reason community members do not bother calling ambulance services.

“We have never called for an ambulance in the village, people prefer to use motorcycles because the road is very bad, and the district has few ambulances. Calling them will come with a cost like fuel,” Andama said.

Borrowed ambulances

At Bondo Health Centre (HC) IV in Arua district, which is the only HCIV acting as the district hospital for Arua district, the only ambulance donated by then District Woman Member of Parliament, Maureen Osoru, has been grounded leaving the facility with no option in case of emergency.

This was disclosed by Bondo HCIV in-charge, Dr Peace Oliver Eyotaru, who said they rely on borrowed ambulances during emergencies.

“Our ambulance, which was donated is grounded and needs serious servicing but our resources are limited and whenever there is an emergency, we call an ambulance from Kuluva Mission Hospital, which sometimes does not respond on time. This puts the lives of the patients in need of medical emergencies at risk,” Eyotaru says.

Ill-equipped and dilapidated ambulances  

The poor state of the ambulances and ill equipment as well as logistical challenges, are other concerns forcing patients to pay for services, according to Arua district senior health educator, Manasseh Anziku.

"The current ambulances we have were donated by the Belgian government over 10 years ago and inside they are dilapidated. They are used to evacuate patients without any support systems and they do not suit the purpose for which they are created. In most cases, they run out of fuel and this forces us to charge patients to pay for fuel which is a big concern,” Anziku says.

Arua Regional Referral Hospital director, Dr Alex Andema, says the class of ambulances used at the facility and region as a whole are not qualified to the desired standard for emergencies.

Dr. Alex Andema, the hospital director Arua RRH. (Photo by Robert Adiga)

“Our roads are not okay for ambulances and also we now need to talk about the class C ambulances because we know how they operate instead of the class A ambulances that we are using for the management of patients. The discipline in the usage of the ambulances is another critical factor such that they can last,” Andeku said.

Need for capacity building

Arua district chairperson, Alfred Okuonzi, says the non-responsive or delayed response to emergencies by ambulance services providers has led to the loss of lives. He has called for more training for medical workers tasked with emergency services.

Identify EMS providers 

Association of Ambulance Professionals in Uganda president, Tom Kyobe, acknowledged the shortage of ambulances during emergencies but challenged the community members to identify those responsible for emergencies in their localities.

“We are losing a lot of lives in the way cases are managed, and in our setting, we have numbers to call in case of emergencies and the responsibility is for you to identify the emergency and notify the people responsible in your community to co-ordinate the emergencies, because we have people who are regional co-ordinators to respond to emergencies in any location," Kyobe said.

Marie Hilda Nanyanzi, the senior programme officer at Twaweza East Africa in charge of Sauti za Wanainchi, says the situation still requires more effort given their findings.

“How many Ugandans can appreciate that yes we need emergency medical services? These are the steps one can take if we have few of those then that gives us a concern in case of an emergency there are several organisations like the Red Cross that offer emergency services even most times for free but do Ugandans know that such ambulance services exist?

Do they know the numbers to call if not, this calls for all the stakeholders to increase awareness to help address the gap because this is a multi-faceted approach to emergency response,” Nanyanzi said.

The indispensable role of emergency ambulance services in public health cannot be overstated. Swift response times, life-saving interventions and universal accessibility form the bedrock of their significance.

By seamlessly integrating with the healthcare system and embracing innovation, these services not only save lives but also contribute to addressing health disparities. As frontline guardians, emergency ambulance services embody a commitment to the well-being of communities, exemplifying their crucial role in maintaining and enhancing public health standards.

State of ambulance services in Uganda

Uganda's ambulance services face several challenges, including a lack of ambulances, poor co-ordination, and a lack of standard equipment: 

In October 2023, Prime Minister, Robinah Nabbanja, revealed that plans were underway for the Government to procure 180 ambulances in 2024 to bridge the gap of ambulances in Uganda. 

“In the FY 2024/2025, we plan to procure an additional 180 Type B and Type C ambulances to fill the gaps. The Government is committed to filling the gaps in ambulance vehicles at the constituency level by FY 2025/26,” Nabbanja told MPs during plenary.

She added that on September 20, 2021, Cabinet approved the Emergency Medical Services Policy that stipulates that one Type B ambulance will serve 100,000 people, which is equivalent to one constituency in Uganda and the revised policy removed the issue of allocating ambulances to health facilities to serve the wider population better.

In 2023, health ministry principal operations officer, Maria Nkalubo, informed Parliament that there are 173 Type A ambulances that the ministry was planning to phase out in Uganda, and this started with the purchase of 140 Type B ambulances, with more 100 Type B ambulances expected at the end of 2023. She defended the phasing out of these ambulances arguing that most of them are old, dilapidated, empty and many are found moving around with onions and jerrycans in the cabin, and with no stretchers for the patients.

She also said that the Government will need to raise sh450b within five years to fund Emergency Health Services in Uganda, with procurement of ambulances featuring high on this hierarchy. She explained that annually, sh10b is required to manage the road expenditure that covers fuel, maintenance, and human resources, while sh1.8b is needed to operate the 14 marine ambulances annually.

According to an ambulance census conducted in 2019 by ministry, Uganda required 460 ambulances to support its health care system. However, at the time, the country only had 178 government ambulances and 172 private ambulances. But following the amendment by the international health standards, which requires Uganda to upgrade its current fleet of ambulances to meet the required health standards, this pushed the shortage of ambulances to 340 including 315 Type B Road Ambulances with each costing sh280m thus creating a funding gap of sh88.2b at the time.

Equipment

Many pre-hospital care providers have improvised ambulances that lack the required equipment, medicines, and personnel. 

Co-ordination

There is poor co-ordination and communication between EMS providers. For example, only 45.5% of districts with more than one EMS provider co-ordinate their activities regularly. 

First responders

Traffic Police and bystanders are the first responders in more than 90% of emergency cases.