Ambulances for Bangladesh: A microcosm of technical assistance

Ninety-five Land Rover ambulances, inclusive of spare parts and at a total cost of €2 million, had been donated, in 1989, to Bangladesh as part of a “post-flood rehabilitation project”. This account concerns the ambulances component of an evaluation of this project, which was undertaken together with that of a “primary schools cum cyclone shelter project” by the same donor.

The two projects were in extreme regions of Bangladesh; that of post-flood rehabilitation based upon Rajshahi and Bogra in the north-west, involved rural primary schools and rural hospitals on 57 sites with up to 160 kilometres between them, and cyclone shelters based upon Chittagong and Cox’s Bazaar in the south-east and on 20 sites. Each site had to be visited. Rajshahi and Cox’s Bazaar are about 500 kilometres apart - were it possible to travel in the straight line reputedly flown by crows. The total time allocated for the combined evaluation mission was six weeks (though six weeks had been the time for each evaluation before they were combined !).

Ambulances were the subject of one-sentence of the four-page terms of reference (tors) for the evaluation of the post-flood rehabilitation project: “Make a review of the 95 ambulances provided by the project including the present location/utilisation/condition of the vehicles (local consultants will assist this work)”.

Two extensive and wide-ranging evaluations in six weeks by an evaluation team of three, could not have reviewed the condition and utilisation of 95 ambulances scattered throughout the entirety of Bangladesh without assistance - for which applicants were to be identified, interviewed, selected, appointed, monitored and paid, all as part of the evaluation project.

The ambulance review was undertaken by Prokalpa Upodeshta who, due to their teaching activity, had contact with students and former students throughout Bangladesh who were willing to be deployed to locate and to assess as many vehicles as was possible.

Less than half of the ambulances, 40 out of 95, were located and only two thirds of those were operating effectively.

In most cases, exterior bodywork was in good condition but many had damaged seats due to rough use. In one half of those found, at least one of two supplied stretchers was missing, a serious condition for vehicles often unable to travel all the distance to rural patients; other medical equipment also was missing. Engines in most cases were in good condition but maintenance was expected to become a problem as spare parts had not been received.

Bangladeshi authorities allocated eighteen thousand spare parts in 474 different categories, from front bumpers to rear lamps and from bleed screws to nipple grease, to four distribution centres of Dhaka, Rajshahi, Chittagong and Khulna. No spare parts were recorded as having been received by any of the ambulance stations located for the review.

Twenty-one months after receipt, one ambulance had travelled more than 106,000 kms, but the majority had travelled less than 20,000 kms; there were delays of up to 18 months between vehicles’ acquisition, registration and first use, one ambulance having yet to make its first journey; wide variations were found between vehicles’ proposed and actual location and, after commencing operations, two ambulances had been out of service for up to 6 months. The charge made to patients for their use of an ambulance was considered excessive for rural people, precluding ambulance use for many and limiting vehicles’ utilisation and effectiveness.

In two cases, a river separated the location of ambulances from the community they were intended to serve, with no bridge or vehicle ferry. Eighty-two per cent of all journeys made had been for medical emergencies, with 11 per cent for “official use”, and 7 per cent for “other” uses. Ambulances were reported as having been used by local officials for their own purposes, by political leaders, and to have been appropriated by local gangs. In two cases, ambulances had been used exclusively for journeys by doctors and, in several cases, to transport a visiting prime minister.

Spare parts that had been required had been purchased locally. How parts had come to be available for purchase, how their stockists had come by them, and how much had been paid and to whom, were questions not requiring investigation by this review.

The evaluation concluded that, even when employed for their intended purpose, ambulances have only a limited usefulness. The majority of rural communities in Bangladesh are remote and accessed by narrow track or pathway too narrow for vehicles of any kind. In the wet season, even four-wheel-drive Land Rovers have difficulty in deep mud.

Most severe cases in hospitals visited appeared to have resulted from lesser problems not treated earlier, such as worms or nutritional problems leading to liver failure. The provision of ambulances could have been organised to help people reach hospital sooner and earlier in the onset of their illness, rather than more quickly much later. Free ambulance transportation would assist such an objective and the provision of technical training for mechanics and drivers would ensure the reliable availability of their vehicles where, due to lack of mechanical competence, routine mechanical servicing was not practiced.

The evaluation concluded that an appraisal of the need of ambulances, and of their anticipated utilisation, could usefully have been made before their provision. For their added effectiveness, large organisations and large budgets require realistic attention over time to seemingly minor details.

I used to be an Ambulance

To this image, Bangladeshi photographer Syed Ashfaqueuddin Priom has applied the title “I used to be an Ambulance!”. He writes:

“I`ve been seeing it like this for almost 10 years (and counting). It was used for a very short time and the sad fact is that, after it was dismantled probably no attempt was taken to repair it. Moreover, I wonder if any attempt has ever been taken to move this wreck outside of the hospital area."

Priom notes that the photograph was taken on 5 June 2008 at Lakshimipur, situated a few kilometres east of the Meghna estuary, 30 kilometres north-west of Noakhali and 100 kilometres south of Dhaka. The Ambulance Review Report and its survey data contain no record of an ambulance being located at Lakshimipur. That this former Land Rover ambulance, however, had been abandoned for more than ten years after its period of use, strongly suggests it to have been one of the 95 that were the subject of this evaluation of May 1995.

Priom: http://www.flickr.com/...

1Golam Mmohiuddin & Shabbir Ahmed Ambulance Review Report Prokalpa Upodeshta, Dhaka. May 1995.

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2009
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