There is a fictitious manual for ‘How to create a Failed State’. I have not read it all, but it has a chapter on
‘Failing public institutions’. If you look in there, there will be a big section on ‘Health Services’. The introduction to the
section reads thus: “The biggest concern for health services is to ensure that people remain healthy. In the event that they get sick, the system should provide care so that they get well quickly. If the illness is of an acute nature, they might need Emergency Medical Services – hence the need for an ambulance.”

Staying healthy requires good basic education, good nutrition, immunisation, services for mothers and newborns, safe water and sanitation, some physical activity... all of which depend on gainful employment and reasonable income.

Unemployment is, therefore, an effective strategy to achieve poor health – one of the reasons it is so critical in the cre-
ation of a Failed State. So, let us talk about Emergency Medical Services.
Ambulances are an expensive resource.
A basic definition of an ambulance is an emergency transport vehicle with medical care on board. It does not matter if it has a siren, a flashing light, or ‘Ambulance’ written on the vehicle. If there is no capacity for medical care – a trained and equipped person – then all we have is emergency transport, not an ambulance.

Let us examine why ambulances are expensive. There is the cost of the vehicle, its maintenance, and insurance. There is the driver and crew – maybe a nurse, or paramedic. Then the equipment, supplies, and emergency medicines. Lastly, communication and management. All these have to be in place and on the ready, ideally 24/7.
Most of you must be thinking, ‘this is way too expensive for a poor country like Uganda.’ There are many ways for
countries (and cities or communities) to finance their ambulance services. That is a discussion for another day, but most people would agree that a trip on the ambulance is cheaper than a funeral.

Now comes the MP’s ‘ambulances’. Most of them have no equipment and no medical personnel on board. In effect, most are emergency transport vehicles. Some are packed at the MP’s home. Often the family that needs to it have to pay for the fuel.

The most distinctive feature on the vehicles is the name of the MP, and at times a larger-than-life portrait. They are moving billboards for the next election.
Don’t get me wrong. These emergency vehicles have saved lives. They do carry sick people. The health system is so sick that even the billboards on wheels are helpful. But how does one call them? Who receives the call? What do the drivers know about critical illnesses and first aid?
How do they decide if the nearest health facility is the most appropriate for the emergency or condition?
Is this the best we can do?

Uganda is a poor country, some will argue, so it cannot afford an ambulance system, except for the President and mem
bers of the First Family. The government they head has not created a system for helping those who need emergency care.
Our legislators should put self-interest aside, and get the Executive to put in place a functional ambulance service. One that serves everyone, not just those who happens to have the MP’s phone number, and who live in a constituency where the MP has bought a billboard for patient transfer.
When the lockdown eventually ends, let us not seek to get back to business as usual. If we have learnt anything, it should be that we need to reform our health service so that it takes care of us all, not just a few people.
Truck drivers, market vendors, doctors,prostitutes, mobile phone merchants from Dubai... our fates are all closely knit. Now,let me get back to the rest of that chapter in the manual, ‘How to ‘How to create a Failed State’.

Dr Kobusingye is an accident and emergency
surgeon and injury epidemiologist at Injury
Control Centre, Makerere Medical School