Okoa Motorcycle Ambulance

In developing countries, transportation delays are a major factor in high maternal and infant mortality rates. Ambulances are scarce and unsustainable because they are expensive and can’t withstand road conditions. Many mothers and infants die making the journey on foot or by motorcycle, and many who don't want to risk the journey die of treatable complications at home.  

Okoa Ambulances are a safe, affordable, and sustainable solution that widens access to maternal healthcare by prioritizing local concerns. Okoa Ambulances are designed with community input, locally manufactured for easy maintenance, and can comfortably transport patients and supplies across difficult sub-Saharan terrain, reducing the physical risk factors of the journey and supporting patients’ emotional health. Okoa Ambulances have been in use since 2018 with programs in Ghana and Tanzania, and if scaled globally could be a key factor in preventing deaths due to obstetric complications in the developing world.

Every day, 830 women in low-income countries die due to pregnancy complications that would be preventable with equitable healthcare access. In the sub-Saharan communities we partner with, pregnant patients cannot safely access healthcare using existing transportation, which contributes to high maternal and infant mortality rates.   

Traditional ambulances can cost up to $200,000 USD and are not built to withstand the local environment. Their inability to navigate the terrain causes problems that cannot be repaired locally, and they quickly fall into disuse. Car-taxi services are prohibitively expensive, and motorcycle travel exacerbates obstetric problems and leaves patients alone and afraid. Women regularly choose between home delivery or motorcycle travel, risking death either way.  

At The Okoa Project, we revisit the design of our ambulances in every new region we enter to account for specific community needs and ensure our ambulances can be locally produced and repaired. By reducing the risk factors of a hospital journey and accounting for the concerns of the patient population, Okoa Ambulances improve access to maternal and infant healthcare.

The Okoa Ambulance is a covered vehicle for the emergency transportation of laboring mothers. Our participatory design process keeps costs down and allows us to create jobs for engineers, dispatchers, nurses, and drivers. We aim to make our ambulances as self-sustaining as possible by creating work for local manufacturers and building the local economy. 

Okoa Ambulances cost 1-2% the price of a traditional ambulance, are manufactured locally for convenient maintenance, and include a tested suspension system that minimizes turbulence on difficult roads. Communities participate in our process through interviews, focus groups, prototype review, and manufacturing, and every aspect of the vehicle is tailored to the needs of each community. To that effect, our Tanzanian ambulance trailers attach to any motorcycle to utilize existing motorcycle taxi norms and are lightweight enough to prevent unnecessary wear, while in Ghana the ambulances are engineered as an independent vehicle with additional space for a nurse and a raised suspension to avoid deep potholes and puddles. 

After a successful pilot in Tanzania in 2018, Okoa received requests to implement projects from over 18 countries and selected Ghana after careful consideration. Compared to urban locations, rural areas like Ghana’s Upper West Region, which houses the Sissala East Healthcare District, have higher maternal death rates, limited transport and access to healthcare, and a lower prevalence of skilled birth attendants and medical professionals. The slow decline in the maternal mortality rate has prevented Ghana from reaching the United Nations Millennium Development Goal of 190 deaths per 100,000 live births by 2015. These problems are mirrored across the developing world, and Okoa seeks to reduce barriers to maternal and infant healthcare worldwide by providing adequate and affordable transportation for similarly underdeveloped areas.  

Okoa partnered with The Virtue Foundation and traveled to Tumu, in the Sissala East Region of Ghana in February of 2020, where we held meetings with community leaders, health workers, medical team members, technicians, and women from 8 different communities to discuss local pregnancy concerns and potential solutions. The team worked with technicians and artisans to alter the ambulance to the needs of the local environment, and built two ambulances that have been in circulation since February 2020.   

The Three Delays Model cites delays in care as the most important factor in high maternal and infant mortality. Okoa Ambulances address the second delay, the delay in transportation, by prioritizing pregnancy concerns and selecting communities with high MMRs for implementation. Okoa’s safety precautions and participatory design decrease travel risks and increase local trust in emergency transportation, which saves lives by expanding medical access and supports patients’ emotional health by incorporating their concerns into the design and providing peace of mind that safe transportation is available to them when the time comes. 

Of the three delays preventing access to healthcare, most nonprofits and aid programs address delays in deciding to seek care or delays in receipt of care. By focusing our efforts on the delay in transportation to receive care, we are able to make a substantial impact on rural communities that are otherwise neglected. 

Our solution improves on previous attempts by capitalizing on the use of local systems and creating designs in partnership with the community. We look beyond the patient's immediate medical need and account for community norms to bring safe and trusted transportation to the greatest number of people while creating jobs for local nurses, technicians, and dispatchers. 

Motorcycle ambulances that have tried to fill this gap have been prohibitively expensive, and failed to understand the local problems. South Africa’s E-Ranger cost $6,600 USD and encountered fatal maintenance issues that could not be repaired. Of the 400 E-Rangers purchased by the Tanzanian government, none are still in use. The Zambian Pulse Motorcycle Ambulance had an inadequate suspension system and required the customer to purchase a specific accompanying motorcycle, totaling $4,000 USD. Neither of these solutions provided space for an accompanying passenger, which we at Okoa incorporated into our design after interviews revealed it to be the most important factor in reducing the fear of making a hospital visit. The participatory design process ensures that all concerns are addressed and all Okoa Ambulances can be locally repaired, and Okoa Ambulances cost no more than $2,000 USD.

Okoa’s solution relies on widely-known technologies, which we use as a foundation from which to adapt our Ambulance’s design to a given community. To this effect, all Okoa ambulances are outfitted with a robust suspension system built to withstand extremely bumpy or muddy road conditions, a roll cage to protect passengers in case of traffic accidents, and a removable stretcher for patient transport. Individual Ambulance models are modified from these fundamentals to include local considerations.  

The mechanics of an Okoa Ambulance are simple, and the dependability and familiarity of its technology is a key factor of Okoa’s business model: by emphasizing local manufacturing and reproducibility, Okoa fosters long-term implementation sustainability that can be trusted to provide emergency transportation and grows the economy of local communities. 

Okoa Ambulances have been in use since 2018, transporting an average of 250 patients per year. In the first 5 months of our ambulance service in Tanzania, we transported over 100 people to the hospital successfully, including pregnant women, malaria, and critical trauma patients. All 3 ambulances we manufactured for our pilot program in 2018 have been repaired by local technicians, and all 3 are still in use today.     

Every new Okoa ambulance serves an average of 5,000 people and transports about 250 patients per year. The three Okoa Ambulances currently in circulation in Tanzania affect a total of 15,000 people in 3 villages, with new additions in Ghana and Tanzania set to add 46,000 for a total of 61,000 beneficiaries by the end of 2020. 

Within the next five years we plan to expand from our Ghanaian pilot site in the the Sissala East district to include all 260 health districts in Ghana, as well as leverage relationships we have built in Zanzibar and Nigeria to begin programs of 10-20 ambulances in each location. This expansion will bring our total affected population to 2,700,000 people.  

In the coming year, we will be expanding operations to 3 new health districts in Ghana and securing a contract with the Ghanaian Ministry of Health. This contract will facilitate our expansion to all 260 health districts within the next 5 years and help establish our operation in Ghana as a model for innovative emergency care in the region. The Ghanaian government’s proactive position on addressing maternal and infant mortality combined with the need for vehicles to supplement the National Ambulance Service make Ghana an excellent environment for scaling our operations country-wide.  

While we work toward expansion in Ghana, we are also continuing operation in Tanzania and exploring opportunities for pilot programs in new countries. We project to have provided 1000 patients with emergency transportation by the end of 2020. We are in the process of developing pilot programs in Zanzibar and Nigeria, to be launched within the next five years, and are in Research and Development for a sensor that will detect and document every use of our ambulances to compile the data we need for accurate Monitoring and Evaluation of our programs.  

One of the most significant barriers to our expansion is the lack of health data in the region. Although it is widely accepted that maternal and infant mortality rates are too high in our operating countries, specifics such as cause of death or the rates of home birth vs. hospital birth are not readily available. There is little data regarding how to implement such a service effectively because previous attempts to provide emergency transportation have been short-lived and unsuccessful. This lack of data limits our ability to obtain funding and, particularly in the face of political attitudes that predispose officials to neglect maternal mortality, make it difficult to meaningfully scale our operation. This posed an issue in Tanzania, where our community connections enabled our initial pilot program, but regulatory barriers impeded our ability to scale in the country for the time being.

Our second major challenge is designing a business model that would allow us to scale in a way that is financially sustainable while maintaining our deep commitment to community involvement. It is essential that Okoa Ambulances are designed with the consultation of community members and patients and manufactured locally, but managing such a decentralized operation poses a unique challenge that the Solve community’s experience would greatly aid in overcoming.  

We have leveraged our partnerships and begun development of new data-collection technology to address the lack of available data. Our local partner, The Virtue Foundation, has been working toward health solutions in Ghana for 10 years; they have agreed to share their data from past programs and partner with us to conduct a data mapping project across Ghana’s healthcare system. Additionally, the sensor project we are developing will monitor the use of our ambulances with GPS tracking to compile the data we need.  

In developing our business model, we have examined microfinancing strategies that will aid communities and entrepreneurs in raising money to purchase Okoa Ambulances and plan to implement a hybrid for profit/nonprofit model that would allow local actors to generate profit from the manufacture and management of Okoa ambulances.To fund the maintenance of the ambulances and ensure that services stay affordable to patients, we have developed community-based insurance and maintenance plans.   

To help overcome political and bureaucratic barriers, we are developing a strategy for picking effective and enthusiastic community partners. Our aim is for each of our country projects to become self-sustaining within 3 years of implementation, and we hope that the Solve network can help us develop this strategy and grow our network in the region.

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Okoa is made up of 4 full-time staff members, 2 part-time staff members, 4 contract workers, and 8 volunteers.   

The four full-time staff members are the Executive Director and the Director of Fundraising and Marketing, both based in Boston, and the Country Directors in Ghana and Tanzania, based in those countries. Part time staff include a project manager and government liaison in Tanzania, and the contract workers are in-country engineers for our existing programs.

The Okoa Project team has spent the past four years becoming experts in emergency transportation, and our combined expertise in engineering, nonprofit operations, and local contexts create a holistic approach that positions us well for delivering this solution.  

We have conducted hundreds of hours of research into emergency systems to learn about differences in staffing and equipment provision, implementation methods, and the local factors that determine a given system’s success. We have worked with 20 public and private emergency response organizations in the region, and understand the contexts of this transportation gap and the considerations that need to be made to resolve this healthcare problem.     
 

Our Executive Director, an MIT graduate in mechanical engineering, works with our experienced, locally-contracted engineers to ensure that each ambulance model is functional, practical, and replicable with local resources. Our Country Directors are Ghanaian and Tanzanian nationals, respectively, with a deep understanding of the local contexts we are operating in; our Ghanaian CD is a project management and program development expert with a Master's degree in Sustainable International Development. He has experience in the country’s health sector, and is well-positioned to both supervise Okoa’s Ghanaian operations and build relationships with local officials to expand and sustain Okoa’s work. Dedicated Okoa volunteers based in the US and Tanzania assist with grant writing, Monitoring and Evaluation, and individual giving to supplement the work of our paid staff and build Okoa's capacity. 

Our country partner in Tanzania is The Olive Branch for Children (TOBFC), a grassroots organization that brings programming and resources to remote areas of the country. We have been working with TOBFC to coordinate and conduct interviews with community members, identify specific needs within each healthcare district, and implement our Motorcycle Ambulance Trailers (MAT). Their status as a nationally recognized organization has helped establish Okoa’s legitimacy in rural Tanzanian communities.  

In Ghana, we work with The Virtue Foundation (TVF) and the Sissala East Health Directorate (SEHD). TVF is a non-profit with over 10 years of experience in Ghana implementing development solutions to health challenges. TVF is very well-connected in the Ghanaian government, with one board member on the supreme court and a well-established advisory council. They assist our operations in Ghana by helping coordinate meetings and needs assessments, and we are working with them to implement, monitor, and evaluate the project. SEHD is the local government body responsible for healthcare in the district. Our partnership with them helps us raise funds for community ambulances and expand into new communities and healthcare districts by leveraging the existing infrastructure created by the NAS.  

Autodesk Technology Center is a co-working space in Boston from which we direct our operations in the US. As a member of their residency program and foundation, we have access to Autodesk resources and technological consultants. 

We are a company that provides collaboratively designed motorcycle ambulances as well as consulting and training services in the initial stages on how to best manufacture the products and conduct an ambulance service in a community context. We provide all of our services through a partnership model, in which we work with in-country partners that have strong community and institutional relationships and can build the capacity to manage an ambulance service once the product is developed and an operational infrastructure is established.  

Up to this point, Okoa has operated as a strict nonprofit that donates the time and capital to develop and manufacture initial ambulances, while our partner organizations leverage community relationships to encourage involvement in our needs assessments and gather the manpower to manufacture and operate the ambulance service. Our aim is to move away from this strictly nonprofit model and toward a hybrid nonprofit/for-profit model that would allow for revenue generation for local technicians, drivers, and other local entrepreneurs.   

The Okoa Project has been operating with a focus on implementation sustainability, but as we move out of our pilot phase we have considered a combination of strategies toward a hybrid business model that would create financial sustainability for our solution. While we are confident we are moving in the right direction with these strategies, the development of a financially sustainable business model is one area we are particularly seeking the Solve community’s expertise to improve.  

 Our plan for a hybrid business model includes in-country, for-profit branches that manufacture automobiles and ambulances, with a non-profit US headquarters that is focused on community innovation and consultation services. Through microfinancing programs with local banks, we expect that communities will be able to generate revenue to buy Okoa Ambulances independently, and with “evergreen funds” that would act as community-sourced insurance plans, we hope that communities will be able to generate enough revenue to cover the maintenance and operation of our ambulances, making them financially viable in the long term.  

As 2019 Solve finalists, we have an acute understanding of the kind of direction the Solve network can offer, and our recent growth has put us in an ideal position to utilize that network. The past four years have proven to us that a community-centered approach is essential to the efficacy of emergency transportation, but that same approach makes expansion, distribution, and management significantly more difficult. We need the partnership of funders, local governments, and technological innovators to expand our reach and realize our potential. Since the launch of our first pilot program, organizations in almost 20 countries have expressed interest in partnering with The Okoa Project, and we are looking to scale our operation. The Solve community’s international scope and experience with both technological and programmatic innovation is exactly the type of support we need to make inroads in those countries and build a revenue model that will allow each program to become self-sustaining. The Okoa Project was born of an MIT class assignment, and the MIT community is one we are extremely proud to be a part of. With the tailored guidance and mentorship of the Solve community, we can further develop our operation and move a step closer to eliminating transportation delays in obstetric care. 

In the near future our priorities are securing our partnership in Ghana and developing a financially sustainable business model that can generate revenue for local stakeholders and can be expanded to multiple countries under the Okoa umbrella. With the Solve community's experience in business innovation and international relationship building, we hope to solidify our partnerships and our business plans, achieving these goals and expanding further in the next few years. 

We are looking to partner with companies in the automotive, healthcare, and telecommunications industries in order to improve our products and operations. Automotive and healthcare companies would be able to provide guidance on the quality of our product and refining our distribution method, while telecommunications companies could help us perfect the dispatch systems we use to direct our ambulances.  

We are also looking to deepen our involvement in Ghana by partnering with government agencies and Ghanaian organizations. We have been working successfully with the health directorate in the Sissala East district, and are on the cusp of a contract with the national Ministry of Health that would expand our operations in the country. The Ghanaian government began focusing on emergency transportation strategies after it was revealed the country only had 55 ambulances serving the collective population. Therefore, we are interested in the Solve community’s guidance in solidifying that partnership on the national level, and would welcome the opportunity to partner with ridesharing organizations to streamline the implementation process.  

We have explored the idea of a partnership with the drone company Zipline, which provides rapid drone delivery of medical supplies to remote locations. With Okoa on the ground and Zipline in the air, our combined efforts can create a holistic emergency response approach.

Our solution prioritizes the concerns of women through the inclusion and prioritization of obstetric patients and maternal healthcare workers. We directly address patient concerns in the design process to reduce fear as well as physical risk in order to improve the quality of life of women and girls. When patients told us that, above all, they were too scared to make the journey without a family member, we ensured that the Okoa Ambulances had the space to accommodate a passenger, and every Okoa ambulance is equipped with a birthing kit for assistance during roadside deliveries.  

We developed relationships with Tumu Technical High School and Kanton Senior High School in Ghana and began creating engineering workshops for female students interested in STEM to encourage their participation in the field. With the funding to scale our production and expand further into Ghana, Okoa Ambulances can provide a reliable enough form of emergency transportation that pregnant women don’t have to live in fear of seeking adequate healthcare. 

As a low-cost alternative suited to difficult conditions, the Okoa Ambulance is a new tool that can support the workforce’s infrastructure to provide better, more prompt healthcare to obstetric patients. In Ghana, rural patients seek care at local clinics, where they are referred to district hospitals. The National Ambulance Service (NAS) was established in 2014 to transport patients between these locations, but as of 2020 only 55 ambulances serve the country’s 30 million people. Additionally, Okoa’s solution necessitates the hiring of health dispatchers, nurses, and ambulance drivers trained in first aid and birthing care for every Okoa Ambulance distributed, which expands the country’s health workforce. We have developed partnerships with Ghanaian government health institutions and have begun discussing plans to expand Okoa Ambulances across 3 new Ghanaian districts and utilize the 133 NAS stations throughout Ghana, many of which are empty, to expand to all 260 districts in the next 5 years.  

The Okoa Project’s commitment to working within local systems makes us an ideal candidate for the Bill and Melinda Gates Foundation Funded Award. We work in collaboration with obstetric patients, healthcare workers, and local governing entities to learn about the myriad obstacles that have prevented the success of previous ambulance services and find the right solutions for a given community. At $1,200 - $2,000 USD, our ambulances are 1-2% the price of a traditional Western ambulance and less than half the price of competing motorcycle ambulances that have proven to be less adaptable to local conditions than our models. Our low price, combined with the microfinancing and maintenance plans we have developed in our communities, make our product the most affordable solution on the market.  Additionally, Okoa’s solution necessitates the hiring of health dispatchers, nurses, and ambulance drivers trained in first aid and birthing care for every Okoa Ambulance distributed, which both expands the country’s health workforce and facilitates opportunities for economic growth within the rural communities we serve.    

While we hope that Okoa will eventually be able to provide reliable transportation for all emergent patients, our top priority remains to be the reduction of maternal and infant deaths. When seeking the consultation of local stakeholders, we first and foremost look for the factors that prevent laboring women from reaching the care of a medical professional safely. When our interviews revealed a collective and prohibitive fear of having to deliver their children on the side of the road or making the dangerous journey alone, we fitted our ambulances with birthing kits and the space to accommodate a family member. Catering to all the patients’ concerns not only encourages trust in the Okoa Ambulance, but also eases the nerves of patients during the ride, which reduces the physical toll on their bodies. 

Our partnership with the Sissala East Healthcare Directorate has shown incredible promise, and we are in the process of securing a contract with the Ministry of Health on the national scale to supplement the Ghanaian National Ambulance Service (NAS). By working directly with government entities, we can appreciably increase our reach and provide practical and sustainable emergency transportation to the greatest number of people.