Emily Young

INCEPTION, EVOLUTION, AND ADAPTATION

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What's your background and how did Moving Health get its start?

My background is in mechanical engineering and product design. The way Moving Health got its start is when I was introduced to the problem space while I was at MIT. I was taking a class through MIT’s D-lab that basically connects students with an international company or organization somewhere abroad in which the students act as design consultants.

The way that most of the projects worked is that the partner came to the students with an existing prototype, but our partner came to us with the problem - getting pregnant women to the hospital safer and faster than existing options in rural Tanzania. We ended up building the first prototype of a motorcycle ambulance that could integrate into the existing motorcycle taxi system. We had a group of four mechanical engineers working on the idea and we built this very proof-of-concept prototype for the class, which was just a two-wheeled trailer that could attach to the back of any existing motorcycle. While our main focus was the build process and showcasing the attachment mechanism for the motorcycle,  we all ended up finding the overall problem space really interesting.

From there we began looking for funding from MIT to be able to travel to Tanzania and actually make a prototype for the partner that we had been working with. We were introduced to an amazing innovation center in Arusha, Tanzania by Mount Kilimanjaro called Twende. That's where I think we realized that we were going to have to scrap everything that we had done in the class and that we needed to have much, much more lived experience to design a solution for this emergency transportation need.

We ended up conducting several hundred interviews with rural community members, local health workers, and clinicians to really try and understand the problem. That's when we started working on a new prototype for the motorcycle ambulance concept. One of the most interesting things that we see with our engineers and designers in Ghana who oversee our manufacturing process is the noticeable difference in design thinking and communication styles, which can be attributed to the diverse training and learning experiences they’ve had. Working with Bernard, a master fabricator in Arusha, or Ambra, one of our engineers in Ghana. They're both incredibly creative and talented, and they communicate early-stage ideas much differently than I would.

I remember I came up with these sketches for the first ambulance design and no one wanted to even look at the sketches. Everyone was like, why did you do this? This is not how we do things here. Everyone learns how to build things by actually building things. My sketch models are not the way that people who grow up with apprenticeship-style training are communicating their ideas. They learn by building, and it's been a cool transition into that design process. Instead of drawing it out, let's build a version of it right now and work through what the shape could look like by actually building different versions. And let's figure out how to make this hinge, not by modeling it in, but by going through the scrap pile and figuring out how these mechanisms can work together. To move away from this computer-aided design prep, to let's just dive in and build was a wonderful experience for me. It's much easier to communicate in this space if we build in person.

It feels like a way to fail faster than we typically would going through a more traditional iterative design process. I got a sense of that when I worked with Ampersand in Rwanda. It very much started out like that as well. Hands-on, let's get dirty. Let's figure out what doesn't work before we figure out what does work. Being from the US and going to a design or engineering school has shown us a much different approach to these types of problems than the people who are there. I went into it thinking I knew what I needed to know and ended up scraping everything. I learned a lot.

Exactly. I think there's a horrible misconception that if you go to an American engineering or design school, you know the way and that people are gonna learn from you. I think it's really important to be able to understand that we have so much to learn from other ways of doing things and obviously the way that I learned is not the only way.

How do you get from Tanzania all the way to the other side of Africa to Ghana?

We worked in Tanzania for three years. We set up a very small manufacturing space for the trailer ambulance and were able to run a pilot in 2018. We ended up gaining traction and getting a lot of interest from maybe 20 different locations of partners who were looking to pilot these ambulances in different countries. At the same time, we started to experience some pretty significant regulatory changes and hurdles in Tanzania. So we said let's make a list of criteria and all of the factors that we would need to seriously consider a pilot in another country. We found all of those criteria checked in Ghana with a partner that we had. That led us to do an assessment trip in 2019.

One of the main things that I was looking for was creative engineers that could lead the manufacturing side of the project. Ideally, these engineers would live in a similar geographic location to where we would do the pilot. We had the opportunity to meet Ambra, a local engineer, inventor, and fabricator who was introduced to us by our partner. He had made a name for himself by building his entire car from the ground up from recycled parts. He had also designed a fufu pounding machine and was working on building agricultural tilling machines. He embodied everything I could have ever wanted in a collaborator to join us on this project. He exuded creativity with everything that he would say and built. That, combined with some other factors like government connections sold us on trying to make it work with this partner in Ghana, the Virtue Foundation.

One of the big things that we have always prioritized at Moving Health is making our products extremely human and community-centered. I believe there is a significant distinction between merely understanding the communities intended to utilize a product and ensuring that these communities not only have a voice but actively engage in the design process at every stage.

“It was a really interesting and beautiful representation of why human-centered design is so important and why working directly with users and having the communities participate in more than just one step of that process is so important.”

We wanted to take what we had done in Tanzania, and not recreate the product, but recreate the process. We conducted thousands of interviews with stakeholders and collaborated closely with both the local health directorate and the national ambulance service. We ultimately ended up designing a completely different ambulance from the one that we created in Tanzania. It was a really interesting and beautiful representation of why human-centered design is so important and why working directly with users and having the communities participate in more than just one step of that process is so important.

The ambulance we designed in Ghana is a tricycle ambulance. It's fully motorized, there's space inside for a removable stretcher, two family members, and a medical provider. Whereas in Tanzania, the ambulance was a trailer that could attach to the back of any existing motorcycle and leverage vehicles that were already widely used in the area. Different concepts entirely, with two very different health systems, geographies, and experiences of the rainy season. We were able to see all of those differences manifest in the two different designs.

Were these design considerations weighted more by the cultural and geographical differences or by what you learned from your build in Tanzania?

I believe it was an equal blend of variations in geography, culture, and our organization's readiness after incorporating all the lessons we learned from conducting a complete pilot with the trailer ambulance.

In Ghana, Ambra was able to make our first prototype of the ambulance in seven days which I thought was unbelievable. We ended up deciding that the way that we wanted to iterate on the next designs was to again focus on prototyping and learning through physical experimentation instead of trying to perfect it in CAD. So we said what we're gonna do is build five of these ambulances in succession and each one is going to be an improvement on the last one. We're going to build one, do some testing, have the whole engineering team meet and talk about what could be improved upon, and then we're going to start building the next one, and repeat this process.

We ended up creating five ambulances this way because we wanted to have five for our pilot. Each of the ambulances was an iteration of itself and was going to be piloted to test out the different features of each iteration.

It sounds like your own style of an intense design sprint. I assume that your design studio looks a bit different than what we'd be used to seeing stateside. Could you paint a picture of what it looks like?

We have a workshop space in Pulima, a town in between the districts of Sissala East and Sissala West. This workshop has two main indoor work spaces. One is storage where we have the chassis of the ambulances which are the only imported part of the vehicle, everything else is sourced locally. The main part of the workshop is all fabrication tools. There are several homemade welding machines, there are angle grinders, a lot of measuring tools, and rivet guns, but there is not as much precision machining as you might think.

Largely what you see are the mock-ups of different designs we are considering. If you were to look in the storage area of our workshop, you’d probably see several different driver compartment form factors that we had been experimenting with. There is also a pretty large outdoor covered space where a lot of the fabrication work gets done. A lot of the finishing is done outside which makes it easy for us to get on the road and start testing immediately. That's the workshop that we’re working with.

I'd imagine coming from the lab at MIT and having all the tools you had access to there, to working with handmade welding machines in your fabrication shop in Ghana has to be a bit frustrating?

You know, people ask me about that a lot and, in contrast to frustration, my main reaction is actually to be very inspired. I feel so in awe of what our engineers are capable of and the creativity that they bring and the fact that they don't get to rely on hyper-precise machines you might have access to at the workshop at MIT. I think that goes to show the level of creativity and ingenuity we’re working with, it’s substantial and it’s extremely exciting to work beside.

For example, the driver's compartment. How would you make a driver's compartment in a shop at MIT? After spending a ton of time in your computer program, you would probably try and mill a dye and then press the individual pieces. You would go about learning how to use the state-of-the-art pieces of machinery and it would likely take you a month. Compared to our workshop in Ghana, where you see our engineers prove ideas by literally hammering a wooden mold by hand that you can then hammer sheet metal onto. And that can be done in two days. It makes the iteration process that much faster and I feel like it allows for a level of concept exploration and speed that I wasn't used to ever seeing before. It is extremely exciting to be around.

From a product and service standpoint, are there any major design changes you made from the earlier prototypes to the Sissala Tricycle that you guys have now?

The prototype ambulances that we used in the pilot were, I'd say, a simple proof of concept. They didn't have as much bodywork done and the form factor wasn't completely decided. We wanted to run those to get feedback on how people used it, generally see if people were interested in this type of vehicle, and build from there. The Sissala Tricycle that we just launched is an aggregate of all the feedback that we heard and all the lessons that we learned. 

A big change we made between the prototypes and our final product was improving the stability of the vehicle. We started with shorter ambulance models and decided to extend the chassis by pushing the axle back. Added stability was important and necessary, especially in the rainy season when there's a lot of mud or even after that mud is dried and the roads become very uneven. 

Another thing we changed was to have our stretcher removable from the back of the ambulance. It's a lot easier to have a fixed stretcher in the vehicle, but we found that if we wanted to carry the patient into the clinic from the ambulance, we needed to make it a removable piece. We added lighting on the inside of the ambulance for night rides. Whereas the prototypes didn't have that.

We also added GPS tracking sensors that can give us ambulance usage data from whoever is running the ambulances and a dashboard in which we can track it. A big thing we learned from the pilot in Tanzania was how important it was to have a backup to written usage logs and how valuable last-mile data is.

However, one of the most interesting pieces of feedback we incorporated into the ambulance based on our community interviews, was adding a birthing kit that would be in the vehicle at all times. We found a very common situation in which mothers would wait until there were very obvious complications late in the pregnancy before they would go to the hospital. So a very common scenario involved mothers giving birth while en route, prior to reaching the hospital.

Is waiting to see if complications arise a cultural norm or just a lack of resources?

It's both. Most women would prefer to deliver at home with a traditional birth attendant who's typically someone they trust. It's often only if there's a complication that the mother will decide to go to the hospital, but they obviously intend on avoiding that situation. I think there's a general lack of trust that the healthcare system in these areas can do everything that you want it to. Or maybe they haven't heard of very good experiences. On top of all that, these people live very far away from the hospitals and in general would prefer to deliver at home. Based on that information, we wanted to include the capacity to safely deliver a baby in the ambulance.

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GEOGRAPHICAL STRATEGY, PILOT SUCCESS, AND GROWTH CHALLENGES

Do you have a headquarters or a dispatch center? How do you decide where the ambulances should be located so that you can reach the max amount of people?

We wanted to work very closely with the local health directorates to identify communities that have the most need, determine where we could reach the most people, and station the ambulances there. The health system in Ghana is tiered. The lowest hierarchical level of facility, the CHPS (Community Health and Planning Services) compounds, are the lower-level rural healthcare facilities. The next level is the health centers or the district hospitals, and then at the highest tier, you have the regional hospitals where you would see traditional ambulances that you’re used to seeing in the United States stationed. Those ambulances tend to remain in the cities and seldom venture into rural areas due to their large size, which makes it considerably harder for them to navigate rural roads. If they were to experience a breakdown in a rural area, there would be significant difficulties maintaining them.

We have been working with the health directorate to determine which of the CHPS compounds are the ones that would make the most impact to have our ambulances stationed at. By stationing a single ambulance at a CHPS compound, we can provide access to emergency transportation to about 2500 people. We saw in our pilot that we were able to increase ambulance rides in the district by about 5x.

Before we get to your pilot, which looks like it was pretty damn successful, can you talk about that moment where you guys took that leap from proof-of-concept to all right, we're going to try and save a mother and baby, let's test this for real.

I think there were a lot of steps in between those two phases. Before we really dove in, we wanted to make sure that we felt very confident about the ambulances being able to handle long distances. We created a 1000-kilometer driving test that all the ambulances had to endure. Someone would drive the ambulance 1000 kilometers. We calculated 10,000 kilometers as a representation of the lifetime of our vehicle and wanted to be sure that our product could withstand the first 10% of its intended lifecycle. That level of testing allowed us to feel a lot more comfortable deploying the ambulances in the field.

We also had a very robust maintenance network that was set up before the pilot started to make sure that the ambulances would not go out of commission if something did end up breaking. Two things that I found interesting in that. The first one was, I had done some work at companies where there's an entire accelerated life cycle testing department. They have huge machines that run functions on products thousands and thousands of times. We didn’t have that. We had to rethink that and say you know, we're not going to have a treadmill that runs the ambulances thousands of kilometers for us. Rethinking what that testing looks like in a lower resource setting was a very interesting challenge in itself. The other piece of that is there's the idea that you want to build something that will never break. But in reality, things break. It's important to be very aware of what is most likely going to be the thing that breaks and create a system that can manage that. It’s crucial to take that type of mentality seriously in rural areas and last-mile settings.

When we talk with partners now, I think the thing that makes them say, ok you guys have really done your due diligence, is that we have our maintenance network. We have trained mechanics on staff and we know what pieces need to be maintained and by what cadence.

It looks like you were able to provide access to emergency transportation to more than 10,000 people in your pilot?

Our pilot started in 2021 and we had about 10,000 people that had access to our ambulances in addition to the actual number of emergency rides that we gave. We were able to take about 300 patients to the hospital during our pilot and over half of those were pregnancy-related cases.

We wanted to make sure that people felt like there was a trusted emergency system if there happened to be an emergency in their life so we also ran educational campaigns about when you would need to take an ambulance. Because of this, there was a pretty dramatic increase in rides in the second year compared to the first year. There is a slower adoption process with introducing a service that communities have never had before. And so if you just drop this ambulance into a community and you're like, this can take you to the hospital in an emergency, but no one's ever taken an ambulance to a hospital in an emergency before, there's gonna be a longer trust-building component of it all.

If I'm a person in the area that you service and I require emergency transport, am I paying for this ride? How do I contact you? Can you walk me through the process of picking someone up and taking them to the hospital?

Within each of the communities, there's a healthcare committee that represents the local health directorate. It was critical for us to integrate our system into the existing healthcare system. So what we've done is work with the healthcare committees to receive the call and run the dispatch while we help publicize phone numbers as emergency hotlines.

We typically see two different types of rides. There is the community to CHPS compound rides, and then the rides from a CHPS compound to a higher level facility as a referral. If you're in the community and you need the ambulance to take you to the CHPS compound, you can call the phone number and someone will pick you up. If there's no network coverage, or if a patient lives close enough to walk to the CHPS compound, they can check in there and then a nurse can refer them to a higher-level facility via our ambulance.

Aside from the product and service challenges we’ve touched on, what are some examples of challenges that you as the CEO face day to day?

I think right now my biggest challenge is scaling up. We've had our product launch and now there's the question of how do we scale up our manufacturing in a way that is still as community-focused as possible. How do we scale up the operations side of deploying these ambulances? One big challenge has been finding reliable pricing within our supply chain because of currency fluctuations. Because the Cedi (Ghanaian currency) has been fluctuating so much, we've been having a hard time getting consistent pricing from our suppliers and that's made it an interesting time to have a product launch.

Setting up the local manufacturing operation has also been a challenge, but it's also been really exciting. One of the largest industrialized zones in Africa is in Ghana called Suame Magazine which is known for its incredible automotive fabrication and invention hub. It's made up of thousands of fabricators who are making everything from their own injection molding machines to the vehicles that they drive.

Our primary objective was to learn from these experienced fabricators, enabling us to explore the possibilities of manufacturing our ambulance locally to the highest degree possible. We ended up collaborating with several bodywork fabricators who specialize in crafting vehicles using hand-pressed metal that you would swear looked like high-end designer vehicles. We wanted to empower our team to learn from this exceptional skillset already present in the country.

At the same time, we began scoping out potential suppliers that we wanted to source from. That process looked quite a bit different than it would in the United States where you can order from McMaster. Instead, we had to physically travel to the steel fabricator shop, only to discover that the master fabricator might not be there. With no website or phone number, you return after a few hours and hope he’d be there. It involved browsing through the available stock, locating the required items, and eventually negotiating a deal. That in and of itself was a pretty lengthy process to get our supply chain set up.

From there, we got to work with this group called ITTU where we built our first production sample.  ITTU is a school or knowledge transfer center that was created to formalize the education and informal talent in Suame Magazine. It's a lot of apprenticeship training, but all the people are wildly talented.

After that, we had to figure out how to replicate this same process in Northern Ghana where our pilot and workshop are. We had to determine what tools we were going to need, what our assembly process should look like, and what manufacturing order we want to work in. Where can we be creative? Can we make it modular? All that came together in the past few months when we had our first batch of vehicles finished in March. Now we're able to manufacture batches of 5 to 10 ambulances in about eight weeks at a time.

How many ambulances do you currently have in use today?

During our product launch, we unveiled five new ambulances, distributing one to each of the communities that actively participated in the pilot. This was a direct result of the invaluable feedback they provided, which greatly contributed to the refinement of our ambulances.

As we continue to expand our efforts, we're not only finishing another batch of six ambulances, bringing our total to 11 new units, but we're also diligently refurbishing the five pilot ambulances. Looking ahead, our goal is to manufacture an additional 10 to 15 ambulances by the end of the year. This growth is not only impactful but also financially efficient – considering that our ambulance costs $10,000 each. Meaning you could acquire 10 to 15 of our ambulances for the price of a single traditional four-wheeled ambulance, comparable to what you'd find in the United States.

That's amazing. Sounds like you’re rolling. That said, where do you currently need the most help?

Our main bottleneck right now is funding. We're a nonprofit, so raising enough capital or finding funding partners to be able to scale up and continue pushing manufacturing forward is one thing.

We're also looking for advisors or volunteers with expertise in automotive product commercialization. We're transitioning out of a more R&D side of the company to a more outward-facing version of Moving Health, so we’re actively searching for people with expertise in those areas.

What's next for Moving Health?

We are really excited to be focusing on expansion finally. We're launching some ambulances in a new district called Wa East later this summer. We’re expanding into our first new district outside of the one we conducted our pilot in, and we are actively looking for partners to be able to expand our operations across Ghana. We aim to prove what it looks like to have a lower-cost ambulance option supplementing an existing national ambulance fleet. We're hoping to be able to provide ambulances to as many communities in rural Ghana as possible. Then eventually in the longer term, expand outside of Ghana to West Africa, East Africa, and all other geographies that are in need of a vehicle like this.

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Emily Young is the Co-Founder and CEO of Moving Health in Accra, Ghana.