The trouble with good intentions

A few days ago, I helped go through a shipping container that an organization in Uganda had received from its main donor in Europe. The Ugandan organization works, amongst other things, with children with disabilities and as such the container held wheelchairs, walking frames and standing frames.

I’d been asked to help as I’m a paediatric physiotherapist and use similar equipment at my workplace in London. Right now I’m on a career break, but am working in a children’s centre for children with disabilities in a small town in Uganda. I was excited to go through the equipment because the centre and this organization both see a large number of children with disabilities who would benefit from assistive equipment. My excitement, however, soon turned into a mixture of confusion, frustration and anger.

The confusion hit me first. Had there been an accident? Is that why everything was a big mess and the majority of the equipment was either broken or had large parts missing?

Frustration then crept in as it became apparent that instead of identifying suitable equipment for those who needed it, we would spend the time trying to figure out what could be salvaged.

Then came the anger, because it was clear that much of the broken equipment had been donated in that state. There were broken wheels, missing parts, seats and belts ripped beyond repair. These had been placed in the container to be donated, despite being broken and unsafe. Why?

The donor organization has been supporting the beneficiary organization from the very beginning. I learned that there have been visits through the years by the donors and they receive regular reports, so I assumed they would have a fairly good idea of what type of equipment would be most suitable.

Once the soup of emotions had settled, another volunteer and I started the task of going through everything, taking pictures and cataloguing all the items to make it easier to identify and distribute suitable equipment. We had planned to put all the working equipment in one pile and the equipment that needed fixing in another. However, most of the container would end up in the broken pile and that was just too depressing, so we decided against it.

I do believe that these donations were made with the best of intentions and I am not saying all donations are bad. But I do think donations that are not clearly planned and managed jointly with the beneficiary can be wasteful, even harmful, for numerous reasons.

Firstly, the majority of the donated equipment was broken or had parts missing – and we’re not just talking about a screw or a strap that can be replaced easily. When a wheelchair is missing brakes or one of its backrest poles, or a walking frame is missing one of its legs, the equipment becomes unsafe and useless. It’s difficult to get replacements and local technical expertise is often scarce, so broken equipment remains broken.

The World Health Organization’s (WHO) Guidelines For Health Care Equipment Donations states: “There should be no double standard in quality. If the quality of an item is unacceptable in the donor country, it is also unacceptable as a donation.”

I doubt that any equipment in that state would, or could, be used in the donor country, so why was it acceptable to ship it to Uganda?

Did the donor think the equipment could be fixed locally? Or was the cynical voice inside of me on the right track, the voice which said that Africa as a whole is often seen as an acceptable dumping ground, from hazardous waste and second-hand clothing to electronics?

Secondly, some of the equipment was not suitable for this setting. There was a supportive chair that requires electricity to be moved but the charger and cord were missing. Even if they had sent everything, most homes here have little or no regular access to electricity. Again, the chair that might be suitable in a home or school in a European country may not work in a small town in Uganda.

Thirdly, some of the equipment could be fixed locally in Uganda, but it would require someone who understands the equipment and how to maintain it.

The aforementioned WHO guidelines also emphasize: “The most important pre-requisite for a successful donation is that the potential recipient truly needs the requested equipment and has the expertise and the means to operate and maintain it.” When we found a couple of standing frames suitable for children with more complex physical impairment, the staff member who carries out the therapy sessions, just looked at me puzzled. Perhaps that would explain why the container had not been touched since it arrived more than a year ago?

Back home, we have to have training before we start using equipment like this to ensure we are competent enough to use them and that the user is safe. I understand that this is not an NHS trust in the UK and during my time here I have been very conscious about not falling into the trap of a ‘West knows best’ attitude. But there are some things that I feel should be universal, such as knowing how to use equipment to minimize any potential risks to the user and the people giving it out.

Lastly, and the issue that I think has the potential for most long-term harm, is that donating things that we would not be able or want to use at home perpetuates the old view of ‘poor Africans’ needing ‘our’ help. It enforces that ‘they’ on the other side are poor, ‘uneducated’ and have no means of supporting themselves, so of course ‘we’ should come and ‘save’ them.

It’s this idea that ‘they’ who have nothing according to our standards, will be grateful for literally anything, even if it is something that is useless.

I know that this is a perhaps a very cynical view on things. I was definitely not thinking like this before I came here four months ago, but my cynicism has grown from repeatedly witnessing how poorly planned donations – no matter how good the intentions are – have caused problems. A doctor told me a European donor sent them several incubators for newborns requiring medical input. This is, in theory, great. Except no one knew how to use them. The donor had not provided any training or an instruction manual. Furthermore, some were broken and no one knew how to fix them, so they are just sitting in a corner, taking up space in an already cramped room. This, unfortunately, does not seem to be a one-off incident. WHO estimates (pdf) that in some countries around 80% of health-related equipment is donated by international donors or foreign governments, but lack of training and poor coordination in the procurement process means only 10-30% of this equipment actually becomes operational.

The response to why this is not brought up with donors seems to be same. The beneficiaries do not want to seem ungrateful as they rely heavily on aid and donations, so donors think what they are doing is beneficial and continue to send equipment that is either broken or not being used correctly because of a lack of training. And so the cycle of continues; the line between donating and dumping becomes blurred.

This is not just an issue with donations to developing countries. I remember helping out at a homeless shelter at Christmas and a group of us were tasked with sorting out donated, winter clothes. There was bag after bag filled with good, warm clothes, which warmed my heart. But there were also clothes that were filthy, ripped and broken beyond repair. Again, I think this is the view that ‘the poor’ have it so bad that they will be thankful for anything. Dignity is not measured by the size of your wallet. We don’t realize that by doing this, we are stripping people of their self-worth.

I am not claiming to have an answer on how to solve this complex problem. The longer I am here and the more I learn, the more I realize just how little I know and how I have been equally guilty of doing the same things that I am opposing. I am also conscious of not letting my growing scepticism toward aid and volunteering take over. There are good examples and there are bad ones. Poverty, Inc highlight some of the these.

Perhaps, as a first step, we need to get better at communicating. We need to ask the beneficiary what they actually need. We need to know what is appropriate for their setting. Without good communication, the beneficiary might end up with a container full of unsuitable equipment and leave its doors locked for more than a year.

Secondly, we need to ensure that both parties are confident that once the equipment reaches its destination there are staff with the right knowledge and skills to set it up, distribute it and maintain it. We also need to be certain that spare parts can easily be found locally. Training is vital and can be delivered in numerous ways. If it cannot be done onsite then there are written manuals, video training sessions, and videos saved online or on a CD if internet access is limited.

Thirdly, we should not focus on the quick fix or that short-term, feel-good factor, as tempting as it is. Let’s face it, we all like feeling good, especially when it comes quickly, but doing so fools ourselves and cheats the beneficiaries. We need to know what the long-term effects are. Donating equipment might solve problems for a few recipients, but a quick fix has numerous problems. It creates a dependency on the donor, which is often not sustainable (what happens if the donations stop?). It also perpetuates the inequality and power difference between those who have and those who do not.

Lastly, is this really the most efficient use of money? The container came from a landlocked country in Europe and was delivered to Uganda which is also landlocked. I spoke to a former colleague at the International Transport Workers’ Federation who advised that shipping a 40ft container from the UK would cost around $3,400. The cost of sending it from a landlocked country would be higher. The average salary for a physiotherapist in this town is around 970,000 UGX or £215 per month. The cost of sending that container could in effect pay the salary of a local therapist for a year. If we are getting most of our equipment from local and national providers, why shouldn’t the same work for other countries? There may be local providers who can provide locally produced equipment, but these groups will struggle to compete if there is an influx of donated items that are free, even if they’re not suitable.

Why not use the money saved on shipping to support someone locally to produce the equipment and use their expertise of what materials can be easily obtained and will work best in the setting? Or if there is not anyone who can make it, why not use the money and work with the beneficiary to help train local people? Surely the long-term benefits of creating jobs locally are too good to pass up.

I am reaching the end of my time here and am leaving with far more questions than answers, but there are two things of which I am sure. One, poorly planned donations are part of the problem, not the solution. Two, access reduces the need for aid. If we help to improve access to training for people in developing countries we can play a vital part in reducing the need for aid and help people and organizations become self-sufficient. Aid should always have an end date.