EBME Forums Forums Management Medical Equipment Management Donation of medical equipment to low and middle in

Hello

I'm supervising a 3rd year Medical Engineering student who's conducting a project on the ethics and practical consequences of donating medical equipment to LMICs. He's particularly interested in the maintenance and repair aspects of this - ie the lack of consumables, parts, training, manuals (in the appropriate language), etc. I wondered if any in this community had any experience in this area or could recommend someone who had? (We've already contacted the Amalthea Trust.)

Please contact me at peirces@cardiff.ac.uk.

Sue Peirce

CEDAR Research Fellow, Cardiff University

Ethics ... lack of this and that ... reads a bit like your student has already taken a negative stance, Sue.

We were very aware of the need not to add to the burden "out there" by sending yet more junk. My own role in the main was checking out the kit before allowing it to be shipped. I only let some "junk" go one time when it had been specifically requested for use as tech training aids (that is, for fault finding purposes).

Where possible, we would put together a complete package:- items themselves, plus parts, manuals etc.. Sometimes even test equipment (if we could get hold of it). And don't forget there is a lot of good information - manuals, but also advice - available these days on line (as evidenced by the many requests for manuals we see all the time on this site).

Our policy was "pull" rather than "push" (that is, only stuff actually requested was sent out - although, of course, we let folk know in advance what kit was likely to be available for the next consignment).

Consumables can be a problem; especially equipment-specific accessories. Sometimes even batteries. But site visits can be invaluable in ascertaining what is available locally (local markets are often better stocked than you might imagine).

Regarding "maintenance and repair aspects" ... technical staff may or may not be in abundance at the "other end"; maybe this is an area where your student shall be able to make the greatest contribution. That is, travel out on reconnaissance (to identify the need), then return next time to clear the backlog, train (or at least "mentor" and encourage) local staff, or even take up a permanent position.

Meanwhile, what is Amalthea saying, I wonder? See also THET. There are many more (probably too many).

I have responded here (in open forum) so that others can see what has been said (and hopefully join in).

Hi Geoff
You're right about preliminary conclusions, but talk of poor practice is based on examples described in the literature. These generally concentrate on the inappropriateness of devices for many LMICs and the lack of consideration given to what is needed to make it work in practice. The student is looking at all aspects of device 'aftercare', including staff availability.
It sounds like you had a developed program of equipment donation - was this from an NHS organisation? It sounds like ane example of good practice, maybe you followed some guidelines (such as those by WHO). I notice you're using the past tense. Are you or your organisation no longer involved? If you're happy to be interviewed about your experience could you contact me by email?

AT provide training in hands-on biomedical equipment repair and maintenance in Africa. Thanks for the recommendation for THET - I've found other organisations as well, such as Global Clinical Engineering Alliance, and Engineering World Health.
Sue

Yes, the literature is correct ... there is a lot of poor practice about (not just regarding equipment donation, but in the tech support of equipment just about everywhere).

About equipment being dumped on LMICs; well I may have already hinted at the answer to that one. "Pull", rather than "push". That is, they need to ask, rather than just accept. By the way, although there are undoubtedly many decent people involved, there may also be an element of "virtual signalling" (the "feel good factor"). Not sure what can be done about that ("human nature", that is), but I'll agree that a fair amount of "pushing" has been going on (in the past, at least).

But, to be honest (for small charity groups, at least), "to send, or not to send" can be a bit of a dilemma. Is it better to send out the Electrosurgical Unit (for example), or withhold it over fears of lack of skill at the far end? Despite assurances ("yes, we have a maintenance man") the donor sometimes has to just send the kit and hope for the best, in the spirit of "the greater good". Sometimes the worry might be:- "do they even have a surgeon"? The only answer there is probably a visit to the site (and who is going to pay for that?).

As you mention, there are many organisations available. When I said there are too many, I was hinting that co-operation across the board would be nice - but I can't see that happening, to be honest. Too many egos, too many vested interests, too many fat salaries (for some, at least) ... and let's not even mention religion.

In the past, I have suggested a "clearing house" approach, whereby equipment for donation would pass through a common workshop staffed by biomed volunteers - techs without affiliation to any particular group. But, needless to say (and perhaps understandably) groups seemingly preferred to maintain full control over their processes.

Yes; there are two aspects to all this:- the donation process, and then the "aftercare" (as you put it). Like your student, it is the latter that interests me the most.

Amalthea is doing a good job. I also like Med-Aid. But I especially commend Frank's practical approach. And, for YouTube videos:- Justin.

As mentioned before, my role was only as a "hands-on" tech. That was as far as I wanted to go. I only got involved with a few small charities, and then only by invitation. One has long since met their initial aim (of equipping a private hospital built by themselves in Kashmir), whilst others have withered on the vine (due to diminishing interest, I would say). Two of the latter shipped to some difficult locations (crossing borders at night, and so forth) in Africa. I sometimes used to accompany folk scrounging unwanted kit from hospitals in the UK. All pretty ad-hoc and low-budget, you might say.

I was acting as a freelance (which has been my usual status over the years); I have only ever worked within the NHS as an agency tech on bookings. Needless to say, as far as I and the other "volunteers" encountered were concerned, there was "no money" in charity work. Personally, I did it because I was asked - by decent people who seemed to have a good cause.

Past tense? Yes, of course. I doubt that a young person could sustain the lack of income (unless holding a full time job elsewhere - in the NHS, for instance). Which reminds me:- no doubt you are aware that quite a few NHS hospitals "partner" with hospitals in LMICs ... I support this approach, mainly as they usually have locum medics going out from time to time as well.

I used to enjoy working overseas (Africa, Middle East, Far East et al), and still would, given the chance. I have learned before that some (many) members of this forum would not have approved of some of the methods I used (spare parts from the souk, cannibalization of junked equipment etc. ... what I called the "shade-tree biomed" approach) ... but those were, in the main, "needs must" situations where kit had been out of order for (in some cases) years. In short, it is (or at least usually was) a different world "out there". Things may be different now - who knows?

"Hands-on" was always my preferred modus operandi, but I often ended up being taken off the workbench to "manage" some project or other - a phenomenon sometimes known as "the burden of competence". Not very "PC", perhaps ... but that was the truth of it.

These days I take the view that techs "out there" are better served - in the long run, at least - from afar via the internet (and surely most if not all hospitals have access to it) and sites such as this one. "Helping folk to help themselves", one might call it. So you may imagine how happy I was to discover both the internet and then this site (a tip o' the hat to Huw and John) when I returned to England twenty years ago.

No need for interviews ... I have nothing more to add. If techs wish to get involved, that's up to them. As you suggest (and unlike in the past), there are lots of good Guidelines available these days. The work I carried out (in the charity arena) was basic "biomed work" (inspections, repairs and what-have-you), so I did not need extra guidance. All that was required was a caring attitude, willingness to work, experience (perhaps) and a good dose of common sense.

Thank you Geoff "...a tip o' the hat to Huw and John" :-)

with regard to medical equipment in poorer countries, it's often necessary to use second hand or non-oem parts to fix equipment. I have worked mainly in the UK, but when I was younger, I also worker in India, Africa, and the Middle East.

If the only way you can fix something is to go down the 'souk' then so be it. Better to have working equipment that can be used to help patients than leave it broken.

In the UK, and other rich countries, money should be made available to Hospitals to enable them not only to repair equipment, but to replace it too. The UK government doesn't invest enough to keep medical equipment up to date, and there is evidence out there to show that if they did, the NHS would be more efficient.

Back to the "Rolling Replacement Programme" then, John.

I can't see that new equipment necessarily leads to improved efficiency, though. IMHO, they need to make better use of what they already have. The NHS probably also needs to spend its (that is, our) money more wisely.

From what I have seen of UK hospitals - and I admit I may not have seen the NHS at its best - I would not say there is a lack of equipment (often quite the reverse), but rather poor utilisation of the inventory, a lack of "sharing" between departments (that sometimes even amounts to hoarding), sometimes a lack of accountability and (dare I whisper it) a lack of properly conducted PM ... in a word, poor equipment management in general.

Worst still (in acknowledgment of the topic of the thread), I have seen equipment smashed up and binned (literally) rather than being donated to places in dire need. One guy did just that right in front of me (deliberately, you might say). Another "manager" had us unload the van of kit that one his blokes had put aside for collection.

Otherwise, yes ... notions such as "Putting the Patient First", "The Greater Good" and "Going the Extra Mile" etc. were quite rightly ingrained during the training (indoctrination?) of us Old School Biomeds.

India you say; I did not know that, John. Whilst serving in Hong Kong, I tried to get to Nepal, but unfortunately got posted back to UK before the trip arose (so my buddy at the BMH enjoyed dragging up and down the hills instead).

My brief contribution from "the other end"
A long time ago, and on the individual initiative of a Hospital Director, a C-Arm was received; from the USA, it may have worked originally but without manuals (it required line voltage and frequency conversion) it only served as a hindrance and bureaucratic justification ("but they already received one"). Over time I learned that a technical service provider had "retired it as obsolete" and it was being rented privately.
Another example was a dental automatic developer for panoramic radiographs; while there was no panoramic dental radiology device.
All cases served to feed the local misery of public exposure for political purposes.
Check if a " good human behavior handbook" can be added to the documentation

Sadly, I have heard of many (too many) similar tales of woe.

No doubt the Hospital Director acted with the best of intentions, but one can only imagine the all-round disappointment. There can be a lot of that if we're not careful. What actually became of the C-Arm, I wonder?

By the way, with "high-tech" (but often old) kit like that, it's always nice when a tech with detailed knowledge comes out to install and commission the equipment. Many donating charities can either find, or indeed have on the books, a visiting engineer.

Regarding your second example - no excuses there, really. Maybe it was just another case of communication failure.

But all in all, I refer back to the concept of "pull", rather than "push". That is, the hospital should only accept items it has actually asked for, or had prior knowledge of (purchased at auction, for example).

By the way, I am sure you may have already come across the type of books you mention ... they are cheaply available almost everywhere.

Hi Geoff,
wrt ... 'I can't see that new equipment necessarily leads to improved efficiency' Yes and no... depends on the equipment. Digital X ray machine are much more efficient, better image quality, etc, etc,
An oxygen flowmeter - the technology doesn't really change.
:-)