Hi. My name is Rob Parsons. I work for a company called Health Partners International some of the time. My job description, well, my business card says Healthcare Technology Management Consultant. I know nothing about healthcare, very little about technology. I am quite good on management, which is why they give me gigs like this.
We do health systems strengthening in developing countries. Mostly in Africa and that is mostly in Nigeria. We do operate in many places all over the world. We have a specialist division that grew organically that deals with, what we call healthcare technology and what other people call, medical equipment. We not have a lot of experience of dealing with how we manage healthcare technology in low resource settings.
Sisyphus, if you don’t know, one of the Greek Myths. He did something wrong and he was condemned to roll a very large boulder up a hill to get it to the top. When he got near to the top it always slipped out of his hands back to the bottom again. He spends eternity trying to roll this thing up to the top of the hill.
That is really what HTM in developing countries is like. It is cyclical and depressing. You put massive effort into rolling things up to the top of the hill and then you watch it roll all the way to the bottom again. Donor money is very good at starting things off and not very good at keeping things going. There is a general lack of money. There is also a general lack of skill. Here I am talking particularly about management skill, as well as technical skill.
Those have been the two key problems for several decades and they remain so. We can investigate the reasons why that it, but that would take another couple of hours.
Constant story; low budgets, low skills, poor support from manufacturers, and so on. There has never been a reliable survey, but estimates from experienced professionals put the proportion of out of order equipment at 50% or above. I noticed in John’s keynote this morning, he quoted from a document which said 25-35%. That was a few years ago. It has got worse.
These two are very typical pictures from Africa. The one on the left is machinery that has never come out of the box. It is still wrapped, it has never been used. It has been paid for, it has been delivered, but they can’t do anything with it.
The one on the right, do you recognise those? Dental chairs. A whole graveyard of dental chairs; probably all with the same part gone wrong. That is a normal picture for many of the parts of Africa that we operate in.
While supply is a basic problem, budget is a basic problem, technical skills are a basic problem; there is also the issue of how you manage what you have got. We have tried to help people to actually develop the skills to manage what they have got as well as they can. Actually, some of these issues have already been referred to.
What we did, was we produced these. I haven’t brought a copy of these along because there aren’t any left. I’ll explain a bit why in a minute. The how to manage guides, known to some of the people who use them as the Zeeken guides, because the company that created them was HPI’s sister company, Zeeken, which is now in mothballs. All the intellectual property has defaulted to HPI.
The reason that they came into existence is slightly magical and shrouded in the mists of administrative history. I rather suspect it was one of those budgetary things. Somebody in DFID found that they had £2.5million left in a budget that needed to be spent before the year end, otherwise they would lose it. They came up with the idea of a knowledge and research programme for disability and HTM. I don’t know why they chose those two, but they did.
We grabbed some of the money to pay people to produce these guides. We collected a bunch of people, a team of experts, mostly Europeans, and we asked them to write up six key aspects of what we saw as the equipment process, which is; organisation, planning, procurement, operation, maintenance, management and finance. One volume for each. Roughly half a million words, just short of the total length of War and Peace.
The writing stage was tough enough, the next stage, and I think the stage that actually made a lot of difference to the quality of the manuals, was even tougher. We went for a review process. This was planned in from the start by the woman who led the project who was one of the authors of a document that John referred to in his keynote; Caroline Temple-Bird.
She planned in a review process; we got half a dozen reviewers, at least, for each volume from all around the world. We paid them, we gave them terms of reference, and we gave them a template for critique of the volume. This proved to be an intensely rich process which the authors didn’t thank us for at the time, but it measurably improved the contents of the volume.
We got volumes of data and suggestions back from our reviewers, and every volume went through a massive re-edit process. Including volume three, a procurement volume, which was written by Manjeet Kaur who was one of the other authors in the document that John mentioned earlier on. She wrote volume three, she got the edits back, she incorporated a little post-it note through the document, got a job in Uganda, and left.
Caroline looked around for somebody capable of editing this document. "Ah, Rob, you’re not doing anything at the moment." I now know more about procurement than I ever wanted to, but I did actually manage to produce a volume that works. That review process, involving people from all around the world, from all sorts of different cultures, all sorts of different social and economic situations, made a great deal of difference to the effectiveness of the volumes.
We were contracted to produce 75 print copies and 1000 CDs. We did that, we distributed them and we made it available online on various websites. That was the point, in 2005, at which our funding ended. There was no money budgeted to follow-up and we didn’t have spare money to do it on our own, so the thing was simply launched and left to its own devices.
What happened next is the most interesting part of the story, but before I go on to that, I want to make a slight digression. You may or may not be familiar with Eric Raymond’s seminal paper; ‘The Cathedral and the Bazaar’. This was first produced in 1997 and he posited two different methods of software production. The cathedral is the traditional management controlled and structured way of doing things, think Microsoft. The bazaar is the open source way of doing things like Linux, which was the subject of Raymond’s paper.
The key issue that Raymond explored was that the bazaar way of doing things was not supposed to work. We know a bit better now, but then, nearly 20 years ago, it was a big issue. You cannot manage things like this, you do not produce equality product, it does not happen. The Linux development community proved that it did. Linux not only emerged, but survived and prospered. The bazaar way of doing things is now accepted as a valid style of operations.
In terms of international development work, we often see the same issues in operation. I think there is an added dimension which I call the food bank. We have the cathedral, we have the food bank and we have the bazaar. In the food bank system, rich people provide stuff voluntarily, free of charge, to poor people. They key feature, I think, of the food bank system, is that it does not change the system which causes people to remain poor, but it does alleviate some of the symptoms of poverty. Arguably, that is the fate of much Western aid.
To prevent people being poor, you need to change the economic system which keeps them poor. We are not going to do that anytime soon, but we keep doing enough to ameliorate the worst consequences.
Now, you can characterise the HP how to manage guides as an example of a typical food bank offering. Paid for with Western money, concocted by largely Western expertise and supplied free of charge to them over there. The key point being with the best will in the world, the food bank solution does not solved structural problems; it just alleviates some of the symptoms.
Production of the manual was done cathedral style, top down. We kind of sidled gently in the direction of the bazaar with the review process by involving so many people in so many ways. It was controlled and directed, but the reviewers took their terms of reference, ran with them and produced genuine critique and vibrant alternatives. It was quite a heady process and it was a kind of hybrid of food bank and bazaar.
What happened post production is quite interesting. Is anybody familiar with that from a film? Not cineastes? This is from ‘Once Upon a Time in America’. It is set in prohibition times and our three young heroes were growing up in prohibition times and boats would smuggle liquor into the United States. If they were pursued by the coast guard, they would drop the liquor overboard. They stayed free, but they lost their cargo.
Our protagonists came up with the idea of attaching a balloon and a block of salt to each case of liquor, so when it was thrown overboard it sank without trace. The salt gradually dissolved and when the weight of the salt was removed, they balloon bought the liquor back up to the surface. This is the point at which you see our heroes collecting the liquor for which they were going to get 10% from the organisers.
I’m reminded of this because it feels like this is exactly what happened with the How to Manage guides. We launched them and they sank without trace. We posted our 75 paper copies; we posted our 1000 CDs to Ministries and to Universities and hospitals all over the world. We got a few emails back saying, “Thanks very much,” and then we heard absolutely nothing. We had no budget, we had no time to follow it up ourselves, and we just had to make the best of a bad job, sit and wait.
About two years later, the guides began to resurface. Our blocks of salt took a very long time to dissolve. It took about two years and they gradually began to pop up. People began talking about them on the Infratec mailing list and various other places like that, and they began to percolate. We found that, mostly, people were using them in training courses.
This is just a map of the world; the colourings mean nothing, as far as I am concerned. I am just using it as an illustration. There are many, many places now in which the guides are being used for training, or indeed, for making policy. Engineering World Health is using them. They have structured their BMET training courses very largely around the manuals.
They have been specifically delivering BMET training in Cambodia with quite a few people there. They are in use in Rwanda. They are being distributed in Bangladesh, and we know that there are copies being used in India and Nepal. I felt one behind in Pune a couple of years ago. I think that was my last paper copy that I still had at that point. They are now like gold dust.
They are used by the University of Cape Town in various courses. They are in use in Swaziland, apparently, sort of. Although one of the issues in Swaziland is there is a lot of debate going on about who controls the policy, and hence, who gets to do what. Ethiopia, they have been used in. We have introduced them in Nigeria and South Africa, Malawi, Uganda, Sierra Leone. The person who told me about seeing them in use in Sierra Leone, added the phrase, he said, “They are timeless in excellent advice.” Which is a really nice thing to hear.
People enjoy them. People like them. People use them. Despite the fact that they are 1600 pages long, despite the fact that they are completely indigestible. You think people have trouble reading a 17 page policy document. 1600 pages of what we have to offer; that’s quite big. Honduras also, where EWH are working; they are using them there too. It has been translated into Spanish. We got an email one day saying, “I hope you don’t mind, but we just translated them into Spanish for you.” This is a bunch of students at the Tec De Monterrey in Mexico. I want a job there, with an office at the back so that I have that view out of my window. It is absolutely gorgeous. They have been translated into Spanish and that Spanish version is now available on our website. They are currently being translated into Mandarin by a bunch of very industrious Chinese students.
We have moved well into the bazaar phase. We have left the cathedral behind; we have left the food bank behind. We are well into the bazaar phase where people are just taking them, running with them, doing whatever they want to do with them. People have produced flow charts, people have produced courses, and people have actually used them to build a policy in various places. They are completely, voluntarily translating into different languages. There is a plan for a Russian language version; there is a plan for a Portuguese language version. I’m not quite sure I really believe either of those, but you never know.
The Russian language one, I think, is quite interesting because not just Russia, but also in a lot of the ‘Stans that used to be part of the USSR, a lot of people still speak Russian. That is more like the lingua franca than anything else and, therefore, a Russian translation probably has a lot of uses.
It has been introduced; it has worked; it has been very nice. People are still picking them up; people are still using them; people are still finding the things that the guides discuss very, very valuable to make what they are doing systematic. That is the key thing. One of the issues for us we find over and over again, is a lack of management capacity; a lack of management skill. Everywhere, and particularly in Africa, that is generally true throughout public services. It is particularly true in the health sector and it is certainly true in the management of clinical technology, and we do try to teach people to manage. I could go on about that for hours, but I’m not going to.
One of the things which I think is very, very interesting at the moment is the change in the way that, particularly in Africa, health systems are being managed and health technology is being managed. They are beginning to become more appropriate and more local. This is one of my favourite bits of kit. Hands up who has seen this before? Nobody? Wow. Developed by a South African company, I saw the prototype about six years ago. I was bowled over by it. The production model, it is wind-up. It doesn’t use mains power, it doesn’t use batteries, it doesn’t use solar power, it is wind-up. It is hard plastic; it’s built like a Fisher Price toy and that is exactly how it is supposed to function. It is the simplest machine imaginable. You wind it, you put the monitor on the belly, you get the foetal heart rate which is the only thing it gives you and voila, you know where you are going.
The key issue with births is, if the foetal heart rate is too fast or too slow, you know you have got problems. If it is not, then you know you are going to be okay. That does it, less than $200 compared to the several thousand pounds people tend to pay for the kind of machinery we use in this country. That sort of thing; cheap and also locally produced, is beginning to change the whole procurement and commissioning process. There is a lot of machinery that will always be expensive, difficult, technical and so on and so forth, but that kind of thing is going to make a big difference. Here is another one. This is a particular lesson about appropriateness. Lots and lots of people in this country and many other places have sent lots and lots of wheelchairs to Africa. They are all four point wheelchairs. They are built for pavements, they are built for smooth floors, they are not built for Africa. For Africa, you need a three point wheelchair which doesn’t fall over when one of the wheels is off the ground. People in Africa are beginning to produce three point wheelchairs.
Three point wheelchairs, in this country, are for people who race in the Paralympics and they cost thousands of pounds. They are beginning to develop three point wheelchairs which you can build for £60, £70, £80, and also maintain locally. It is a very, very important issue there.
Another example; the bicycle centrifuge. It is a bicycle tyre. You stick your sample on the outside of it, you wheel it and voila, your ingredients have separated. These are in action all over the place and these really are a genuinely local development. I am not aware of a company that actually produces these and sells them. I have seen them in operation in India and various places in Africa because people cobble them together from local spare parts; wrecked bicycles and that kind of thing. Now, that is going to change massively. Africa in particular is moving towards that kind of thing. Also, Africa is moving towards a very mobile form of communication. Just about everybody in Africa has a mobile phone. We have seen some of the things, well, we are gradually creeping along the path to getting Cornwall hooked up to a Telehealth system. They have already done it in Africa. They are doing all sorts of really creative things that we need to import from them. Those are things that really make a great deal of difference.
That is my illustration of mobile working. Did you know they do unicycle hockey? Isn’t that quite extraordinary indeed? Being on a unicycle and trying to play with a hockey stick is kind of like trying to keep control of the development of mobile applications.
I came up with this a little while ago; what is going to happen in the future? Two things in particular are going to happen, particularly in Africa, but also in other low resource countries. Budgets are not going to increase that much. We are stuck in a situation where budgets for healthcare will remain really quite limited. There are many, many places where the middle class is growing and where there are markets growing for more expensive healthcare. But, for most people in the developing world, particularly with public services, budgets will remain very, very tight. You think we have got austerity here? Nothing like what they have got there.
Connectivity is increasing. It is increasing very rapidly indeed. That will drive the move towards mobile care and all that kind of thing. That, again, will change the way in which we do our management because, we can’t keep control of this. What we can do, is use what people have got.
One of the ways in which we do that, for instance, is that just about every tech in Africa has his own mobile phone. We can put all of our inventory software onto a mobile phone. If you are doing inventory, you need to take photographs, you need to be able to read QR codes, and you need to access documents. You also need to have a place onto which you can enter the data that you want for all the machines that you are inventorising, if that’s a word.
We put the form onto the mobile phone. Everything that you need to take an inventory is now on this phone. That can go anywhere, it will take the data locally if you are out of range and when you go back to base you upload it to the database. That kind of thing is changing our relationship towards data; changing our relationship towards information, and it provides a different kind of challenge for management.
Where do we go now? What we have with the guides, and what people are using is a static object; it is a finished product. It has been given to people and they have been developing stuff with it, but there is a lot more that we want to do with it. We still haven’t cracked the issue of deriving a teachable form from it for actually teaching management. What we tend to have is that the principals from the guides and materials from the guides is used in teaching people how to be technicians and it is used in teaching people how to be clinical engineers.
I am beginning to develop a very little specialist niche which takes me to places in the world of teaching clinical engineers how to manage. Management, to my mind, is a very specific thing. When we talk about management, actually what we are talking about a lot of the time is administration. We talk about policies, we talk about how we ensure compliance, we talk about how you make sure job cards are filled in properly, and you talk about the movement of information. That’s what administration in.
Management is making sure that everybody is working towards a common goal. It is people skills; it is a mind to mind operation. Those are skills which are used by everybody in the organisation, not just by the ones who have the job title of managers.
One of the biggest problems, I think, that clinical engineers face is training the users how to report faults. That is a management thing. That is getting people to understand that they need to tell you more than, “It’s not working.” That is less helpful than a more detailed explanation.
Doing that stuff, working with people, those are key skills and that kind of management, I think, is something which is very much needed. I am desperate to get the time, and get the money, to develop a course which can be delivered either face to face, or online, or on a mobile phone. If anybody has any source of funding that will allow me to do that, it would be very welcome indeed.
Thank you very much.
Download Rob Parsons' presentation here: http://www.ebme.co.uk/downloads/download/14-2014-seminar/92-4-how-to-manage-rob-parsons