This guest post by Mike Miesen was originally published in WhyDev, a blog for individuals passionate about development, aid, and other global issues.
Well, no. It’s broken.
Spend any time speaking with a physician or administrator at a hospital in Uganda – or, really, in any country in Sub-Saharan Africa – and, without fail, the topic of broken medical equipment will come up.
At one hospital, a physician may show you a donated anesthesia machine that worked once before it broke (true story); at another, an administrator will open the door to a spare room dedicated to storing broken and inoperable equipment: the “medical device graveyard” of the hospital.
Every piece of equipment in these equipment graveyards is a testament to a system that is failing to do what it set out to do.
There are so many reasons why equipment breaks – and stays broken – in developing countries that it’s easy to get overwhelmed, so let’s focus on two of the most severe: equipment ill-designed for use in developing countries, and a lack of in-country supply of spare parts and repair know-how.
Because I know something about the anesthesia market, let’s look at each through the lens of a typical anesthesia machine.
(Full disclosure: I know something about the anesthesia market because I work with Gradian Health Systems, a non-profit social enterprise that manufactures and distributes the Universal Anesthesia Machine, which is specifically designed to be used in difficult hospital environments)
Forgetting to know thy hospital
The typical anesthesia machine is designed for use in a hospital in, say, the United States, Japan, or Australia – places with consistent electricity, adequate infrastructure, and functioning supply chains.
In these countries:
– A regional power outage is so rare that you’ll hear about it via a “Breaking News!” update on your smartphone
– Any hospital that ran out of concentrated oxygen would be vilified, sued, and heavily fined by regulators; it would be a scandal
– Anesthesia machines are designed with few fiscal or infrastructural constraints holding designers back; patients and clinicians demand the best possible machine that engineering prowess and money can buy, and that’s often what they get
– When an anesthesia machine breaks, a knowledgeable technician with all of the unique, proprietary spare parts to fix it will be immediately available (as per the costly service contract the hospital purchases); in the meantime, there’s probably a backup machine at the hospital that can be used. The situation is annoying but probably not life-threatening
And on and on – you get the point.
None of the above applies to low-resource hospitals in Uganda, Nepal, or South Sudan, where many of these same anesthesia machines are sold or donated.
(Note that I’m only referring to low-resource hospitals; speaking from experience, there are excellent hospitals in Uganda, too.)
When the electricity or oxygen run out – as they often do in infrastructure-poor countries – so does the typical anesthesia machine’s ability to work.
When an anesthesia machine designed for use in an American hospital is used in a poorly-supported hospital in Uganda, things often go wrong – even when it’s a brand-new machine (and, as we all know, often it isn’t). The machine isn’t designed to work in low-resource hospitals, which violates the cardinal rule of medical device design: Know Thy Hospital.
The Universal Anesthesia Machine works with or without consistent electricity and compressed gas because that’s what our customers need in an anesthesia machine: reliability in difficult circumstances. And it was designed for affordability, because that’s what our customers need: functionality at an affordable price.
But critically, the Universal Anesthesia Machine isn’t a second-best, “good enough for them” piece of equipment; it’s CE-marked, meaning it can be (and is) used across Europe. It’s inexpensive – not cheap.
In-country maintenance and repair
Because conventional anesthesia machines are designed with the assumption that any necessary infrastructure will be readily available, they’re often quite sophisticated – bells and whistles galore. But pull away the infrastructure and sophisticated just becomes complicated; the bells and whistles just get in the way. Machines with a lot of proprietary, moving parts end up in environments without the infrastructure to support them.
And, as with any machine, every moving piece becomes a potential failure point. When a part of the machine fails, someone needs to repair it – which requires having the spare parts and know-how to do so available. A proper “repair ecosystem” should ensure that when a machine breaks, it can be quickly and cost-efficiently fixed.
Unfortunately, the repair ecosystem in many parts of the world is broken; spare parts and available know-how are luxuries.
Spare parts can be frustratingly hard to procure in developing countries, whether because they no longer are produced or because there’s a very small market for them in a given country. As a result, they can often be quite expensive – sometimes even, in sum, more expensive than the initial purchasing price, which is, on average only about 20% of its lifetime cost.
Even if the right part is available, a biomedical engineer trained to fix the anesthesia machine may not be; there’s a notable dearth of training programs available, and those that are generally only focus on the basics and not machine-specific learning.
Most health centers and hospitals have someone available to help with minor issues – an electrician or a tinkerer, maybe – but the typical machine is simply too complicated for most of these workers. Scheduling and paying for a biomedical engineer to visit the hospital takes time and money – both of which are in short supply for low-resource hospitals.
While the machine sits broken, patients suffer.
The Universal Anesthesia Machine is designed to be durable and “sophisticatedly simple,” with as few moving parts as possible. When something malfunctions, an electrician with a screwdriver or hex wrench can often fix it, usually with spare parts that can be found in any nearby large city (the air filter used in the machine is a basic car filter, for example).
If the problem is extensive or particularly difficult, that electrician can call the in-country biomedical technician that we guarantee was trained to fix the machine – because we trained him or her.
All of which is to say: We don’t have to accept medical device graveyards as inevitable. But if hospitals in low-resource settings are forced to use equipment that wasn’t designed with them in mind, that’s what we’ll get.
Getting rid of equipment graveyards starts with recognizing the importance of Knowing Thy Hospital, and building devices – and an accompanying repair ecosystem – to fit what the hospital needs.
Mike Miesen is a former Business Strategy Analyst at Gradian Health Systems, a non-profit social enterprise dedicated to increasing access to safe surgery. Follow him @MikeMiesen.