By Mercy Asiedu
Engineering is the backbone of medical advancement, in that it equips medical professionals and hospitals with tools necessary for diagnosing and treating medical conditions as well as enabling medical professional to do their work more efficiently and accurately. However, there are disparities in availability of technology between clinics and hospitals in higher resource settings and in lower resource settings. The presence or absence of necessary medical equipment can affect the quality of medical care and affect global health indicators such as years of life lost, years of life lived with disabilities, etc. On November 16th, we heard Dr. Malkin talk about engineering and its presence in global health. He touched on several topics including ineffective donation of medical equipment to developing countries, potential ways for improving the technology deficits and methods his work had taken to tackle these disparities.
First, we heard him talk about ways in which equipment donation was actually harming health care in developing countries instead of helping. He mentioned an experience where he and other organizations had donated several pieces of equipment to a hospital in Nicaragua. However, during a visit to the hospital, he realized that none of the equipment was being used. As a matter of fact, a lot of money was being used to store all the unused medical equipment in a large rental space. As Dr. Malkin pointed out, over ninety percent of medical equipment in developing countries are donated from high income countries with about seventy-five percent meeting that same fate of disuse or misuse. Some of the reasons for this include donations of broken equipment, lack of trained technicians, lack of dependable electricity, etc. Dr. Malkin disputed the idea that initial low capital investment cost and complexity requiring training were problems for this. Since most of the equipment is donated, initial capital costs are the most prominent issue; in actuality donors prefer to donate equipment with higher capital costs. Additionally, research has found that complexity of equipment is also not a problem and that after training, most medical personnel are able to effectively use highly technical equipment. The bigger problems with the use of the equipment is availability of initial training, long term costs including need for expensive, unavailable consumable components as well as long term maintenance and fixing of broken equipment.
This raises an interesting issue in the ethics of medical equipment donation. Recipient hospitals have a responsibility to use the equipment donated to them where and as needed. However, donor hospitals should also have the responsibility of ensuring that the equipment they donate are in full functioning order and can be used by the hospitals they donate to. It can also be argued that donors should also be responsible for providing initial ground training to the hospitals accepting the equipment since these might be not the standardly used equipment in the recipient hospital settings. There is also the need to ensure easy access to consumable components of devices. Blind provision of medical equipment, anywhere in the world, whether in high income or lower income regions, without training or without access to consumables will inevitably lead to disuse. However, this might be seen by donors as too much responsibility and eventually lead to decrease donations. This might also raise the issue of “beggars can’t be choosers” and that “some help is better than no help at all”..
Some potential reasons for the disuse of medical equipment that Dr. Malkin did not touch upon are political and cultural barriers. Use of medical equipment needs to be approved by the ministries of health in most countries hence, the government has a responsibility to ensure that medical equipment being donated are in the best interests of their countries. With the excess flow of donations, the government of the recipient hospital could decide to choose which donations to take and reject and could instill guidelines for both donors and recipients of the medical technologies. Governments also have to ensure that the necessary training and technical assistance is available for the use of these equipment. Donors could work with governments of the recipient country to ensure that this is available. However, this does not overcome resource restraints such as lack of dependable electricity. Another issue is cultural perception of use of the equipment. It would be interesting to see how much acceptance by the medical personnel according to their work flow culture and acceptance by patients affects use of these equipment.
There are several angles of looking at the problem of lack of or disuse of medical equipment in lower resource settings and Dr. Malkin pointed out some of the ways in which he had tackled this problem. Through organizations, he has started such as engineering world health and the global public service academies, he addresses training of on-the-ground technicians to use and repair medical equipment. His research also develops medical devices designed for use in developing countries. He ends on the note that different type of technology, not low quality technology is the way to address some of these disparities.
Discussion question
- What are some political and cultural barriers you can see affecting use of donated medical equipment in developing countries?
- Do you think it is the responsibility of the donor, the recipient of the medical technology to ensure its full use and why?
- Describe other ways in which disparities in engineering technology between developed and developing countries can be overcome;
Global Health Challenges 2016 
Thank you very much Mercy for the wonderful piece above on the contribution of engineering in global health. Advanced medical equipment play a key role in the provision of quality healthcare across the world. Innovation is what is driving excellence in healthcare in developed countries and this is done mainly through new and advanced equipment. It is therefore necessary to keep the flow of equipment to developed countries. It is however important to have some ground rules laid for all stakeholders to ensure maximal benefits are reaped from this flow of equipment. I know that some hospitals remove from service equipment after a specified number of years even if they are still in good working conditions. Such hospitals should have a prearrangement with the middlemen or recipient countries or hospitals to have plans in place to transport the equipment once the time arrives. They can even have some personnel from the recipient hospital come to see the equipment while it is still operational and learn about maintaining it before they receive it in their hospital.
LikeLiked by 1 person
I appreciate Mercy for your informative blog, which helps me catch up with some details that I missed in the lecture. Indeed, engineering is an interesting topic in the global health sphere, and the equipment donation is a part I’d like to discuss. China proudly donate billions of RMB to some African countries, even provide all resources needed to build a hospital in a county with”poor” health infrastructures. What I concern about is: one, even though the country has a hospital equipped with high-techs, the country doubtful run it properly; two, the country cannot build another one without China or other countries’ help; and third, the high-techs in the country would probably hinder the local technic development. I understand it is hard to decide how far we can go to help; however, the equipment donation is definitely not “the more, the better” thing.
LikeLike
Thank you, Mercy, for sharing your thoughts through a very informative blog post. In your commentary, you alluded to the power differential that exists between donor and recipient. This is very difficult to combat, as there is no formal mechanism to oversee the process of donating medical equipment to lower resource settings. Among many potential strategies, there are three main ways in which I foresee this power dynamic being addressed. First, I think one major problem is the communication gap between the donors and the recipients. There is no systematic way for donors to assess the needs of hospitals in lower resource settings. Many medical devices have hidden costs associated with them and so even if a medical device that is donated is functional, it may not be needed, adding to the burden of the recipient hospitals. Second, training programs such as the work of Engineering World Health have shown to be highly effective, and one sustainable solution to the need to fix donated equipment that is broken, as manuals are often missing and technical support is often very sparse. However, a more sustainable solution is to develop technological innovations that lead to production of more simple devices that contain fewer components and that are suited to local contexts (i.e. voltage compatibility, and locally produced replacement parts). Without such innovations, the cycle of dependency of hospitals in low-resource settings on donations from higher income countries (whether or not this process becomes more functional) will continue, and the power differential between donor and recipient will persist.
LikeLike
I really enjoyed this lecture and reading this blog post. I must admit I had no idea how little of the donated equipment that is sent to developing countries is operational. I agree with the previous comments that the recipient hospitals of the donated medical equipment must be given a platform to speak about what they need in donations and how the process of donating medical equipment can be made more productive for both sides. Communication between both the donors and recipients is needed to better form a solution that will ultimately increase the number of patients in LMICs that benefit from the use of working medical equipment.
LikeLike
Thank you Mercy for such a comprehensive note on Engineering and Global Health. Thank you everyone for sharing your opinions. I agree with the above comments, that there should be communication between the donors and recipients and that the burden of ensuring full use should not fall on just the donor or the recipient. As mentioned in the above comments, there needs to be a close assessment of the needs of the recipient country. Once need is determined, capacity to handle the new equipment should also be determined , whether it is space, trained professionals, refill/ repair associated with the equipment. The recipient countries should be in close communication with donors by providing necessary information that will enable donors make a careful decision on what to send or not. I was also thinking if close monitoring could increase use of donated equipments. If donors closely monitor and check on how the donated equipments are operating, it might encourage recipients to start using them so that they maintain a good relation with the donors and receive more in the future.
LikeLike
Thank you Mercy for writing a great post reflecting upon and outlining the current disparities in donated medical equipment and it’s uses in LMICs. This lecture and topic reminds me a lot of a lecture I went to when I was in college, where a public health physician came and talked to our class about his experiences in the field. He had said that when he got to the country he was working in (I believe Uganda), he was surprised to find a row of trucks that weren’t being used. When he looked further into it, each of the trucks had small transmission issues that were generally easy to fix, but the people there didn’t know what to do or how to fix them because they had never been trained. Resultantly, it was easier for the people within that community to wait for a new truck to be donated than to find someone to fix the cars.
While that story speaks to transportation and medical equipment, I can’t help but wonder if the situation in LMICs are similar. How much of this equipment is being donated, with training on how to use it, but not how to fix the glitches? In that respect, I believe that the donor holds a large responsibility to recipients of the medical technology on not only how to properly utilize the technology, but also on how to troubleshoot and fix the equipment. If the medical equipment that is being introduced is new, then likely there aren’t many people around to ensure that it is being utilized properly or that glitches are being fixed. In that respect, I wholly believe that donors have a responsibility that extends beyond merely donating the technology. They should be responsible for checking in to ensure proper maintenance is being done on the equipment, that it is being utilized properly, and/or training local members to be able to maintain and fix the equipment.
Furthermore, prior to donating the equipment, research needs to be done by donors on the cultural and political context of the country to ensure the equipment is societally appropriate. If it is not, it is their responsibility to provide more appropriate equipment or engage in discourses with the recipient about where they see the importance of this equipment. Medical technology does not come cheap, so it is important for donors to ensure that their contributions will be worthwhile, and not just something that will accentuate their PR in the media or society. While the gesture is noble, I think a greater onus needs to be placed upon donors to be critical and wholly engaged within the process beyond delivering the equipment.
LikeLike
Thank you for the great blog post! I think this is a really interesting issue. Specifically, I think the differential power relationship that exists between donor and recipient countries is a critical issue. In reading this post, I wonder if a key issue that perpetuates this unbalanced relationship is the idea of how knowledge is traditionally transferred. There is an assumption that resource-poor communities/facilities/countries should happily accept the aid of more resource-wealthy entities. However, as discussed in this post, that knowledge or aid doesn’t necessarily transfer from one setting to the other. I was particularly interested in the issue regarding inconsistent electricity. Given that this is a predicament most resource-wealthy countries don’t deal with on a regular basis, those who experience this situation would likely be the best source of innovative ideas. I agree with previous comments which argue that greater communication needs to exist between donors and recipients. Specifically, I’d add, more attention needs to be given to the voices of recipients who better understand their own circumstances and who could be a valuable source of innovation.
LikeLike
You guys asked some really good discussion questions. The second bullet point regarding functionality of donated equipment hits home in particular for me, since I spent two summers working for a nonprofit in rural areas of Peru. Most of our operations involved access to care and medication in poor regions, but we also used funds to purchase equipment to donate to surgery wards and to children with cerebral palsy that receive little, if any, benefits from local governments.
What I have seen firsthand is the power of gifting a tangible, effective, and useful piece of equipment to a family or group of people who truly appreciate it. We mainly bought our donations through medical supplies site that was located in the country, in order to insure correct functionality.
However, if that piece of equipment does not function properly, where does the guilt fall? I honestly would feel terrible donating a piece of equipment to someone or to some community that truly needed it, only for them to find out that it did not work.
Responsibility of functionality should fall on the donor. We should discourage gifts that are given solely to make the donors feel like they are doing good, when they really are not.
LikeLike