Appropriate Medical Technology for Developing Countries6th February 2002, IEE Savoy Place, LonThis 2nd seminar on this topic was organized by the IEE Healthcare Technologies Professional Network. WHO estimates that 40-60% of medical equipment is out of service; & many other problems hinder the provision of healthcare in developing countries (DCs). There is much to be done to improve the situation and the seminar provided an opportunity for healthcare experts to share their experiences and to offer solutions. It was led by Len Cornish (Global Healthcare Projects) as technical adviser to the PN, & covered two themes: Managing Healthcare Technology and Applications & Supporting Systems. There were 9 presentations and 16 poster exhibits; this is an increased response from the inaugural seminar of 15/02/2000. 1. Managing Healthcare TechnologyYunkap Kwankum (WHO Dept. of Health Service Provision, Geneva) presented their viewpoint derived from their global healthcare technology management (HTM) work. The crux is "appropriate management" not "appropriate technology" (any technology is appropriate if it is suited to local needs) - experience shows that maintenance is not a technical problem but a systemic management one. HTM must be part & parcel of health service provision. How can local capacity be built to absorb a wide range of technologies, when staff in DCs have limited authority, resources, vision, or experience of management? Typically facilities are built, equipped according to static equipment lists, and then not sustained. WHO developed a tool (concept, methodology, & software) which systematically relates planning to essential health interventions. Their Essential Healthcare Technology Package (EHTP) software links all internationally classified diseases (ICD codes), to their respective procedures (CPT codes), then to the technologies (medical devices, drugs, human resources, facilities) required for their execution. The EHTP templates are modified through country specific consultations & consensus. An in-built query and simulation capability ensures that planners can see the implications & costs of their choices. The EHTP is being field tested & modified in 20-25 countries; for availability contact: heimannp@who.int. For other WHO management initiatives and tools, contact: issakova@who.int. Enrico Nunziata (HCG, Finland) presented work undertaken with the Departments of Maintenance, Planning, & Statistics, MOH Mozambique. An important part of asset management is access to information. But an information system (IS) for healthcare technology management (HTM) is often disregarded as an inappropriate western hi-tech instrument of little value to DCs. Thus they developed an HTM-IS of their own. Important lessons were: an IS involves more than data-entry and computer programming - it must be correctly designed, process-led, follow the data-flow, collect & update HTM data of use to staff & managers, monitor performance. There are indicators on: system/institutional development, asset status, technology level, activities, economics/finances, & quality. Scoring on the indicators & data is displayed for provinces, workshops, etc. The MOH has used it successfully for 3 years & consequently improved HTM performance. They are modifying it to become a generic software tool for use in DCs globally. It will be: a multi-level system (same data from clinics-MoH-donors, for all types of assets); an open system (same data whichever DC, with country specificity); multilingual tool for cross-country comparisons (using common indicators), with data protection & control features, & compatibility with other management software tools. Contact: engbio@botte.net. Maurice Freeman (European Commission (EC), Global Harmonization Task Force) presented their Global Medical Devices Nomenclature (GMDN). There are many medical device (MD) regulations & no consistency globally for regulating products appearing on the market; in the '90s EC began talks with global partners. Unification is going to be difficult, so a 1st step was to describe MDs in a common way. The EC used 4 sub-groups (technical & safety issues, incident reporting, design consistency, control of manufacturers), 70 experts from 18 countries (the equivalent of 40 person-years). They combined features of existing systems: UMDNS, NKKN, JFMDA, EDMA, ISO, FDA. The resulting GMDN covers 12 broad categories of devices, 7000 primary terms with full definitions, 7000 synonyms, & 1000 templates/headings. NOTE: the terms are Generic Device Groups useful for regulators, manufacturers, healthcare providers, data-exchange, certification, vigilance; the work must be expanded to differentiate between Device Types for procurement & e-commerce. It is encouraging that Australia, Japan, Canada will use it, US is considering it, and countries from Eastern Europe, Asia, & Sth. America are showing interest. The original version is currently available on CD-Rom from: www.gmdn.org. In future, the Maintenance Agency will distribute, license, up-date & expand it, & incorporate country requests for additional terms and categories. Contact: maurice.freeman@btinternet.com. Yunkap Kwankum (WHO Dept of Health Service Provision, Geneva) exhibited a poster on the WHO Guidelines for Donations of Healthcare Equipment. A tool is required due to: the inconvenience & unforeseen consequence of many donations; poor communication between donors & recipients; poor analysis of needs & suitability to local policies & systems; the complexity of healthcare equipment quality issues. The guidelines provide information on: institutional policies; administrative procedures, responsibilities, & management; requirements for donations; coordination of donors, preferably with a lead agency. They make use of process/activity flow diagrams. The guidelines are not yet published formally, but contact: kwankamy@who.int. A briefer earlier version (by the World Council of Churches) is downloadable from: www.echohealth.org.uk/resources.html. Andrew McDowell (ECHO International Health Services Ltd) exhibited a poster on an Equipment Maintenance Training Project in the Gambia. The project comprised: a 2-week course in-country; the provision of books, toolkits, test equipment & spare parts; and a follow-up feedback & evaluation visit. Theoretical & practical training was given on 'Basic Maintenance of Medical & Laboratory Equipment' to 35 trainees. Outcome: trainees had more confidence in tackling problems, & managers reported a noticeable change in the level of maintenance activities, confirming: a vast need for this kind of programme; even a short-duration 'basic' course has significant impact; it is essential to combine training with tools, spares, etc; staff benefit from being brought together; such an initiative can help 'change the culture' from replacement to maintenance. For details of project & outcomes see website: www.kar-dht.org/nl1.html; for course details contact: biomed@echohealth.org.uk. J. Crawley (Cardiac Research, Northwick Park Hospital) exhibited a poster on Twinning over the Internet with the Ghana Atomic Energy Commission & University Medical School. Since the '80s the IAEA has promoted one-to-one relationships where depts. in developed countries provide parts, training, information, & technical support to their "twin" in a developing country. New possibilities due to the internet are suggested: access to website literature, telemedicine adapted to technical consultations with experts, computer diagnosis of faults, telesurgery adapted to minor repairs. Technical requirements are discussed, including the need for developed countries to bear the cost of experimentation & teething problems. Contact: j.crawley@physics.org. Existing mail groups may be fora for providing assistance & establishing twinning, eg. WHO's INFRATECH discussion group - for subscribing contact: listserv@listserv.paho.org; for reading messages: infratech@paho.org. John Mahady (Adelaide, Meath, & National Children's Hospital, Ireland) exhibited a poster on Management Systems in Developing Countries. They examined 4 types of commonly used equipment management systems in DCs: user-based (communication only) system, paper-based filing system, in-house developed computerised system, off-the-shelf computerised system. They were evaluated & scored on criteria for: environmental conditions, customer support, user competency, language, cultural, financial, maintenance, & system flexibility. Outcome: paper-based systems are more appropriate for DCs because of their robustness & ease of use; however computer-based systems should be tried, where viable, due to their extra features & reporting facilities. Contact: john.mahady@amnch.ie. M.I. Bhatti (Sir Syed University of Engineering & Technology, Karachi) & S. Khursheed-ul-Hasnain (Pakistan Navy Engineering College, Karachi) submitted a poster on Bio-medical Engineering in Health-Care. Medical equipment is so complex & the choice so extensive, that hospitals must pay attention to technology management - an accountable, systematic approach which assures that cost effective, efficacious, safe & appropriate technology is available for delivering quality patient care. This trend has made the role of biomedical engineers: change, become crucially important & recognizable. They discuss this changing role i) for technology activities, & ii) in the structure of the healthcare system. Contact: fhasnain@super.net.pk. Andre Mboule (SOFRECO, France), working with the Ministry of Public Health, Guinea submitted a poster on Tools for Appropriate Medical Technology. 1) They developed Standard Lists of Medical Devices based on needs expressed: in their Healthcare Minimum Package of Activities, by users, by procurement records, by experts. The room-by-room lists link the device to the room & the activities. 2) They developed a Strategic Maintenance Plan based on National Maintenance Policy & a situation analysis. It covers 4 main programmes: implementation of internal maintenance units, human resource development, equipping & rehabilitation of health facilities, special projects. For details contact: mboulea@yahoo.fr. 2. Applications and Supporting SystemsRoger Drew (Healthlink Worldwide) & Anne-Laure Ropars (GIC Ltd) presented an Update on progress with the DFID Knowledge and Research (KaR) Programme on Disability and Healthcare Technology. The UK govt. wants new knowledge & sustainable new technologies which are poverty focused . The programme is externally managed by a consortium of experts. Funding has 3 prongs: fast-track projects, in-house commissioned projects, & projects awarded under competition. For healthcare technology there is a broad definition which includes "systems", & key features should be knowledge dissemination & shared learning. The 1st round had £1.2 million (excl. prog. management costs), of which £170,000 went to 4 fast-track projects (completed), £120,000 went to 2 in-house commissioned projects (completed), and £910,000 went to 12 projects awarded under the competition (from 50 concepts) - mainly 1-2 year projects for <£100,000. Applicants under-estimated: skills & resources required for dissemination; need to 'repackage' global materials for local use; need to 'repackage' electronic materials into printed format. Future: next round launch in March 2002 (similar funding); a series of roundtables for obtaining expert opinion; evaluating impact of projects. For applications, scoring criteria, results so far, links to projects, see website: www.kar-dht.org. For queries & details of contributing to roundtables of experts, contact: alropars@giclimited.com. Jim Warrington (Royal Marsden Hospital, Sutton) presented Reviving the Use of Cobalt 60 Teletherapy for Cancer. Over 20 years, external beam radiotherapy has moved from Cobalt 60 units to more complex linear accelerators & computerised treatment plans. Can high quality, radical radiotherapy treatments be delivered using isocentric cobalt units? They use older technology: simpler electronics, timer, controls to line up beams, rather than the CT scanning used with linacs. They compared the images from conformal & intensity modulated plans obtained from Cobalt-60 & 6/10MV linac beams, using a modern 3D Treatment Planning System. Clinical lesions were planned & compared using cumulative dose-volume histograms of: brain, antrum, parotid, thyroid, breast, oesophagus, prostate. They worked on low melting point lead beam blocking systems. Outcome: broadly speaking radiotherapy treatments of equivalent quality to those from the 6/10 MV Elektra linacs were achieved with cobalt units. Over 10 years, Cobalt-60 is ½ the cost of linacs (saving £1.7 million per unit), but it is (marginally) slower due to lower energy beams. For maintenance, repair, quality control, & downtime, cobalt units are easier to sustain. Cobalt-60 is more appropriate for DCs. Only one manufacturer remains. Users require some training. Contact: jimw@icr.ac.uk. Roy Rickman (Primary Health Diagnostics Ltd) presented Diagnostic Tools for Regular Medical Surveillance. There is epidemic sleeping sickness (SS) (in Africa) & other endemic & opportunistic diseases in rural areas. Their aim is to find a practicable, effective & affordable method of controlling major infections & providing primary healthcare to rural populations. They developed a 6-part method & suggest a range of strategies in each, eg:- (i) transport - a strong multi-geared bicycle with carrier, dynamo, & solid neoprene tyres for every public health worker to keep after 2 years of satisfactory service; (ii) supplies & equipment - polypropylene capillary tubes, 'Pima ' Hb/PCV% reader card, 'Spinette' manual microcentrifuge, 'Spindoctor' microhaematocrit centrifuge disc, 'Jabric' multi-purpose manual centrifuge, 'Solacen' battery/solar centrifuge, 'Portasol' solar panel, 'AnaemaScan' electronic Hb meter, 'Solmic' pocket field microscope; (iii) training - 1-2 week courses & development of microscopists; (iv) surveillance - pairs of health workers to do monthly outreach for Hb tests, feverish & sick people; (v) community health activities - DIY strategies & supplies for: malaria - impregnated nets, expanded polystyrene beads; for SS - clear bush; schistosomiasis - clear waterweeds, build VIPs; hookworm - swing-pump & decking, fly-borne diseases - fly-traps; (vi) schools - PHC & health promotion on curricula, lab tests every 3 months, microscopes at schools. Such programmes need to be implemented & funded. For further details & the products described, contact: royrickman@aol.com. John Cooper (veterinary surgeon working in East Africa) presented Practical Approach to Veterinary & Wildlife Training to show the parallel equipment constraints to the delivery of health services in rural areas. He teaches on under- & post-graduate courses which combine wildlife, domestic animals, environmental health & community issues (ie. chickens can get sick, are food & revenue, can spread disease). They run crash courses on a single animal (ie. for crocodiles: farming, conservation in wild, threat to people, health & welfare). All training & work is in class & in field. But no electricity, no communication, poor roads, bad terrain, only natural running water, security issues - must carry all equipment will need on 4½ hour hikes. Equipment must be portable, compact, low cost, environmentally acceptable, reliable, easy to use. Want: makes that no longer exist, eg. field microscope with mirror (McArthur); solution to battery problems for auriscope, otoscope, focuscope, endoscope; solution to processing blood samples in the field, or how to transport them for hours. Has developed lightweight field kits for collecting samples using recycled materials - plastic film pots, plastic/wooden stirrers, etc. Due to zoonotic infections, which transmit between animals & humans, the role of the vet is not separate from the health worker & they must collaborate for work & common equipment solutions. Contact: NGAGI@compuserve.com Roger Eltringham (Gloucestershire Royal Hospital) presented an Update on progress with the Glostavent Project. Modern anaesthetic machines (AMs) are complex, cost £20-40,000 each, require constant electricity or O2 supplies, are no longer affordable in most DCs & waste resources. They designed a new AM costing £7,500. It comprises: (i) draw-over anaesthesia system using atmospheric air as the carrier gas (avoiding pressurised gases or cylinders); (ii) Manley Multivent ventilator - a mechanical bellows driven by O2 or air, only 2 controls, economical on driving gas (1/10 of other systems), max. savings as O2 is used twice - for ventilator & the patient; (iii) electric O2 concentrator - produces unlimited supply from atmospheric air without expensive & heavy cylinders, zeolite canisters absorb N2 & do not require recharging (unlike soda lime), if electricity fails - 2 reserve O2 cylinders are provided; (iv) air compressor - a separate unit is not required as a modification of the O2 concentrator enables some of the generated compressed air to drive the ventilator. The components are trolley-mounted (visually like any AM). Since the last report, there has been full testing, several DC field trials, support from govt. agencies. Outcome: more economical to run (£1.17/hour), easy to use & understand, requires minimal maintenance & repair, versatile (for use in theatre & ICU). Roger offers training; contact: 106147.2366@compuserve.com. Website: www.nda.ox.ac.uk/wfsa/html/wa03-01/w03-1-08. For sales, contact Alan Green of Penlon Ltd via: general@penlon.co.uk. Prof. D Picken (De Montfort University) presented an Update, & exhibited a poster, on progress with the De Montfort Medical Waste Incinerator. Previously this cheap, non-electric, solid-fuel economic unit, built from local materials had been developed & launched. Various modifications were requested by countries/agencies - these were designed, tested & accommodated in different models: (i) using diesel not solid fuels - diesel trickles onto the load; (ii) a larger model - covers the needs of 1000-bed hospital; (iii) using natural gas - fed into primary combustion chamber above grate; (iv) improve emissions - increased secondary combustion time & temp. - passed international standards; (v) taking a variety of loads - wide variety of even wet loads combusted as long as mixed loads used containing materials of high calorific value; (vi) higher chimney - 10m chimney; (vii) prefabricated for emergency situations - composite cement blocks bolted together, no outer bricks or base, thin stainless steel chimney liner; (viii) simpler construction - based on prefab model & not relying on machine tools being available. Outcome: A success - approx. 500 in 25 countries around world with new queries all the time; customers range from satisfied to delighted with the performance; some problems if poor manufacturing on site, poor materials, poor construction, language constraints, operators change - it is essential to get feedback from users. Cost only £1-2000 (nearest comp. $3000, commercial £20,000 up), <1L fuel/per day. Continue to work on modifications. Design is downloadable from web & De Montfort offer training. Contact: djpicken@iee.org.uk. Website: appsci.dmu.ac.uk/mwi/. Gerald Verollet (WHO Dept. of Devices & Clinical Technology, Geneva) exhibited a poster on Haemoglobin Colour Scale (HCS). WHO developed a simple, reliable & inexpensive tool to screen for anaemia in the absence of laboratory-based haemoglobinometry. Improvements in materials & spectrometric analysis enable the HSC card to show 6 shades of red that represent Hb levels from 4-14 g/dl. Requires no specialised training, doesn't depend on electricity or batteries, needs no maintenance, is portable & gives immediate results. Starter Kit of 1000 test strips costs $20. Contact: verolletg@who.int or hbcolourscale@who.int, website: www.who.int/bct/. David Morley (Tropical Child Health, University of London) submitted a poster on Health measurements, numeracy, & development. Cost-benefit analysis of growth monitoring shows that it doesn't influence nutrition levels or mortality, since graphic representation of number isn't taught in primary schools & isn't understood by parents or many health workers including doctors. A Direct Recording Scale (DRS) was developed: a mother places her child in the trousers below the scale (containing her child's chart), sees the spring stretch up the chart, marks the chart at the top of the spring, compares the mark with previous ones, understands faltering growth, & takes action. The DRS leads to apparent appreciation of something as complex as a line graph; other simple measuring technologies (height, upper arm, 'Thermo-Spot', Anaemia-Check', etc) could help in the understanding of practical numeracy & empower families to take action. Contact: david@morleydc.demon.co.uk. Nick Bosanquet (Dept. of Bioengineering, Imperial College, London) exhibited a poster on Can Middle Income Countries Catch up in Cancer Treatment? They propose a programme requiring co-operation between public & private sectors; comprising: (i) a rapid diagnostic service (max. 2-weeks from referral to start of treatment); (ii) day/short stay surgical unit for breast & other cancers using local surgeons on contract basis; (iii) radiotherapy unit maximising throughput, drawing on national & international expertise in treatment planning (or possibly a network of linked centres); (iv) partnership with local doctors (public & private) to follow up & provide chemotherapy; (v) use of WHO list of essential anti-cancer drugs (generic), targeting higher cost drugs on higher risk patients; (vi) focus on quality & monitoring of outcomes. The International Union Against Cancer has helped such positive developments in Latin America & Asia. New investment in such programmes could significantly improve access to treatment. Contact: n.bosanquet@ic.ac.uk. Dr A. Brown (School of Engineering, Liverpool John Moores University) exhibited a poster on PhiSAS: a Low-cost Medical System for the Observation of Respiratory Dysfunction. Respiratory illness is a major problem in DCs. PhiSAS (Physiological Signal Analysis System) is a new computerised lung sound acquisition & analysis system which helps doctors to observe lung sounds. It's made up of a PC; chest microphones; digital signal processing; sound playback & spectrographs; Fourier, Wavelet, & Time-frequency analysis. It would be: low-cost to manufacture, operated by users with minimal experience, useful for data collection & analysis of patients based in DCs, & used as a training aid for health workers involved in respiratory medicine. Contact: eeeabrow@livjm.ac.uk. Gelareh Mortezaie (Institute for Studies of Theoretical Physics & Mathematics, Iran) submitted a poster on Analysis of Mammographic Microcalcifications (Mcs) using grey-level images & neural networks. Mammography is the only effective & viable method for mass screening for breast cancer. MCs are a sign of breast cancer, but it's difficult to distinguish between benign & malignant ones. Automated methods of diagnosis are required to indicate suspicious areas. They are developing a computer algorithm to automatically detect MCs (objectively & reproducibly) & flag them for the mammographer; it doesn't, yet, make a diagnosis but will assist them to find even subtle MCs, recognize the pattern formed by all the MCs, & draw attention to those that might be overlooked due to a more prominent feature. Contact: gelareh@ipm.ir. Stephen Burns (Harvard/MIT Biomedical Engineering Centre) exhibited a poster on A Biomedical Instrument Development Centre (BIDC). Although colleagues in DCs have spirit, work-ethic, & intellectual capacity, many local technology-production efforts have failed. Background & evidence is given for a proposal for a BIDC to be based in a University in a DC, chartered to develop new & innovative medical instruments based on commodity computers & computer components, made to world standards, according to a sound business plan. Examples of products: gas chromatograph in Vietnam, various electronic instruments from MIT, through-the-eyelid tonometer from Harvard. Examples of constraints: copying technology, commercial production, paying for development, business management. The traditional instrument manufacturing structure is not available everywhere, but PC use, supplies, support & repair are familiar everywhere. Contact: steve@hstbme.mit.edu. Goh Ong Sing (Faculty of Information, Science & Technology, Multimedia University, Malaysia) submitted a poster on an Intelligent Virtual Doctor System (IVDS). In DCs there are shortages of medical expertise & problems reaching rural communities. Instead of clinics with nurses who consult doctors by phone or periodic visits, they propose an IVDS. It's an interactive user-friendly system built on the platform of chat technology carried out by an animated agent character or avatar (to reduce the intimidation of technology). Users key in questions, the system searches for answers within the knowledge base (using artificial intelligence markup language), & responds either in text or speech. Trials have run successfully on a knowledge base concerning asthma. Contact: osgoh@mmu.edu.my. Mr W. Lyons exhibited the work of Claude Lyons Ltd manufacturers for > 80 years of quality electrical power control equipment such as voltage stabilizers, power conditioners, and variable transformers. Such products are useful for: countries that experience supply line fluctuations, items which need reliable supplies (such as medical equipment), & have been sold worldwide. Website: www.claudelyons.co.uk. Mr D. James exhibited the work of Restored Sight Projects Ltd who develop ophthalmic examination & surgical equipment. They translate the latest technology into cost-effective transfer packages, which provide highly efficient solutions for ophthalmic surgery in DCs and outreach surgery environments. Website: www.restoredsight.com. Priorities for the Future: the meeting agreed that:-
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