March 2012 - Institute of Physics and Engineering in Medicine

MEETING REPORTS | SCOPE
FIGURE 2.
The ‘iceberg
syndrome’ of
lifecycle costs for
healthcare
technology. 4
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THE STRUCTURAL BURDEN OF DONATED
EQUIPMENT: THE ‘VICIOUS CYCLE OF AID’
During his TED talk and later in my interview with him,
Professor Malkin referred to a book by best-selling author
and economist Dambisa Moyo, entitled Dead Aid: Why Aid
is Not Working and How There is a Better Way For Africa. 2 In
this book, Moyo describes how ‘overreliance on aid has
trapped developing nations in a vicious circle of aid
dependency, market distortion, and further poverty,
leaving them with nothing but the need for more aid’
(http://www.dambisamoyo.com). Moyo is an economist
and not an engineer, but Malkin remarked that the issues
dealt with in the book essentially reflect the problems that
he has observed certain equipment donations to cause. In
my interview with him, Malkin cited the example of how a
large-scale donation of wheelchairs and other mobility
equipment to an area in Tanzania met an immediate need,
but on the other hand put capable local craftsmen out of
business. The subsequent lack of local support and the loss
of skills meant that it was only a matter of time until the
area became fully dependent on intermittent and
unpredictable foreign donations; a clear example of the
‘vicious circle’ that Moyo describes.
WORKLOAD BURDEN OF DONATED EQUIPMENT:
SUSTAINING INAPPROPRIATE TECHNOLOGY
Equipment donations can also create a set of challenges
that are faced throughout their life in the clinic, particularly
with their practical up-keep. These problems arise from a
mismatch between medical technology and the
circumstances of hospitals in resource-poor settings.
Discussions with Julien Benchetrit highlighted the
following statistics, taken from a webcast by Clinical
Engineer Ismael Cordero on the Drexel BIOMED website: 3
n ‘80 per cent of the world’s population is unable to afford
£60 (US$100) per head per year on health. In many sub-
Saharan countries, that figure drops to ~£9 (US$15).
n The vast majority of medical equipment is designed in
countries that spend over £1,240 (US$2,000) per head per
year on health.
n Thus, the standards and technology set by the medical
equipment manufacturing nations are not sustainable for
over 80 per cent of the world’s population.’
Fundamentally the global majority who need healthcare
technology are rarely even an after-thought in equipment
design and delivery. As such, supplies of spares and
consumables are difficult to sustain, conventional technical
support is impractical and the lack of skilled maintenance
personnel means that even easily preventable device faults
render equipment unusable.
FINANCIAL BURDEN OF DONATED EQUIPMENT:
ACCOUNTING FOR THE LIFETIME COST OF
MEDICAL EQUIPMENT
The workload burden of managing donated equipment is
significant, but donations often create more direct,
financial burdens. In the past, large equipment donations
have been thought to be beneficial because they remove
the purchasing costs of technology acquisition for the
recipient. However, in what has been termed the ‘iceberg
syndrome’ of lifecycle costs for healthcare technology, 4
operating, management, maintenance, transportation and
decommissioning costs are often overlooked (shown in
figure 2).
The structural, financial and workload burdens of
donations have culminated in growing stockpiles of
underused medical equipment. In a recent study carried
out by Lora Perry and Professor Malkin, ‘inventory
reports were analyzed from 1986 to 2010, from hospitals
in sixteen countries across four continents’. They found
that about 40 per cent of medical equipment is out of
service in the developing world. Of the hundreds of
thousands of devices surveyed, not one donated item
(new or used) was found to be fully functioning and inuse
after 6 months.
EWH’S TURNING POINT
Professor Malkin and his associates steered EWH’s
mission away from donation 3 years ago, after he
witnessed a shocking example of the mounting
equipment storage costs that can be caused by poorly
targeted donations. Malkin visited a Nicaraguan hospital
where a container full of medical equipment had been
shipped 6 months earlier, only to find the equipment
absent from the operating theatres and intensive care
units. He recalls: ‘I spoke to a colleague and he took me
across town to a nondescript building and I saw a sea of
donated medical equipment. This hospital had received
so much donated medical equipment (including that from
EWH) that they had to rent this enormous building just to
house it all. It probably would have been cheaper for
them to buy the few pieces of equipment they were using,
than to rent this huge facility. In essence our donation had
hurt this hospital.’
At that point, EWH stopped donating, cleared its
warehouses in the US, and 3 years on the decade-old
organisation has moved from being a prominent
equipment donor to becoming the world’s largest postdonation
provider of medical equipment servicing.
EWH’s development work aims to reverse donordependence
and assist in implementing sustainable
resources. This is achieved through a number of
programmes.
EWH’S DOMESTIC PROGRAMMES
Through the open publishing of carefully researched
design briefs under the ‘Projects that matter’ list at
ewh.org/ptm, and through the ‘Kits programme’, EWH
encourages large-scale participation in both the
development and construction of appropriate
technologies (such as the EWH electrosurgery unit tester
kit, available through the website). EWH’s university
‘Chapters’ specifically engage students, raising awareness
of challenges in technology provision and support in
resource-poor settings. In EWH Chapters across the US
and more recently in the UK and mainland Europe,
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SCOPE | MARCH 2012 | 13