The EssentialMed approach
The context in which technologies are placed and used in LMICs presents considerable challenges. We noted that these challenges can be broadly and rationally grouped into five categories:
- Lack of Financial resources. LMICs are, by definition, countries where financial resources are scarce (according to the World Bank, Cameroon’s health expenditure per capita for 2016 in international dollars was 169 at purchasing power parity, compared to 4’178 for the UK and 9’870 for the United States). This affects not only their ability to purchase the technology in the first place but also to pay for services and consumables related to the technology. When financial resources are scarce and operational budgets unpredictable, we propose that it makes better economic sense to consider the Total Cost of Ownership (TCO) of the device, rather than the initial purchase cost alone. This is because most of these devices typically have recurring costs for them to continue functioning (e.g. maintenance contracts, consumables), and thus periodic budgetary deficits can be a crippling factor for sustainable social impact. TCO calculation involves adding up all the costs incurred by the owner of a product, including the initial purchase price, taxes, transport, commissioning, training, operational costs and consumables, maintenance, repairs and disposal, during the complete life cycle of the product. Unfortunately, many buyers of medical equipment in LMICs especially still focus on acquisition costs and fail to evaluate product life cycle expenses, including consumables and maintenance. If they did, they would either plan accordingly for those costs (if they have the means) or choose an entirely different product. Therefore, the challenge is to optimize costs for the complete lifecycle, not just the initial purchase price. If the device can be designed intelligently such that it is robust and requires very little maintenance over its lifetime and no consumables, then if a TCO approach is adopted it would likely represent a more affordable and sustainable approach towards improving access to medical devices, even if the initial purchase price is higher than that of readily available devices. Thus, the technology’s lifetime is a key parameter and it seems reasonable to aim for a lifetime of 10 years for such a piece of capital equipment.
- Lack of quality infrastructure in key areas such as electricity supply, roads, water supply and buildings poses a major challenge. Poor electricity ranks as the highest infrastructural challenge for medical devices in LMICs: frequent power outages reduce equipment availability, while electrical perturbations (spikes and sags) are highly deleterious and account for about 30% of medical equipment damage. In order to confront these challenges, it is necessary to rethink the design of power supply circuits, which are the main unit in direct contact with electricity grid.
- Harsh Environment. In many LMICs, the environment within the hospitals is typically hot, humid and dusty, which can be highly damaging to medical technology products and will reduce their longevity. The climate in some LMICs is characterised by temperatures in excess of 40°C and close to 100% humidity, which fall outside the product specifications of most medical devices.
- Lack of Skilled personnel. Even if a robust and well-adapted technology product were available, the lack of suitably qualified personnel can lead to improper use and product breakdown. Creative ways need to be proposed to facilitate the use of the technology even by people who lack complete and recent training. For example, the use of pictograms and images can improve ease of use, while at the same time removing language and cultural barriers.
- Poor Governance. Major medical equipment needs to be correctly managed to guarantee continued effective results. In LMICs, issues with mismanagement can be frequent and affect all aspects, from the initial purchase of the technology, through to maintenance and repair, all the way to the final decommissioning and disposal. Especially problematic is the current practice in the industry of selling maintenance contracts, which have an annual fee. Often the funds lack at a later stage, and maintenance contracts are not renewed, which results in the maintenance being stopped. For large equipment, like imaging devices, this is especially problematic and represents a serious impediment to product sustainability. The problem requires a bold solution. One idea could be to do away with recurring maintenance contracts, but instead include several years of maintenance in the one-off initial purchase price (e.g. six years with an optional four-year renewal). Such an approach might help towards addressing the common challenge of poor financial planning in the management of major medical equipment. It is appears preferable to offer real additional digital services for a fee, than forcing the customer to “pay for uptime”. This should be all the more feasible if the technology has been designed for robustness and durability. In addition to this, it is now also technically possible to monitor each machine remotely from a centralized location. This could be useful to predict and prevent potential breakdowns beforehand, via preventive maintenance planning, or to provide remote assistance.
All five factors discussed are interrelated and interdependent. Each one may significantly increase the risk of failure of a technology product. Of course, there is one more component, which is the cultural specificity of every region or country. Differences can be quite important, and these elements cannot be emphasized enough. As an example, the look and feel of a product is highly important and adequate attention devoted to this aspect can drastically improve the chances of product uptake, as in any market in the world.
Application to our projects
In the frame of the GlobalNeoNat project, a team was sent to audit 25 hospitals throughout Cameroon in 2012. They surveyed the available neonatal equipment available at each facility, and whether it was functional or not, in order to assess the actual need for such equipment.
In the field of access to medical oxygen, the situation has already been assessed by other organisations, such as PATH or in the case of our pilot country by the regional government of Bungoma County itself.
Of course the Covid-19 pandemic dramatically changed the landscape of oxygen needs and availability globally. The Every Breath Counts coalition offers several resources to monitor the situation.