Monday, 2 June 2008

Appropriate Healthcare Technology

I recently attended the Institution of Engineering and Technology conference on Appropriate Healthcare Technology for Developing Countries. You might think it's not the sexiest thing to do but a) it's at Savoy Place with a gorgeous view over the Thames, b) healthcare technology in developing countries means the differencve between life and death for a lot of people c) they showcase the most alluring bits of kit and d) you get to meet a lot of really interesting people from all over the world. It happens every two years. I first went in 2006 and was bowled over by items such as the open source solar powred wireless router for setting up intranets in the jungle, and the $300 foetal heart monitor that works off mains, battery, solar power or wind up.

This conference was much like the 2006 one in having two strands. The first and brighter strand is the introduction and discussion of new pieces of kit or new uses for known technology. Stars of this occasion were
- the Shakerscope - a light source which is powered by shaking it up and down, and then has ophthalmoscope, otoscope and laryngoscope fittings.
- the U-Flow meter – primarily because of cost. The standard machine costs about £4000, compared with the U-Flow's, wait for it, £7. I now know a lot more about urology than I did before.
- the touchscreen medical record system devised by Baobab in Malawi.

The second strand, for which there were more presentations, and which was keenly debated, was a number of presentations on management issues. The first presentation, given by GTZ's Joseph Riha, was typical – an account of the four year process, still not completed, of getting the idea of having an HTM policy accepted in Cameroon. This was typical of the presentations which followed, and of informal conversations, in which the talk was of equally long lead times, lack of coherence or cohesion in approaches at different elvels in the organisation, if not in the same level, and general difficulty and intransigence of the situation. This mirrors the feeling at the last AHT conference I went to in 2006. Two years has not moved us very far. One of the key factors is that GTZ were big funders of HCT and decided a while ago to pull out of the field. The outlook for funding was quite bleak two years ago, but this year there are some indications that other people are beginning to step into the hole left by GTZ. There is, however, a clear picture of unjoined up thinking going on among health ministries and districts all over the developing world.

There were further examples of badly specified equipment, badly maintained equipment, lack of ground preparation, careless handling, machinery useless due to lack of spare parts, etc – we don't seem to have moved forward there at all. The figure normally quoted (and used by Mladen Poluta in this conference) is 50% of hospital equipment lying idle for one reason or another. There was a debate at the conference as to how true that figure is with some maintaining that there is evidence that it is only 30% - it's still a lot of millions.

Peter Heimann noted the lack of research tools to meassure impact, and even the lack in our knowledge of whether the difficulties are policy driven or capacity driven.

Mladen Poluta - - (you need to scroll to the bottom) started from the definition currently adopted referring to "the drugs, devices, and medical and surgical procedures used in healthcare, and the organisational and supportive systems within which such care is provided.". And its goal is "…optimising the acquisition and utilisation of healthcare technologies to achieve maximum beneficial impact on health outcomes" (quoting Rakich et al). And issues in the field are that HTM is or has:

highly politicised
many role-players
low skills base in DCs
environmental constraints

He advocates a formal framework for management policy, much as project management as such has a formal framework. He suggests AIM-HIT, as developed at Cape University over some years,

Assessment – Innovation – Management
Healthcare Infradstructure and Technologies

I think this has the particular virtue of focussing on infrastrcuture as well as on technology, but it also seems to leave a lot uncovered. Earlier in his presentation, Mladen talked about the need to see HTM in project management terms. Much of the other stuff he talked about was different ways of saying the same thing – in other words the need to manage properly:

a) Match delivery to capacity
• Prioritisation
• Asset management
• HR– building and retaining capacity
• Information

b) determining efficacy and effectiveness (bearing in mind the much greater difference in the developing world between efficacy and effectivenss)

c) providing quality, coverage and doing it at the right cost.

All these are things which good managers do, which raises in my mind the question of whether the capacity exists in many places to do this properly. This is clearly a key issue because of the proportion of budget that is sunk in HCT already, and the impact that HCT could have on health and survival rates.

There's a lot more in his presentation which can be found via: but the key thing is this issue about management - if we don't get it right we will continue to lose millions of pounds and millions of people unnecessarily.

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