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close this bookBetter Health in Africa: Experience and Lessons Learned (WB, 1994, 260 p.)
close this folderChapter 7 - Infrastructure and equipment
View the document(introduction...)
View the documentInfrastructure and equipment problems
View the documentThe special problem of tertiary care facilities
View the documentAssessing technology choice

Assessing technology choice

In many African countries, modem technology is often not used properly, even in leading hospitals and medical schools (Free 1992). It is complex technology that requires every component to interact at the right place and the right time, but the more complex the technology. the greater the risk that a link in the chain will break down. The introduction of oily technology should therefore include the introduction of all the things needed to make the technology work: equipment, training, maintenance, quality control, and the capacity to translate the results of quality control analyses into corrective actions.


The public sector In Zambia is facing great difficulties in providing and sustaining medical equipment services. In public hospitals, about 20 percent of medical equipment is working poorly and 40 percent is completely out of operation. Zambia Consolidated Copper Mines (ZCCM) has established a health care system of its own, separate from the public sector, that consists of eleven hospitals and fifty-eight health centers. It has developed a good maintenance system for its medical equipment, which is about the same-age as that in the public sector) Its ability to do this has been due to the following factors:

- It has established an autonomous body, the Medical and Educational Trust, to operate all health care facilities and train health care and operational personnel)

- It has established work practices that encourage good staff performance, combined with strong supervision and incentives. It offers better service conditions than the public sector and has higher staff retention rates.

- ZCCM has recognized the importance of maintenance in its operations and health care activities. Mine hospitals are financed significantly better than their public sector counterparts and therefore receive adequate maintenance budgets and foreign exchange.

- It has separated medical equipment maintenance and safety policies from its operational activities and wisely applied technical and human resources, maintenance, and management expertise from industrial instrumentation to medical applications.

- Initial training in management and maintenance for health care specialists has been conducted by mine operational staff. Some operational maintenance staff have been seconded to mine hospitals.

Source: Templ + Bird 1991.

New technologies have expanded the potential scope of the health system; some examples follow.

- Computerized systems make it possible to store and retrieve the large amounts of vital statistics and other data needed to assess risks and to plan, implement, and evaluate health programs. Pharmaceutical supplies can be managed more efficiently through computerized updating of inventories, thus preventing waste and reducing costs. Computers are only helpful, however, to the extent that they support a management information system With adequate software and maintenance.

- Radio communication has proven essential in mobilizing the resources. needed to deal with epidemics and natural disasters, Health activities in rural areas can be better integrated into district health care through the use of two- way radios, particularly if transport is available to evacuate patients when necessary. Supervisory consultation by radio improves the efficacy of services and. reduces the cost of referral.

- New diagnostic tests, such as "dipsticks" to diagnose HIV and other sexually transmitted diseases, or tests using saliva, may give community health centers diagnostic powers that were previously restricted to specialized urban laboratories.

- Noninvasive diagnostic tools with high sensitivity and high specificity,. such as uItrasound machines, may sharply improve diagnosis at the district level. Less invasive treatment “keyhole" surgery, for example-can minimize patient trauma and reduce the length of hospital stays. A shift to one-day surgery with improved technologies and care practices, as is now being done in many industrial countries, could help to contain the growing demand for hospital beds and other health facilities (Porter 1992).

- The development of powerful drugs that can be effective when administered in a single oral dose has drastically modified the therapeutic approach to such diseases as helminthiasis and amoebiasis. Similarly, thermostable vaccines that can be given in a single oral dose have increased the prospects for controlling common children's diseases, such as measles and polio. Drug kits and blister packs fall in the same category.

The greatest obstacle to improving medical technology in Africa may be "technology philanthropy" - the uncoordinated donation of equipment to African countries by foreign agencies and charities. Given their. often precarious finances, developing countries find it hard to refuse such gifts, even when they are unsuited to the-country's immediate needs. One solution would be to devise "donation protocols," whereby the kinds of equipment to be donated would follow a model-paralleling, for example, the selection of drugs by using essential drugs lists (Porter 1992).


There is generally no established mechanism in African countries for planning the acquisition of new health technologies. Awareness of technologies is not a problem, because there is a sufficient pool of knowledge at universities, among staff returning from abroad, and among consultants and donors. It is the process of technology transfer that is problematic, since it is usually made on an ad hoc basis according to vested interests, pressures, and prejudices. When there is some form of planning, the acquisition of new technologies is to a large extent controlled-by physicians and, more likely than not, by clinicians trained abroad. They are generally not the best persons to perform this task While the medical profession can readily pinpoint a problem, it generally has little idea of the complexity and extent of the engineering problems or the level of training associated with the technologies needed to solve them. Rather, a team is needed, including public and nongovernment health care providers, engineers, planners, and social scientists—to ensure that the broader cultural, social, and economic dimensions are considered) Public, private voluntary, and private commercial perspectives are all useful to this end. Because the choice of health technologies determines the allocation of human and financial resources in health care, African governments need to support operationally oriented research that will facilitate decisions about whether to introduce new tests, treatments, and their associated technologies into their countries' health care systems. Factors to be considered include the appropriateness and cost-effectiveness of the intervention, its links to the basic package of health services, its impact on health equity, the ease of its use and maintenance, its training requirements, and its life-time cost. A cautious attitude toward uncontrolled diffusion of medical technology is emerging in the industrial countries, and African policymakers would do well to exercise prudence in the face of quite understandable pressures for investment Selection of appropriate equipment, and arrangements-to ensure its maintenance, are appropriate ministry of health roles.

Much of the work of technology assessment will require intercountry cooperation, because the costs of undertaking assessments and preparing appropriate recommendations are likely to exceed the capacity of most individual African countries. Some support for such work exists at the international level, including a joint Technology Introduction Panel inaugurated by UNICEF in 1988 in cooperation with WHO and other international agencies (Box 7-2) (Free 1992).


Strengthening the management of infrastructure and equipment is one of the several health system reforms needed to achieve health goals in Africa. One concrete step would be for governments to assign responsibility for decisions about health facilities, equipment, and technology to a senior ministry of health official. Another would be to establish norms for health facilities at different levels in the system and to support operational research on the most cost- effective technologies available. Budgetary standards and provisions for maintenance and operating costs need to be established, particularly in public sector, health facilities. Since the financial resources required to provide basic health services are frequently depleted by cost overruns and-inefficiencies at the tertiary level, more efficient use of technologies, equipment, and facilities in large urban hospitals should L-e a priority. African ministries of health might take a look at the global -action plan devised by WHO for the management, maintenance, and repair of health care equipment.