1. Medical maintenance at national level and district hospitals in Rwanda: where to start? Sankaran Narayanan BTC Health Sector Days Brussels - December 2014

2. Medical Equipment Maintenance Biomedical Equipment &Electromechanical Equipment “Medical equipment maintenance essential for safe and effective patient care, medical equipment also has significant impact on the income and, thus, vitality of healthcare sector”

3. Contents 1.The developments in East African Community for Curriculum Development. 2.Plans for Rwanda in the development of sustainable medical equipment maintenance support in the East African Community 3.How Medical Technology and Infrastructure division of Rwanda Biomedical Center can achieve a leadership position in EAC

4. EAC Rwanda Burundi Tanzania Kenya Uganda 150 million EAC citizens 10 th Largest population in the world. Health sector needs – Equipment

5. Situation Analysis in EAC 70% of critical and 50% of non-critical medical equipment is not functioning survey in 2011. Lack of qualified manpower and dependence of foreign expertise to install and maintain medical devices. ( Human Capital) No infrastructure to organise the work shop space Proper tools are not available for Technical staff. No specific Policy, strategy and planning for medical equipment.

6. Initiatives by UNECA (United Nations Economic Commission of Africa) “Engineering Capacity for Improved Healthcare Outcome in Africa” Pilot Project in 2011 for 3 years Pilot Projects involves 5 countries( Ethiopia, Kenya, Malawi, Uganda and Zambia). Pilot projects were done in 6 universities - Makerere University Addis Ababa University, Kenyatta University, University of Malawi, University of Nairobi and University of Zambia

7. “Engineering Capacity for Improved Healthcare outcome in Africa” Recommendations from the project and Policy Brief in April 2014 Support and promote biomedical engineering training in institutions of higher learning Inspire biomedical innovations among students and researchers through the establishment of competitions and awards Use public procurement contracts as a tool for technological learning and commercialization.

8. UNECA African Consortium of Biomedical Engineering was formed in 2012- o Facilitate the exchange of information o Harmonize training and research programmes o ensure quality of BME university programmes at member institutions.

9. Development of Centers of Excellence in EAC African Development Bank Loan of $98.22Million.sanctioned on 3 October 2014 Rwanda, Kenya, Tanzania and Uganda Creation of a network of Centers of Excellence (CoEs) in biomedical sciences and engineering. o Nephrology and urology in Kenya, o Oncology in Uganda o Cardiovascular in Tanzania o Biomedical engineering and e-health in Rwanda.

10. Rwanda in action Govt of Rwanda wants to develop skilled and trained manpower Rwanda wants to become a model for medical equipment maintenance in EAC Expenses for Medical equipment maintenance should show tangible reduction.

11. Roles and responsibilities MoH has the mandate to put in place the policies and guide lines. Rwanda Biomedical Center( RBC) has the mandate to operationalise the medical equipment maintenance through Medical Technology and Infrastructure Division ( MTI)

12. Current System of MTI Central work shop supporting the Hospitals -No specialisation Spare parts procured centrally but not by MTI Funds are allocated by RBC for operation MTI Administratively reporting to RBC and operations are directed by Clinical services and MoH

13. Medical Technology and Infrastructure Division Civil engineers (2) (3) Medical Equipment Director of Unit Medical Equipment Engineers (5)(0) Health technology and infrastructure planning Director of Unit Preventive maintenance specialist(1) (0) Health infrastructure manager (1)(0) Biomedical technicians(5) Infrastructure Director of Unit Division Manager Technical Data analyst (1) Biomedical engineer procurement specialist(1) (0) Health facilities equipment planning specialist (1) (0)

14. MMC’S WORK LOAD DDG Biomed services Minister of Health Minister of State MOH PS MOH Procurement RBC Procuremen t SPIU Procurement Donors/Pa rteners Donations University Hospitals Ref Hospitals District Hosp Medical Technology and Infrastructure Division MEDICAL MAINTENAN CE CENTRE Health Center s DG and PDDG RBC Private sector

15. Service delivery of Medical Technology and Infrastructure Division Central level support to 500 health centers, 35 district hospitals, 4 Provincial Hospitals and 8 referral Hospitals District, provincial and referral Hospitals have inadequate and not qualified BMETs Spare parts procured by procurement divisions located in RBC, MoH, or SPIU- Minimum lead time of 9 months.

16. Hospital Level Maintenance BMET in the Hospital do the first line of fault finding and reporting to MTI for central level for help. Very few equipment are maintained properly

17. Human resource challenges in Central and Hospital level Educated experienced and Trained Manpower –No qualified Biomedical Engineer with Basic degree in BME. in the country –Experienced and trained technicians are few in Govt as well as private sector in Rwanda –EAC also has the same problems

18. Few steps taken for Biomedical Engineering HR development General Electric foundation and Engineers for World Health program for training Biomedical Engineering Technicians -3 years Integrated Poly technique Regional Center- continuing the second batch with help of USAID. Capacity Development Fund assisting to send BMET for graduate and post graduate program in Biomedical Engineering overseas.

19. HR development Biomedical Engineering Bachelor’s degree program in College of Science and Technology – Rwanda University o Syllabus – courses and course content are already developed 9 o Detailed cost estimate is ready o Concept note submitted o External evaluation and senate approval to be done

20. Training Seniors Training Juniors

21. Training by manufacturers Technical Training in Autoclave Matachana Spain( BTC) Technical Training for Haematology analyser in South Africa by SYSMEX( BTC) Technical Training in Human Chemistry Analyser in Germany (BTC) Philips and GE agreed to train BMET on site while installations are being done.

22. Proper tools Tools are not adequate in central level specialist and QA support Proper tools are not available in Hospitals Installation equipment are not there both in central and hospital level

23. Tools

24. Quality control Instruments. Technical and user manuals Quality control Instrumentation partial procurement ( BTC) Tools Partial Procurement fir central level ( BTC) Technical Manuals, user manuals and equipment specifications ( BTC)

25. Space in the Hospital for repairing WHO specifies the space requirement for a medical equipment repair workshop. Plans are available for less than 100 as well as more than 100 beds hospital 38 out of 42 Hospitals are not having workshop space.

26. Current make shift arrangement

27. Medical Equipment Maintenance Policy and Guidelines Medical Equipment Policy developed way back in 2009- It has good content but implementation is poor Guidelines for accepting medical equipment as donation is developed but many procedures for validation and approval.( BTC) Guidelines for scrapping non serviceable and obsolete medical equipment is developed but many procedures for validation approval.( BTC)

28. Medical Equipment Maintenance Policy and Guidelines Guidelines for design of Health facilities is being developed (BTC) Guidelines and standards for Ambulance services ( BTC) User maintenance manual for medical equipment( BTC)

29. Medical Equipment Maintenance Management System(MEMMS) Web based system for inventory, preventive and curative maintenance management and spare parts procurement ( USAID- CHAI in 2013) System is non functional for 14 months Data collectors and IT engineers are at work for making the system operational (BTC)

30. Operational Challenges Many equipment are not yet installed Many equipment are not having room preparation, but bought with donor funds. Equipment installed but not commissioned due to one reason or other

31. Delivery beds not used in a hospital

32. Many equipment in boxes

33. Important issues which need attention from MoH Waste management – Clinical, Hospital and domestic. o Pilot study was conducted ( BTC) o Waste management practices are far from standards.

34. Waste management in pictures

35. Important issues which need attention from MoH Radiation protection for X-ray and CT scan rooms – Study conducted ( BTC) o 80% X-ray rooms need radiation protection to be done. o 11 X-ray equipment are obsolete and needs replacement. o Personal protection and monitoring needs to be done in the whole country

36. Interventions Educate and train BMET so that each hospital will have a qualified and trained biomedical engineer On phased manner build space for Hospital workshop – distant one first, Standards from WHO. On phased manner procure tools, QA equipment for all BMET, as well as workshops Make online specification and technical document bank

37. PPP Explore PPP to maintain the critical equipment and one which requires higher level of maintenance Contract out to private sector the equipment which are more revenue earning

38. MTI effort Build momentum for the Govt: willingness and commitment to recognize management and maintenance of medical devices as an integral part of Rwandan Public Health Policy. Initiate transformation of MTI in order to improve both quality and access to care. Conduct in-depth study of asset and medical equipment maintenance management

39. Standardization of medical equipment ECRI National Health System UK Local Initiatives and regulations RPPA, RBS

40. Support from WHO Contacts: http://www.who.int/medical_devices/ en/http://www.who.int/medical_devices/ en/ mailto:medicaldevices@who.int Phone: + 41 22 791 1239 Fax: +41 22 791 48 36 Skype: WHOHQGVA1 (then dial 11239) Objective: to ensure improved access, quality and use of medical devices.

41. Information Kangaroo ChairLocal Stretcher

42. Information Electronic waste Local make Phlebotomy chair

43. Where to start It is a dynamic scenario? Many donors – reducing AID? Attempt all interventions mentioned ? Make a strategic plan ? Do MTI need paradigm shift in the way MTI strategise and operate?

44. Life Ain't Easy" by Mac Miller