Transnational donations of medical devices in Sierra Leone

Transnational donations of medical devices in Sierra Leone and Ghana: facilitators of healthcare or white elephants? Dinsie B. Williams, Ph. D 4 th WHO Global Forum on Medical Devices AMTZ- Kalam Convention Centre, Visakhapatnam, India 15 th December 2018 1

Unusable donated devices (proportion of total) 100% 90% Sample of humanitarian initiatives - devices The Gambia 80% 70% Haiti 60% 43 countries 50% 40% Malawi (central) Malawi Mali, Tanzania, Rwanda, Uganda, SL etc 30% 20% Tanzania (Dar Es Salaam) 10% 0% 2004 Ethiopia (mixture) 2006 2008 2010 2012 Year of publication 2014 2016 2018 2 (Ademe et al. 2016; Howie et al. , 2008; Mullally and Frize, 2008; Perry and Malkin 2011; Dzwonczyk and Riha, 2012; Harris et al. , 2012; Zomboko et al. , 2012)

Disposition of medical devices Donations 80% Funds for equipment Equipment 30% Put to use 70% Out of pocket 20% Abandoned For every $1 donated for devices, up to 90 cents are wasted 3

Where does the funding go? Majority of donated medical devices are… § § § missing components electrically incompatible terminally inoperable/obsolete redundant or. . . 4

Where does the funding go? § Devices may be deployed under inappropriate conditions 5

Why does this matter? § Little or no value for money (donors) § $2. 1 billion market [Int’l Fin. Corp, 2008] § Environmental harms § Healthcare givers need devices § Unpredictable access 6 (Coe and Banta 1992; World Health Organization 2000; Mavalankar et al. 2004, Petti et al. 2006; World Bank 2008, Perry and Malkin 2011; Perkins 2014, Ademe, Tebeje, and Molla 2016)

Case studies – current information Metrics National donation policies Life expectancy at birth Availability of essential devices Staff interviews Dates Administrative Clinical Technical/support Funders Total Sierra Leone ü Ghana ü 45 years 61 years 2% ≤ 10% March 2016 4 1 2 2 9 January-April 2017 17 8 32 0 57 7

Case 1 – Sierra Leone “No. I am not aware of a national policy document…” Field Officer (funder) “Inclusiveness in decision-making and communication are lacking. ” Mo. HS Director “[The] equipment is expensive to repair over MOHS Manager there so it comes under the guise of donation. ” “We are in a funny position… donations are publicized, yet products might not function. ” Technician “[The devices] worked fine at installation. Most Procurement Officer aren't working now. They were left to the government to maintain. ” “The capacity to install, use, and maintain Field Officer equipment is not there [at the Mo. HS]. ” (funder) Mo. HS = Ministry of Health and Sanitation 8

Case 2 - Ghana “There is no policy at the hospital. Whatever comes in we accept. But here is the one from the government. ” Administrator “Those [that] come from donors who ask about our needs, they are useful. ” “…donated items have helped us a lot…They tend to solve our problems” “We really appreciate their contribution. They are very helpful to us. ” Store Manager “I know there a lot of things people donate to Africans because they want to get rid of them… they should not see Africa as a dumping site. ” Medical Director Anesthetist Facilities Manager “If you donate anything to me and it has not come to Anesthetist serve a purpose then, the donation, excuse me to use the word, but it has become a white elephant. ” Some facilities are not able to finance the purchase of Laboratory Manager the reagent. So the laboratory equipment [goes to waste] 9

Donations and the medical devices lifecycle Clinical engineering basics: Multiple steps in the lifecycle of a device are interconnected Funders focus on a few steps of the lifecycle 10 (WHO 2000; Dzwonczyk & Riha 2012; Malkin & Teninty 2014; Ankomah 2015; Japiong 2016)

Technical oversight is critical Is the device clinically relevant? No Yes Is it effective and safe in its present state? No Yes Is it compatible with existing infrastructure? No Yes Are its operating costs within budget? Yes No Is technical leadership available to provide consistent oversight? Yes Fund or accept the device A (simplified) acquisition and management framework for medical devices No Facilitator of healthcare or potential white elephant? 11 (Derived from: WHO 2000; WHO 2011; Dzwonczyk and Riha 2012)

Disclosures Acknowledgement: § This information was completed in partial fulfillment of Ph. D degree requirements at the University of Toronto Conflicts of interest: § There are no conflicts of interest to declare Funded by: 12