A neonate receives care at the St. Boniface Hospital NICU in Haiti, in an incubator procured by BHI (photo by Jess Rinaldi)

Procure, Train, Repair. Repeat.

How high-quality biomedical equipment — and the capacity to maintain it — can help prevent 100,000+ pneumonia deaths each year.

To adequately treat patients, hospitals need to be stocked with the appropriate biomedical equipment to deliver care, and the equipment has to actually work. This might seem self explanatory — why would hospitals have biomedical equipment if it doesn’t function? Unfortunately, this isn’t a given the way it should be. Previous research has shown that an estimated 40% of equipment is out of service in low- and middle-income countries (LMICs), as compared to less than 1% in high-income countries.

Build Health International and our partners see this reality first hand in our daily work. As a non-profit, architecture, engineering construction organization focused on health equity, BHI builds and equips dignified healthcare facilities, such as NICUs, emergency departments, and maternal health wards, in the world’s most vulnerable communities. We aim to provide local clinicians both with the infrastructure and equipment needed to work at their full potential, and also the capacity and training necessary to sustainably maintain it. Having worked in 22 countries to date, BHI has witnessed the need for sustainable equipment all over the world.

Maintaining and repairing biomedical equipment is necessary for addressing a host of illnesses and medical conditions, but chief among them is pneumonia. Globally, pneumonia is the leading infectious cause of death for both children and adults alike, having claimed the lives of 2.5 million people, including 672,000 children, in 2019 alone. Pneumonia takes a particularly devastating toll on newborns — 30% of pneumonia-related deaths in children under five occur in the first month of life.

Despite this devastating toll, most pneumonia deaths are preventable with a strong health system and the right care. Reliable equipment, like oxygen concentrators and incubators for neonates, is a critical but often overlooked aspect of preventing pneumonia deaths. Studies have shown that strengthening global oxygen systems could prevent an estimated 122,000 child pneumonia deaths each year. An integrated health systems approach to addressing preventable pneumonia deaths means investing in equipment — procurement, repairs, and technician training — alongside vaccine development and clinical interventions.

Here are three examples of what can happen when we address equipment needs head on by making procurement, repair, and training a priority.

Procuring Equipment for Burundi

The Van Norman Clinic (VNC) is a health center and NICU in Bujumbura, Burundi, which delivers over 500 babies each month. VNC also serves as the referral NICU for other hospitals and clinics in the area, with the referred newborns often arriving in critical condition. Despite the volume of patients VNC sees, prior to 2019, it didn’t have the best equipment to sustainably provide sufficient care to all babies who needed it.

Donated incubators waiting to be packed and shipped to from BHI’s warehouse to Burundi (February 2019)

To address this need, the Gould Family Foundation (GFF) partnered with Build Health International to procure neonatal incubators for the Hospital. Much of the biomedical equipment that BHI supplies to our partners is acquired through in-kind donations. Brand-new incubators from leading manufacturers can cost up to $50,000 a piece, an inaccessible price point for healthcare facilities in LMICs. “Through in-kind donations, BHI is able to secure neonatal intensive care equipment that our hospital partners could never afford yet desperately need” says BHI’s Director of Partnerships Zac Chase, who manages in-kind donations and corporate partnerships. “Donations of high-quality, used biomedical equipment are critical to helping address equipment gaps at our partner hospitals.”

As such, BHI worked with Boston hospitals to secure an in-kind donation of five incubators — all of the same make and model, important for reliably sourcing replacement parts — , ensuring that they were fully tested and certified before shipping them to Burundi. Through this donation, VNC was able to increase previous incubator capacity and finally replace wooden, lightbulb powered baby warmers that were previously used in place of incubators.

Since the refurbished incubators were first installed in the VNC NICU, they have achieved a 99% uptime, with support from GFF-trained biomed engineers. As GFF Founder and CEO John Gould reported proudly, “proper sourcing, refurbishment and maintenance have helped VNC to earn a “20/20 on the annual Ministry of Health NICU review.”

Repairing Equipment in Sierra Leone

BHI Facilities Biomedical Engineer, Steve Mtewa, is no stranger to seeing the equipment in disrepair and finding a way to bring it back to life. Affectionately referred to as the “equipment man” by the many colleagues that he has trained, Mtewa has a knack for repairing a wide range of equipment, from x-rays, to oxygen concentrators to incubators. “Often when I go to sites, they think that the equipment can’t be repaired and there is no way to get the parts,” Mtewa says. “But we show them it is possible.”

Steve Mtewa assesses a C-Arm X-Ray for repair at a hospital in the Bahamas (2020)

One of the most meaningful biomedical projects for Mtewa came in 2019 on a trip to one of BHI’s partner hospitals in Sierra Leone. The initial objective of Mtewa’s trip was to help with general hospital efficiency, training the local team on how to repair the equipment like the air conditioning units and x-rays. When he arrived, however, he realized his skills were needed for a much more time-sensitive repair.

At the start of his visit, while walking through the warehouse, Mtewa observed a number of incubators stored away. But later, in the pediatrics ward, he saw there were only baby warmers — one with two with very small premature babies. “They needed the incubators because the babies were so small. The baby warmer was not enough,” Mtewa said. “When I talked to the nurse in charge, I realized he did not know there were incubators in the warehouse.”

Recognizing that access to these incubators could be a matter of life and death for the babies, Mtewa got to work with the local team, fetching and repairing the incubators. Mtewa remembers the nurse saying, “if it had not been for the incubators, we might have lost those babies.”

Later on the same trip, there was a similar urgency to repair oxygen concentrators. Initially, when Mtewa asked if the hospital had an oxygen analyzer — a device to check that the oxygen being produced was pure enough — the facilities team reported that they had none. But later, in the workshop, Mtewa came across an oxygen analyzer that had been disregarded. Because it had never functioned properly, the staff did not know what it was, and as a result did not know how to use or fix it.

Mtewa replaced the battery, calibrated the device, and showed the staff how the machine worked. Mtewa and the facilities team then began testing all the oxygen concentrators. In the process, Mtewa recalls, “we found that some were producing very low oxygen so we had to take them to the shop. I showed the staff how to change the air filters and repair them.” Just as with the incubators, once the oxygen analyzers were repaired, they were immediately deployed to treat patients.

Training Technicians in Haiti

As demonstrated by Mtewa’s work in Sierra Leone, the ability to identify problems with biomedical equipment and repair it are essential to reliably providing quality care. This need also extends to Haiti, a country of 11.2 million, where there are currently only four NICUs. This scarcity of specialized facilities is underscored by Haiti’s high neonatal mortality rate: 25 for every 1000 live births, nearly 7 times that of the United States.

Recognizing the importance of biomedical upkeep, BHI worked with Health Equity International (HEI) to develop and launch the REPARE program. Based out of St. Boniface Hospital, REPARE is a training program for local biomedical technicians, designed to ensure that critical equipment can be used at full capacity.

The need for a program like REPARE was exemplified for HEI’s CEO Conor Shapiro, on a visit to the neonatal spaces at the General Hospital in Les Cayes, where he saw babies being kept under light bulbs for warmth. When he asked if the hospital had any incubators, the nurses opened up a closet revealing the broken incubators inside.

“It was this horrible juxtaposition of ‘if we could just figure out how to repair these incubators and make sure they were working and choose the appropriate ones, these babies would have been in those incubators’, Shapiro remembers. “But instead, they were under light bulbs.”

In Haiti, one of the leading causes of admission to the NICU is sepsis, caused by pneumonia and other infections. REPARE-trained technicians have helped St. Boniface Hospital to be self-sufficient in maintaining in-house equipment, including the 24/7 NICU they operate. The same technicians have also been able to return to Les Cayes and fix the broken incubators Shapiro saw hidden in the closet.

A nurse prepare to take the vitals of a neonate at the St. Boniface Hospital NICU (photo by Jess Rinaldi)

From Burundi, to Sierra Leone, to Haiti, the capacity to both procure high-quality biomedical equipment and ensure that this equipment can be in continuous use are essential to saving lives from pneumonia and other critical illnesses. There is still a great need to build more NICUs — and other healthcare facilities — to reach underserved communities, but an important first step to expanding access is ensuring that the equipment within existing healthcare facilities is functional and is able to be maintained and repaired sustainably.

Olivia Duggan is Build Health International’s Communication Strategist. She writes about the intersections of health and infrastructure, with a focus on the impact of BHI’s work on fragile health systems.

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