Beyond equipment: The value of training and service to support anaesthesia provision in the developing world
Gradian Health Systems illustrate their approach to strengthening surgery through a global network of people, services and distribution channels and the development of the Universal Anaesthesia Machine
In 2015, the newly formed Lancet Commission on Global Surgery published a landmark report  that revealed a series of unsettling findings about the state of global surgery, including that roughly one-third of the global disease burden is attributable to surgically treatable conditions. Further, a majority of the world cannot receive that treatment reliably: five billion people worldwide lack access to safe surgical care . The authors estimate that the world would have to perform an additional 143 million surgeries per year to meet the global need  – a daunting task considering the need is greatest in the poorest regions of the world, where delivering surgical and anaesthesia care is constrained by a host of financial, infrastructural and human-resource challenges.
There are myriad factors needed to ensure safe, effective surgical care, and, as readers of this journal know well, one critical element is the reliable delivery of anaesthesia by a combination of trained providers and high-quality equipment. Unfortunately, this baseline requirement is often hard to come by in low- and middle-income countries (LMICs). On one hand, there is the issue of the sustainability of medical equipment like anaesthesia machines. Nearly 80 per cent of devices in many LMICs are donated , meaning they are not only prone to breaking down because they are old, but when they do, it is difficult to find the spare parts and technicians needed to repair them. It is therefore not surprising that anywhere from half to three-quarters of all medical equipment in developing countries lies inoperable .
On the other hand, it is imperative to have sufficient infrastructure to support an anaesthesia machine. Equipment that is donated – whether new or used – is primarily designed for sophisticated operating theatres in hospitals able to sustain its use over time. The reality in hospitals in LMICs demands a wholly different design. For example, on average, only one-third of hospitals in sub-Saharan Africa have reliable access to electricity . While back-up generators can address this issue, generators also suffer from servicing and spare-part issues and rely on fuel that is often unavailable or prohibitively expensive . Similar constraints apply to medical gases and running water: one study found that 35 per cent of LMIC hospitals have no access to medical oxygen, and nearly 40 per cent have inconsistent access to running water . There is also a severe shortage of operating theatres, often less than one per 100,000 people .
Gradian Health Systems and the Universal Anaesthesia Machine
It was with these challenges in mind that Gradian Health Systems developed the Universal Anaesthesia Machine (UAM) – a CE-certified inhalation anaesthesia workstation designed to operate in resource-constrained settings, using a combination of continuous-flow and draw-over anaesthesia to enable it to function without power or compressed oxygen indefinitely. The UAM features an integrated oxygen concentrator to generate its own oxygen and provides standard connectors for cylinder, pipeline and portable oxygen. If no electricity or external source of oxygen is available, the machine automatically draws in room air as the carrier gas. Its optional ventilator provides electrically driven automatic ventilation in volume- and pressure-control modes, will operate without mains power for up to six hours on rechargeable battery power and comes with a manual ventilation option as a final safety measure.
Gradian works with a factory in the UK to manufacture the UAM and with a team of in-country distributors to sell, deliver and support the UAM in hospitals around the world; however, we’ve learned that designing and distributing anaesthesia technology to LMICs only addresses part of the problem; we must also ensure that its users are skilled at operating it and that it remains functional for the long term. To do that, we invest in extensive training for clinical and technical staff at the hospital and commit to ongoing service, including easily accessible spare parts to maintain the equipment.
Training doctors, nurses and technicians on the UAM
Unlike health systems in high-income countries, those of LMICs often exhibit a shortage of trained anaesthesia providers. In one study of 12 LMICs, 11 countries had fewer than one anaesthetist or non-physician anaesthetic provider per 100,000 population, compared with roughly one per 5,000 population in the UK . This reality presents a stark human-resource challenge for efforts to deliver high-quality surgical care in some of the most vulnerable parts of the world – and a heavy burden on those who are practising in those countries.
This is why for every UAM installed, Gradian offers a complementary two-day, on-site clinical and technical training led by our team of regionally based physician-anaesthetists and biomedical equipment technicians. Their contributions have enabled us to offer personal training to hundreds of hospital technicians and clinical providers to date – from highly trained physician-level anaesthetists, to rural anaesthesia providers without formal medical education and/or previous experience with a general anaesthetic machine.
Gradian’s current training programme consists of clinical and technical components to build the capacity of a hospital’s full operating theatre team: from anaesthesia providers to biomedical equipment technicians to administrative staff. The clinical training begins with a one-day didactic classroom session to provide an overview of the UAM and its ‘hybrid’ design. Trainers walk the hospital’s staff through the machine’s primary parts and functions before leading them through situation-specific preparations based on the availability of electricity and/or compressed oxygen. The next day’s training is in the operating theatre, where we supervise trainees as they use the UAM in real surgical cases. These sessions are designed to ensure that trainees are able to use the UAM confidently and safely in their own environment, and can be followed up with refresher courses upon request.
While the clinical training shores up the ability of anaesthesia providers to use the UAM, the machine’s long-term reliability depends (in part) on the capacity of biomedical equipment technicians, whose roles are too often overlooked in global health. While installing the UAM, our technicians demonstrate to the hospital’s technical staff how the machine is assembled, how to manage common repairs and how to conduct preventive maintenance checks. As part of this training they also supply technicians with manuals, training guides, instructional videos and other materials to aid future service needs, which are often able to be managed using basic tools provided with each UAM. These trainings not only help us build a dependable team of technicians for the UAM, but help cultivate skills that they can use in their careers moving forward.
Providing timely, reliable service to UAM users
The challenge of maintaining medical equipment in LMICs is not new or affordable for many hospitals. According to the World Health Organization, the initial purchase price for medical equipment is typically around 20 per cent of the total lifetime cost, “with many recurrent costs hidden underneath, such as service contracts, spare parts, depreciation, consumables (e.g. accessories such as needles), training, etc.” . This challenge is especially pronounced with donated equipment, as donors rarely provide after-sales support and often fail to account for critical local considerations like supply chain weaknesses, staff capacity and the availability of spare parts. Only 10–30 per cent of donated equipment becomes operational in LMICs , with maintenance representing a leading barrier to effective equipment operation.
Overcoming this maintenance challenge lies at the heart of Gradian’s mission. We strive to mitigate lifetime device expenses for our customers by enabling the use of generic disposables and consumables and including a multi-year warranty that accounts for after-sales service and support needs. This is executed through two primary channels of support infrastructure: local partnerships and ongoing customer service.
For any market we enter, Gradian cultivates a strong in-country support team through partnerships with local distributors that have biomedical equipment technicians on staff. We thoroughly vet and select partners based on their ability and commitment to provide fast, accurate and comprehensive support to UAM users wherever they are in a given country. This support includes both repairs upon request and biannual preventive maintenance visits. Gradian’s in-country distributors are typically either independent entrepreneurs or small businesses, so the technical skills they gain during our training, combined with the sales and operational support we provide, helps them grow their business while fulfilling an important need for us. Our distributors also manage a number of our regional and in-country spare parts depots around the world, which offer UAM customers the fastest response possible to service issues.
At a global level, Gradian’s customer experience manager manages this network of distributors. Using a combination of email, phone and SMS platforms, our team remains in close contact with our distributors, technicians and focal points at each hospital to monitor the state of the UAM, report repair requests and organise preventive maintenance visits. Our staff also provides technical expertise to anticipate and troubleshoot any operational challenges that arise, building a bridge of know-how that extends from our headquarters to each of our markets.
The bigger picture
Ultimately, all of the technology, training and support that we provide to ensure the successful use of the UAM in lifesaving procedures is geared toward a much bigger goal – ensuring that timely, essential surgery is available to all people everywhere. To that end, there is a fourth pillar to our work at Gradian: advocacy. We are clear that we address one small, important aspect of a field with enormous need. The preliminary data is clear: the world needs every possible stakeholder – from governments to NGOs, academia to industry – doing their part in changing the status quo so that surgery does not remain an intervention only available to those serendipitously born in high-income countries. If you’d like to learn more about how to raise awareness about the importance of global surgical care, visit the Global Alliance for Surgical, Obstetric, Trauma and Anaesthesia Care website (www.theg4alliance.org) and speak with your colleagues about doing your part.
Gradian Health Systems is a non-profit social enterprise that equips hospitals to deliver anaesthesia safely and economically. Based in New York with a global network stretching from the UK to Southeast Asia to sub-Saharan Africa, the Gradian team manufactures, sells, maintains and trains users to operate the Universal Anaesthesia Machine (UAM). To date, the UAM has been installed in more than 130 hospitals across 23 countries, contributing to an estimated 100,000 safer surgeries worldwide.
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