ESSENTIAL EQUIPMENT FOR DISTRICT HEALTH FACILITIES IN DEVELOPING COUNTRIES - experimental edition - Editors: H.Halbwachs (GTZ) A.Issakov (WHO) Authors: M.Kamwa (Preface) A.Brandrup-Luckanow GDietz H.Halbwachs B.Miethe H.J.Schmidt published by GTZ, Division of Health, Population & Nutrition Eschborn, June 1994DEUTSCHE GESELLSCHAFT FUR TECHNISCHE ZUSAMMENARBEIT (GTZ) GmbH, Abteilung Gesundheit, Bevolkerung und Ernahrung Postfach $180, 65726 Eschborn, Germany WORLD HEALTH ORGANIZATION (WHO), Division of Strengthening of Health Services 1211 Geneva 27, SwitzerlandTABLE OF CONTENTS Preface The Authors Acknowledgements Summary Classification of Health Facilities Section I: Selecting the Right Equipment LI Current Situation 12 National Equipment Policy and Infrastructure 13 Importing Health Care Equipment 14 Selecting Health Care Equipment 1S Maintenance and Repair Systems 16 Appropriate Technology Section II: Equipment for Treatment 11 Introduction T.2Intemal Medicine 11.2.1 Overview 1122. Treatment 0.2.3 Equipment 113 Surgery 113.1 Overview 113.2. Treatment 10.3.3 Equipment 1.3.3.1 General Equipment 1.3.3.2 — Surgical Instruments 13.3.3. Endoscopic Instruments I4 — Anaesthesia 114.1 Overview 14.1.1 Role of Anaesthesia in Developing Countries 1.4.1.2 Draw-over Anaesthesia 041.3 Oxygen Page wey an 10 it 1B 15 16 19 an14.1.4 Mechanical Ventilation 11415 Anaesthetic and Recovery Room 114.2 Treatment 1143 Equipment TLS Obstetrics ILS.1 Overview 115.2 Treatment 115.3. Equipment 115.3.1 General Equipment 15.3.2 _ Instruments Necessary for Obstetric Procedures 116 Gynaecology 16.1 Overview 11.6.2 Treatment 11.63. Equipment 1.6.3.1 General Equipment 1.6.3.2 Theatre Equipment 1.7 Ophthalmology IL7.1 Overview 17.2 Treatment 1.73. Equipment 1.7.3.1 General Equipment 1.73.2 Equipment for Essential Support Services for Ophthalmology Section IN: Equipment for Support Services TI] Laboratory MLL. Overview M12 Services IL13 Equipment 11.2 Radiology 12.1 Overview 1.2.2 Equipment 112.3 Diagnostic Imaging: a Comparison M13 Sterilization 113.1 Overview 13.2 Equipment &ftRE 48 48 49 50 50 54 55 55 36 ST 37 58 60 60 61 62 62 63 Ses n 8 75 8 80 80 81IL4 Physiotherapy M41 Overview m42 ‘Treatment 1143 Equipment ILS Library T.6 Hospital Workshop TL6.1 Overview 1.6.2 — Workshop Equipment Section IV: Lists of Equipment IV.1 Investments TV.2 Maintenance Requirements IV.3 _ Instrument Sets Section V: Literature and Resource Organizations V.1 Annotated Bibliography of Documents Dealing with Essential Medical Equipment fir Health Institutions in Developing Countries V.1.1 General Medical Equipment V.1.2 Special Equipment V.121 Appropriate Technology V.122 Ophthalmology V.1.23 Traumatology, Surgery, Orthopedics V.1.2.4 Laboratory Equipment V1.25 Buildings V2 Resource Organizations Index 82 82 82 83 84 85 85 86 93 95 98 103 105 106 106 113 13 114 1s 116 n7 7 122PREFACE For more than three decades, the international community through the United Nations system and regional and sub-regional health organizations have been making tremendous efforts towards improving the health status of both individuals and communities, in particu- lar in developing countries. ‘These efforts include: - The sensitization and involvement of the individuals and the communities in solving their own health problems. + Setting-up and training of health teams with researchers, planners, managers, administrators, doctors, nurses .... - The launching of important health programmes such as Primary Health Care (PHC), ‘The Global Programme on AIDS (GPA), The Tropical Diseases Reseach Program me (TDR), The Drug Action Programme (DAP), The Expanded Programme on Immunization (EPI), The Control of Diarrhoeal Diseases (CDD), The Acute Respi- ratory Diseases Programme (ARD). ~ The rationalization of health-care delivery services. ~ The enacting of suitable legislation and regulations. During the same period, a large stock of assorted equipment was acquired through donati- ‘ons, purchases with locally generated resources, purchases with loans ... without a prelimi- nary survey of needs, and without taking into consideration determining factors such as the quality of the health establishments, the quality of staff using them, the availibility of re- sources to ensure their operation, maintenance, renovation and replacement, and finally the climatic environment. This negligect results in the high rate of unavailability of equipment (30 to 60%) owing essentially to the absence of preventive maintenance, spare parts, know-how and financial resources and in the non-use of newly installed equipment because of its complex nature. The rational use of technical equipment, as a matter of necessity implies the elaboration of a policy governing the use of basic equipment (such as that for drugs) adapted to each level of the health-care delivery services: as far as possible, they must be generic, of good quali- ty, easy to operate and to maintain, and favourably priced This is the real challenge to be met in facing large-scale mechanization of health-care In this context the manual makes an important contribution by proposing sets of equipment ‘geared to specific task levels. It can be done, collectively ! Dr Matthieu Kamwa Director of Medical Services - Ministry of Public Health, Yaounde CameroonEDITORS AND AUTHORS Dr. med. A. Brandrup-Lukanow Regent's College Inner Circle, Regent's Park London NW1 4NS United Kingdom Dr. med. G. Dietz ‘Deutsche Gesellschaft fiir Technische Zusammenarbeit (gtz) GmbH Division of Health, Population, and Nutrition P.OB. 5180 D-65760 Eschbom Germany Dipl.-Ing. H. Halbwachs, IEng MIHospE. Deutsche Gesellschaft fir Technische Zusammenarbeit (gtz) GmbH Division of Health, Population and Nutrition P.O. B. 5180 1D-65760 Eschbom Germany Dr. Ing, Dipl-Oec. B. Miethe ‘Am Gallichten 27 D-35398 GieBen-Allendorf ‘Germany Dr. med HJ, Schmidt Habichtsweg 12 D-73230 KircheinvTeck GermanyACKNOWLEDGEMENTS ‘The authors wish to thank the following persons and organizations for their cooperation: Bemhardt, H., Dr. med, Paediatrician, D-3500 Kassel Burman, Bill, Dr., Medical Specialist, D-7000 Stuttgart Dammann, Vera, Dipl.-Ing., Fachhochschule, D-35390 Gieflen DIFAM, D-7400 Tubingen Fleischer, Prof. Dr, med., Missionsérztliches Krankenhaus, D-8700 Wurzburg Frey, Alois, Mr., BEGECA, D-3100 Aachen Klau8, Volker, Prof. Dr. med., Universitatsaugenklinik, D-8000 Munich Kithnert, K., Dr. med., Gynaecologist, D-8620 Lichtenfels, Lallinger, G., Dr. med., Medical Specialist, Dar-es-Salaam, Tanzania Poschi, Rupert, Dr. med., Department of Anaesthesiology, University of Gottingen, D-3400 Gottingen Rottjes, M., Mr., Dipl.-Ing, FAKT, D-70184 Stuttgart, Germany Schmidt, Doris, Dr, med., D-73230 Kirchheim, Germany ‘Schénhals, C., Dr. med., Paediatrician, D-8000 Munich, Germany Springer, L., Dr. med., MPH, GTZ, D-65760 Eschbom, Germany Walia, Dr. D. S., Consultant Eye Surgeon, Kenya Ophthalmic Programme, Programme Coordinator, Nairobi, Kenya Wemer, Heinecke, Dr., D-73230 Kirchheim, Germany Wolff, Michael, Dr.med., Misereor, D-52064 Aachen, GermanySUMMARY ‘The purpose of this manual is to propose ways to health planners, management teams and donor agencies for more adequate and considerate provisions of medical equipment in the developing world at district level: equipment in a position to satisfy identified health needs, ‘equipment which can be operated by the existing staff under known conditions and equipment which - through systematic maintenance and repair - has a satisfactory lifespan in economic terms, Section Fundamental Requirements for Managing Equipment The section deals with general problems of health care equipment management including policy, health care technical service organization, approaches to equipment selection, procurement and maintenance. Section 1 Equipment Requirements for Clinical Services ‘The section discusses equipment needs for various fields of medicine at different levels of the district health system and provides suggestions and explanations for the selection of essential equipment Section I Equipment Requirements for Clinical and Hospital Support Services The section discusses equipment needs for clinical and hospital support services. Section IV Essential Equipment for Different Health Services within a District Health System The section presents essential medical and technical equipment for health services within a district health system including approximate data on costs and durability Section V Reference Literature and Resource Organizations. The section gives a list of resource organizations and a critical review of available literature The experimental edition will be further developed and tuned to the needs of the target groups The next edition would eg, include generic specifications In order to achieve this objective, more relevant know-how and experience from all over the world must be collected, analysed and put into an applicable format. The manual can only con- stitute one step in this direction, complementing other deliberations in the field We would therefore like to call upon all readers to contribute complementary information, suggestions and corrections for follow-up editions, and thank those who have already done so in commenting on and contributing to this frst edition (refer to list of contributors) The editorsClassification of Health Facilities For reference purposes, this book classifies district heath Level: Health post or sub-health centre without beds (village/community based) This is the simplest and most elementary structure at the periphery, run by resident staff and carrying out basic health care, Its location may be urban or rural. There are no in-patient facili- ties or maternity services. Level I: Health centre or small district hospital with 1-75 beds (sub-district based) Health facilities working in routine health care are restricted to general medical, surgical and obstetrical services, Clinical and radiological services may be unavailable at this level. Usually institutions at this level provide in-patient and out-patient services including matemity. As a general rule only normal, uncomplicated deliveries are assisted. Beds for rehydration therapy should be available. Preventive and promotive activities are predominant. ies as follows: Level Ill: District of provincial hospital with 76 - 250 beds Hospitals of this bed capacity should have a wide range of diagnostic and therapeutic services for more specialized diseases / patients requiring special attention from specialized personnel and special medical technical equipment (including an intensive care unit) according to the complexity of the disease and following local epidemiological patterns. Medical sub-specialities such as urology, neurology and ophthalmology often not offered at levels I or II are available Basically, the first referral level hospital complements the health centre by providing a wider range of services and more expertise for those complicated cases which require attention from ‘more highly qualified and/or specialized personnel and special technology, and which cannot or should not be decentralized further.The classification used in this book can be related to the one adopted by WHO as follows. Level I health post or sub-centre Level I and II are levels of first contact (health centre types 1, U, I eld including health post, sub-centre, health centre or small hospital health centre and referral health centre) Level II district hospital Peripheral health units are key components of the health service continuum since they are the point of first contact with the formal health care system and deal with most of the health and medical problems of the population. There is no satisfactory universal definition for them because there is a significant difference from country to country in terms of their size, staffing, resources, provision of services and population coverage. Depending on location, such units might be called a general practice, a dispensary, a health post or a health centre. For ease of reference WHO calls the health facility at first contact level a health centre with the following working definition: a health centre is concerned primarily with ambulatory patients. It provides both curative and preventive services, and whether staffed by a doctor or not, it has a multidisciplinary team capable of providing a range of services Health centres have developed into three broad categories, or types, based on the sophistication and breadth of services provided. Health centre type I might be called a dispensary, a health post or a sub-centre and provides limited ambulatory curative service and community development. Health centre type II is what is most often called a health centre, and its role is to provide ambulatory curative services, health promotion, prevention and education and support for sub-centres, if any exist Health centre type III is called a referral health centre and has the same role as type Il plus day surgery, short-term in-patient care and expanded health promotion, prevention and education function. It should be recognized that in practice it may not be possible to place many health centres clearly into ether of these three categoriesFUNDAMENTALS IN SELECTING THE RIGHT EQUIPME! I SECTION I CURRENT SITUATION NATIONAL EQUIPMENT POLICY AND INFRASTRUCTURE IMPORTING HEALTH CARE EQUIPMENT SELECTING HEALTH CARE EQUIPMENT MAINTENANCE AND REPAIR SYSTEMS APPROPRIATE TECHNOLOGY =10-1.1 CURRENT SITUATION ‘The common phenomenon in most developing countries is not a lack of health care equipment, but the presence of equipment which is not usable or not used. Around half of the inventory, in some cases as much as 75-80%, is inoperable at any given time. Clearly, these lead to poor quality of care and high wastage of scarce resources as well as a negative effect on the morale of health workers. In almost all developing countries the most pressing problem is not merely a substantial burden of ‘equipment which is inappropriate to the country’s needs and conditions. Many of the equipment are appropriate and could contribute to the country's health goals, but idle due to the inappropriate management of its introduction to the country. Although national and regional variations exist, common factors can be identified: Equipment is not used because = itis not appropriate for the local needs and local context, ~ the site is not suitably built or serviced, = no expertise is available to install or commission it, = stafflack the knowledge to use it, + no instruction manuals have been received or are written in a foreign language, = some parts have not been specified or delivered, = it is defective on delivery, = it is not supported by adequate supply of special consumables and short-lived components, ~ Jong term logistic support is too costly Equipment is not usable because it has become faulty due to ~ inappropriate use, = no preventive maintenance, including baseline maintenance by users, = inadequate utilities (electricity, water, etc.), = adverse environment (heat, humidity, dust, etc). ‘No repair service is available because of = no repair and maintenance facilities, = no competent staff in-house or with local agent, “1.= no commitment from a local agent, = no service manuals, ~ flo spare parts, = no funds for spare parts or service. The underlying reasons for this situation are often: * lack of awareness, * lack of policy, * lack of health care technical services infrastructure, * lack of qualified manpower, * lack of information suppor. In most developing countries a general lack of awareness, technological management expertise and technical competence leads to unsystematic selection and purchasing, Recurrent cost implications of the purchase or donation of capital equipment are usually not fully appreciated by the recipient and the donor, which results in a lack of budget provision for maintenance and other operating costs at the planning and purchasing stages. Health care technical services, if they exist at all, perform inadequately because of inadequate ‘workshops, logistics, manpower and organization. ‘The maintenance manpower development process comprising planning, training and utilization stages usually lacks continuity, The structure of required staff according to the current and future needs is grossly underdeveloped. Performance is also weak and ineffective due to the lack of a conducive working environment, attractive salaries, career prospects, incentives, etc., in one word lack of motivation, Finally, the problems are compounded by the great diversity of equipment obtained under various multilateral and bilateral assistance programmes though some countries have already developed standards and regulations on equipment. The health system based on primary health care comprises social, preventive, diagnostic, therapeutic and rehabilitative services at various levels starting from the community and up to the tertiary level of sophisticated university hospitals, All those services utilize a wide range of ‘equipment. Today. the universe of medical devices encompasses some 6,000 distinct types or generic entities and an estimated 750,000 or more brands, models, and sizes ranging from simple disposable devices to very complex systems Obviously, most of the equipment offered is needed within the complex health care system, in the right place, at the right time, and in the right balance with respect to the many other health needs of the population. Despite the rapid development of modern health technology and the wide range of existing, ‘equipment, it is nevertheless possible to define general equipment requirements for various levels of a health system and set up standards for commonly used equipment. Such guidelines are based on a clear understanding of health services’ functions at a certain level required to meet the needs of a -12-In Selecting the Right E target population. Such guidelines apply to generalized situations and must be translated by users to suit the country's specific needs. Demographic, epidemiological, climatic and other conditions may be very different and may require further thorough analysis. 1.2 NATIONAL EQUIPMENT POLICY AND INFRA- STRUCTURE All countries need to have an explicit national health care equipment policy throughout all levels of the national health system in order to ensure quality care and a wise use of health resources. It should be consistent with a country’s needs and resources, should cover and integrate planning and budgeting procedures, regulations on standards of safety and efficiency, a clear understanding of and capability for needs assessment, selection and procurement strategies, adequate financial and infrastructure provisions for maintenance and repair, a manpower developement process, and many other factors. In order to implement the health care equipment policy and to make any sustainable progress, a health care technical service within the health system is needed, extending from the ministry down to the district level. It should have a strong managerial and technical input at the ministry level, effective intersectorial links, a clear structure, adequate funding, and an information support service. A full range of staff from craftsman to technical manager with salaries and career prospects which are adequate and appropriate to the level of their responsibilities would be a long term objective. The technical service should enjoy equal standing with other services at all levels of the system. Human resources development, physical infrastructure strengthening and information support should occur simultaneously and not serially. It is only with a coordinated and comprehensive approach that equipment management will be improved and as a result quality of health care delivery enhanced. Good technology management starts at the top, and, in order to develop and implement national equipment policy, a dedicated technical department is required at the central level close to decision- makers in a health system hierarchy. It should be headed by a well-qualified engineer with leadership potential ‘The work to be undertaken at the national level is much more than the planning of a nationwide corps of staff and provision of working facilities for them, There must be a continuing action to improve the overall management of technology, ensuring that its appropriateness, quality and ‘quantity are in conformity with the country’s needs, resources and conditions at various levels of the system. Control or influence over equipment selection and procurement is an urgent task for a health care technical service generic specifications, approval of manufacturers and agents, -13-tals in Select Right Equipment tendering procedures with correct indication of support required, brand reduction, acceptance testing, etc. are some factors on which guidance must be given. This will help to avoid one of the most tragic and, regrettably, common symptoms of technology mismanagement - the sight of expensive equipment deteriorating into scrap metal because it was delivered to an unprepared site. An essential precondition for an effective health care technical service is ideally a well established network of maintenance facili Planning, supporting ‘Maintenance e evaluating, controlling, eee monitoring, achiving Complicated repairs, Provincial Provincial supporting levels below, Workshop Workshop servicing prov. hospitals, 7 advising routine preventive maintenance, District District District simple repairs, servicing levels Workshop Workshop Workshop simple repairs servicing The staff required could be grouped into three broad ranges of personnel designated as A, B and C. Staff range A have duties which are predominantly technical, and the level of technical complexity remains comparatively low throughout the range, In most countries this range will include many grades of craftsmen, craftsmen supervisors, and polyvalent technicians who are limited in their skills and experience. Staff range B have duties in which the managerial responsibilities are more important, and whose technical responsibilities are considerably more complex than those of range A. Some of the more experienced or capable polyvalent technicians in developing countries will enter this range Staff range C will have duties which are predominantly managerial, and the technical component will be demanding and complex. There will be staff in this range who are responsible for policy decisions at the ministry level, for managing health care technical service at the central or provincial level. It will include senior engineer or scientific grades and possibly a few of the most senior technicians. The number of staff required can be roughly estimated. If a 100-bed district hospital were to be taken as an example, experience shows that up to six people should be employed (two in range B and four in range A). If there are satellite health centers or clinics to look after, the numbers might bbe doubled. Numbers do not increase in simple proportion for larger institutions, e.g. 200 beds might be served by 3B + 6A. -14-Selecting the Right Equipment Although the majority of resources should be applied to the development of range B and A staff, the imperative need is to train competent and knowledgeable staff in range C for key positions in a health care technical service to formulate policy and manage its implementation. Therefore, in ‘general, care should be given to ensure that all three levels of staff are developed simultaneously 13 IMPORTING HEALTH CARE EQUIPMENT ‘The successful and sustainable introduction of new technology and import of the respective equipment involve considerably more than just the purchase of a piece of hardware. They require a complex package of inputs whose elements are closely interrelated and include Selection ensuring appropriateness of equipment to country's needs and conditions. These require access to and capacity to use relevant information for identifying needs and defining selection criteria. Availability of generic specifications and standardization are essential ‘components of the process. Decision-making should be based on a team approach, Procurement ensuring that contracts include everything required - maintenance, training, manuals, spares, etc. - from the outset. The procurement process requires skills and experience in preparing tenders, negotiations with suppliers, Since a significant proportion of purchases are funded by international donors or equipment is donated, only a strong and knowledgeable medical equipment unit at the ministry is able to place such gifts under the same scrutinity as its own purchases Financial planning ensuring budgeting and allocation of resources for the whole life cycle of equipment, including initial purchase and installation as well as running costs. These should be based on a clear understanding of the relationship between expected investment, running costs, life span and potential benefits and should be done before purchasing of equipment. Operation including provisions for proper installation, commissioning, acceptance testing, calibration, safety, user training, supply of consumables, etc Maintenance based on a planned preventive maintenance programme as well as ensuring repair services (for details please refer to section 1.6) National capabilities in technology assessment, research and development are required in order to evolve a country's technological capacity, such that it becomes able to influence the irections of technology development and participate in development of appropriate technology. ‘And, eventually, some countries will wish, as a long-term goal, to increase regional self sufficiency by developing local production, by assembly or manufacture, of spare parts or whole units. -15-Selecting the Right Ei Primarily, local resources must be taken into account when importing medical equipment, and every effort must be made to base its selection, use and maintenance on them. Failure to adequately assess local capacities and their imitations may entirely jeopardize the use of certain technology and equipment. 1.4 SELECTING HEALTH CARE EQUIPMENT The selection of adequate equipment requires a significant investment of time and resources, and involves many factors including its relevance to priority health needs, available capacity to use and maintain it, the purchase price and life time costs, etc. Therefore, close attention should be paid to the following issues: - Public health and epidemiological considerations: equipment should be relevant to the specific local health problems to be solved. Therefore, itis essential to have a clear understan- ding of the health needs of the target population and corresponding health service functions required to meet those needs and, eventually, of the capacity and level of different technologies to perform the required fictions, Helpful are country specific data with special regard to vital statistics, epidemiological data (such as prevalence and incidence rates of the most important diseases), special risks of certain diseases to patient and community, etc - Economic considerations: particular emphasis should be placed on equipment cost- effectiveness, taking into account the economic situation, financial control and the overall cost of the equipment (user cost) comprising: * investment (purchase) cost + transport, taxes, customs fees * site preparations (mounting base, power supply, etc.) staff costs including training costs * consumables and spare parts * disposal of disposables and waste * energy consumption keeping “ready to use" cleaning, disinfection, recharging of accumulators, storage * maintenance * replacement cost in connection with life span * disposal costs, = Technical considerations: the specific situation with regard to the purchase and maintenance of equipment, local representatives of suppliers, governmental and parastatal organizations, -16-ti juipment Section 1 nature of workshops at different levels of health care. Equipment which is unreliable or not continuously available for use may tun out to be worse for the user than no equipment at all. ‘The resources available for maintenance and repair determine the standard of technical equip- ‘ment in hospitals, The efficiency of such resources also depends on: * user and service friendliness of the equipment * availability of spare parts and consumables * availablity of adequate user and service manuals suitability of the equipment with regard to climatic conditions and the technical environment (quality of water, electricity, gas supply, type and size of room or building, ventilation, etc.) compatibility with existing equipment * warranty terms: training resources of the supplier. = Managerial considerations: planners and managers should ensure the availability of a sufficient infrastructure to operate, service, maintain and repair the chosen equipment or while negotiating the contract ensure the suppliers support for maintenance and repair and additional training for local staff. Evaluation and monitoring indicators should be established and data made available for further planning and decision-making (information system), Most important is the availability of health personnel and operators, their qualifications and job descriptions, workload, need for and possibilities of further training = Psychological and sociological considerations: certain technologies or their design might not be acceptable in certain communities due to specific cultural or religious traits. Historically, selection and purchase of health care equipment have often been influenced or even decided by individual medical professionals, They rarely arrive at unbiased and rational decisions in this area, They usually tend, for many reasons, to purchase unnecessarily sophisticated equipment Selection and purchase of equipment is a multidisciplinary effort and can be effectively carried out only as a result of a collective decision-making by a multiprofessional team comprising medical professionals, engineering staff, public health managers and administrators. Team members should be on equal terms to allow rational decision making. Technical committees should exist at all levels of the health system from the ministry down to the first referral hospital level. A technical ‘committee at a district hospital should be responsible for equipment selection for the hospital itself as well as for smaller health facilities at lower levels The process of obtaining medical equipment, from the planning state until its full operation, is time- ‘consuming and expensive “17Steps involved are: - planning phase ~ negotiations with suppliers and possible donors = ordering procedure, tender = transportation into the country = import formalities = distribution within the country - installation, acceptance procedure = organization of maintenance and repair, spare parts ~ training of operators and maintenance staff ~ payment The time of delivery for medical equipment may vary between 6 months and three years, costs of planning, delivery, training and installation often exceed the cost of the equipment, Purchasing, *cheap" equipment is still very popular with e.g. tender boards. The costs of transportation and installation of such equipment of usually poor quality are, however, at least as high as for more expensive equipment of possibly better quality. Replacement of poor quality items is necessary in a shorter period of time, Additional expenditures will arise and the users will soon have to wait again for their equipment For most developing countries with their long delivery routes, financial constraints and difficult operating conditions, equipment of high quality is, in the end, the better and more economical choice Highly sophisticated equipment typically offers a large number of different settings for oper Electronic data processing makes it possible to choose and display many of these parameters independently. This leads to a great number of different modes of operation. Routine users usually do not utilize that many different possibilities. They do not even have enough time to become sufficiently familiar with all the equipment features. Most users, therefore, should prefer single control type equipment, Studies have shown that routine users can usually cope with equipment allowing three different settings. More settings require specialists For example, some brands of ultrasound equipment in use in German gynaecological clinics offer 99 different adjustments which can be altered independently. In addition, one standard adjustment can be loaded which uses routine values for grey level, depth mode, imaging mode, measuring programme, etc. In practice most doctors have never used any other than the standard adjustment. -18-the Right Equipment 1 1.5 MAINTENANCE AND REPAIR SYSTEMS ‘A maintenance and repair system has two basic fumetions. One is to keep up technical operability and the second is to provide information essential for equipment management and especially for deciding about the procurement of equipment. Keeping equipment working Ensuring the operability of medical equipment, hospital plant etc. requires: ~ inspection regular service (cleaning, disinfection or sterilization if need be, preventive maintenance) = repair = assurance of necessary supplies (media, consumables, etc.) = managing maintenance workshops = training of users and maintenance staff = reception of new equipment = managing extemal maintenance services (private sector) = providing and maintaining technical information. Emphasis must be put on a systematic (planned) and preventive approach. Through preventive measures, such as inspection and servicing, major breakdowns can be avoided, leading eventually to drastic savings. Maintenance is not expensive, repair is! Maintaining equipment of different levels of sophistication calls for different levels of maintenance: = Simple equipment can usually be maintained, and to a certain extent even be repaired, by the users, This is mainly equipment used in primary health facilities. = Equipment of medium sophistication requires higher levels of skills for maintenance and repair. This kind of staff would ideally be skilled workers or technicians working within the public health service at routine level. Typical equipment are sterilizers, boilers, cooling devices, microscopes, etc. = Sophisticated equipment, such as X-ray units, incubators and sonography, requires house personnel as well as the spi know-how of the supplier. This is of crucial importance when the purchase of highly sophisticated and expensive equipment is considered -19-vent Section 1 In any case, the availability of spare parts deserves special attention. An appropriate set of spare parts should be included in the purchase agreements for the projected lifetime of the equipment. These sets should be defined on the basis of the local conditions and not necessarily according to the recommendations of the supplier. Local suppliers should be asked to ensure the future availability of such parts, Also user and service manuals must be made available on a contractual basis. They must contain detailed information on the technical characteristics and specifications of the equipment. They should include circuit diagrams, PPM schedules (Planned Preventive Maintenance), application troubleshooting and technical faultfinding routines, spare part lists, safety procedures, adjustment procedures, calibration tests, Unfortunately frontpanels and manuals are often not made available in the proper language. Therefore the language must be specified in the purchase contract In many countries, the supply of spare parts and consumables meets great obstacles within the national logistical systems. Apart from hard currency constraints, additional problems may stem from complicated and costly customs and order procedures. In most cases it is advisable to order all necessary parts together with the new equipment. As a rule of thumb, 10-20% of the purchase cost of the equipment is required for an appropriate spare part set. For parts with short shelf life, a voucher system could be negotiated, Evaluation of equipment operations As already stated, proper management of equipment and its purchase requires information about performance and economy. Most departments and organizations, however, lack monitoring and ‘evaluation systems for this purpose in developing countries. Regular feed-back of experience from the user to the buyer or provider of equipment does not occur. Exchange of views about different kinds and makes of equipment and their suitability is the exception. Collecting and forwarding such information and data constitute an important task of in-house maintenance services on the basis of a systematic recording and report system. Such an information system should be an integral part of health (management) information systems and corresponding, supervision structures, thus feeding the purchase committee with the required facts for decision making, ‘Training. Training of users and in-house service personnel is a most important component for long-term successful operation of medical equipment. The sort of training courses required for users would be different from the ones for service personnel. Users need skills in handling the equipment and in baseline maintenance. The latter skills seldom go beyond cleaning and adjustment routines and very basic troubleshooting. Courses could be provided by the health authorities themselves (possibly assisted by some foreign donor), suppliers or other local technical training institutions. At least some user training (esp. -20-Fundament training of health authorities'instructors) and maintenance training of technical personnel should be included in the contract with the supplier, in particular when purchasing new items. 1.6 APPROPRIATE TECHNOLOGY WHO underscores the importance of adequate and appropriate technology in primary health care in the Third World, Most medical equipment has been developed for use in industrialized countries. Therefore much of it is not appropriate for being operated under difficult climatic and environmental conditions. There seem to be solutions at hand: articles about "appropriate" technology and "low cost" technology frequently appear in all sorts of publications, describing alternative designs of equipment. They are supposed to be simple, effective and sustainable under the circumstances in developing countries and may even be locally produced. With regard to ‘medical equipment many of these designs do not meet expectations. Often only a single prototype has been built. Some equipment has only been designed and tested in industrialized countries Whether itis useful in developing countries remains to be seen. To prove the suitability, a number of criteria must be checked = effectiveness - ease of use = ease of maintenance, sturdiness - safety = low cost (purchase and follow-up) = relevance to existing health problems = acceptability = accessibility = local production. In practice the following procedures should be followed = Try to find out how many pieces of this equipment have been built already ~ Communicate with previous users of this equipment = Compare their situation with your own, especially with regard to conditions of use (climate, roads, knowledge of users, availabilty of service staff, energy and water requirements etc ) = Calculate costs and energy requirements, - Ifconstruction plans are published, check on availability of materials and on potential local producers. Build one prototype first, calculate the costs and check economy. -21-Eun Appropriate technology has shown its usefilness and effectiveness in certain areas, such as solar water heating solar panels for telecommunications, lighting (microscope, emergency lights in theatre and labour ward, etc.), pumping of water, etc solar stills mechanical equipment which has been used for decades (foot-operated suction pumps, hand centrifuges, orthopaedic aids) locally produced furniture, appliances, etc. ‘Some literature on appropriate technology is listed in the fifth section of this handbook. -22-IL IL2 W3 TL4 ILS 11.6 IL7 SECTION II EQUIPMENT FOR TREATMENT INTRODUCTION INTERNAL MEDICINE SURGERY ANAESTHESIA OBSTETRICS GYNAECOLOGY OPHTHALMOLOGY -23-IL1 INTRODUCTION ‘The second part of this handbook presents common medical problems in developing countries. Different diseases have to be treated at different referral levels of health institutions. Important factors influencing the choice of the appropriate health institution are: - the severity of the disease and complication «the level of medical specialization and qualification required - the necessary technical and diagnostic equipment. ‘The technical equipment should account for the spectrum of diseases, medical specialization and workload of the respective health institution, as well as its manpower and financial capacities. 1.2 INTERNAL MEDICIN 112.1 Overview Diseases relating to internal medicine may be divided into the following groups: Infectious diseases: ‘very common: acute respiratory infections (ARI), diarthea, pneumonia, menengitis tubercu- losis, intestinal parasites, malaria, sexually transmitted diseases incl. AIDS, common hepatitis, skin infections Diseases of the blood, lymphatic and reticulo-endothelial system: very common: anaemia (iron deficiency, megaloblastic, dehydrogenase, tropical sple- nomegaly syndrome, and after infections) ess common: malignant lymphomas, Burkitt's lymphoma and leukaemia -24-‘Equipment for Treatment Section II Diseases of the cardiovascular system: very common: recurrent rheumatic fever common: hypertension and cardiac failure, cardiomyopathy, infective endocarditis, pericarditis rare: ischemic heart disease Metabolic diseases: common: diabetes mellitus (frequently with complications) Gastrointestinal diseases: common: liver cirrhosis, hepatitis, portal hypertension, gastritis, ulcers rare: diseases of the gall bladder, appendicitis, pancreatitis, Chagas’ disease very rare! Crohn's disease, ulcerative colitis Malignant diseases (Oncology): ‘common: hepatoma, cancer of the esophagus, Kaposi's sarcoma rare Jung cancer, coton cancer Diseases of the urinary system: common: pyelonephritis, glomerulonephritis, nephrotic syndrome less common: renal and ureteric calculi rare: bladder stones (more common in arid areas) Nutritional diseases: common: nutritional deficiencies, vitamin deficiencies, malabsorption Toxicology and addiction: very common: alcoholism less common’ intoxication (occupational exposure to pesticides, chemical solutions, local medicine, traditional remedies, pharmaceuticals, narcotics, fish poisoning, venomous bites and stings) -25-Equipment for Treatment. Section 1 ‘Neurological diseases: ‘common: infections of the central nervous system (meningitis, encephalitis), congenital and developmental disorders, neurological complications due to trauma, in- toxication or metabolic disorders. IL2.2 Treatment ‘Treatment in internal medicine in developing countries according to the level of health institu- tion Internal medicine at Level I: + Health education, reporting of notifiable diseases, surveillance of epidemics. ~ Management of most infectious diseases, most cases of anaemia, and malnutrition ~ Diseases suspected/diagnosed and referred: Serious infective diseases (e.g. meningitis), metabolic disorders, cardiac diseases, diseases of liver, kidneys, cardiovascular system, malignant diseases. Internal medicine at Level I: - Planning, coordination and supervision of health education, preventive services, con- trol programmes (e.g. onchocerciasis), staff training and supervision. Management of the majority of internal diseases. = Diagnosis and referral of curable malignant diseases, of cases which cannot suffi ciently be diagnosed and treated, especially in the field of cardiology, nephrology, neurology, haematology. Internal medicine at Level I: Planning, coordination and supervision of health education, preventive services, con- trol programmes (eg, tuberculosis), supervision and in-service training of staff, moni- toring diseases, promotion of clinical discussion, forum of case presentation and ex- change of information - Management of the whole spectrum of internal medicine except for curative care of terminal diseases and life-prolonging treatment of incurable diseases -26-Equipment for Treatment Section 11 11.2.3 Equipment Equipment requirements for internal medicine at different levels of health institutions Internal medicine constitutes such a great portion of medicine that nobody can be expected to master all possible cases. A library with adequate handbooks at each level is therefore essential, It is also expected that specialists and consultants share their experience with less qualified doctors and paramedics through supervision, clinical ward rounds, publications and promotion of open discussions. Reliable laboratory services are essential to intemal medicine, For complicated cases radio- graphy and ultrasound are of equal importance. Endoscopic procedures are gaining more and more importance in industrialized countries. Endoscopy, however, is @ time-consuming procedure and needs experienced specialists. Endo- scopes are very delicate instruments which require good care and often need repair or replace- ‘ment. In most developing countries the use of endoscopy is therefore restricted to larger institue tions Equipment for internal medicine at Level I: = good stethoscope (Littmann type) plus spares (diaphragm, earpieces) - thermometer = tape measure = tongue depressor = light source = auriscope (battery operated, can be used with small Ni-Cd cells) = robust mercury or aneroid sphygmomanometer (mercury sphygmomanometers are more expensive, more accurate and easy to repair, but they are more fragile than an- eroid sphygmomanometers.) = baby + adult scales Equipment to perform the following laboratory examinations: - haemoglobin (a simple but reliable method will do - e.g. Sabli method) - urine examination: protein, glucose, sediment (eg. test with sulphosalicylic acid, Nylander’ reagent) -27-Equipment for Treatment Section I = microscopy: examination for malaria parasites and other protozoa, for helminths, stool examination for ova For details see chapter on laboratory equipment.) Equipment for internal medicine at Level II: Same equipment as at basic level plus = peak flowmeter to test lung function (bronchodilator aerosols should be kept) ~ direct ophthalmoscope - laryngoscope - full blood count (WBC, diff. WBC, RBC, PCV) - — Sickling test = full urine report (bile salt, glucose, protein, specific gravity, pH, sediment) ~ examination of cerebrospinal fluid (CSF microscopy, glucose, protein) = microscopy and cultures: microscopical examination for bacteria = limited serological examination (eg. HIV, VDRL, blood grouping and cross- matching) = electrolytes (flame photometer) = blood urea, blood sugar, bilirubin bleeding time, clotting time Optional equipment: ~ set of rigid metal bronchoscopes (different sizes) rectoscope + electrocardiograph (three channel ECG) ultrasound Due to the unavailability of proper maintenance and repair, and to insufficient training of doc- tors and paramedics, the following equipment is usually not reasonable at level II: = laparoscope, gastroscope, sigmoidoscope X-ray unit: fluoroscopy, angiography = laboratory: electrophoresis, histology, cytology, bone marrow, blood gas analysis - dialysis = intensive care unit with continuous monitoring of ECG, mechanical ventilation, etc., but rooms/beds for special observation -28-yment for Treatment Equipment for internal medicine at Level III: ‘Same equipment as at basic and routine levels plus: = spirometer = bronchoscope (different sizes) = sigmoidoscope and gastroscope with fibre light source = electrocardiograph (three channel ECG) ~ ultrasound = laparoscopy = simple ventilator = X-ray: fluoroscopy = laboratory: culture and sensitivity, electrophoresis, blood gas analysis, clot- ting factors, serum enzymes = histopathology: histology, bone marrow examinations Optional: = echocardiograph + electromyograph = fibre optic bronchoscope and laparoscope 11.3 SURGERY 11.3.1 Overview Surgically treatable diseases are not the major killer in developing countries, but many unneces- sary deaths still occur due to the lack of surgical facilities. Too many out-patients who could be helped by surgery still die because hospitals can only handle a fraction of the surgical workload ‘Accessibility to the health institution is also a major problem for a great part of the rural popula- tion. Once health services are available for the population in order to prevent and treat major diseases, surgical services should have the next priority -29-nt In most developing countries, surgery is usually concentrated in district hospitals. District hospitals (levels IT & IIT) thus deserve special attention when it comes to their technical and ‘medical equipment, especially concerning the surgical departments and theatres. Roughly 10-15% of hospital admissions are surgical cases. ‘Common surgical cases are: - hernias, - urethral strictures, ~ tubal infections, - pelvic inflammatory disease (PID), = abortions, - volvulus - fiactures, bums, accidents, abscesses = fibroids, = osteomyelitis - tuberculosis, ‘Rare diseases include ~ diverticulitis, = colon cancer, ~ haemorshoids, - varicose veins, - thromboembolic complications Half of the cases needing general anaesthesia are obstetric or gynaecological problems, followed by 15% fractures and dislocations due to trauma. About 10% of surgical interventions relate to infectious diseases. ‘Traumatic bone injuries are dislocations of the upper and lower extremities (shoulder, elbow, wrist, radius, ulna, tibia, fibula). Road and work accidents are common, Essential companions to surgery are the support departments: + radiology (X-ray) anaesthesia = sterilization, Due to their importance, these are described in a seperate chapter (Section ITT) of this manual.Equipment for Treatment Section II 11.3.2 Surgery Treatment Surgery can be divided into two main domains: 1 Emergency procedures that cannot be delayed and must be handled even at lower levels of health care. The basic level must initiate treatment (e.g. infusion, ligation of bleeding ves- sels) before referring the patient Tl, Routine (scheduled, cold) surgery that can be referred Emergencies are either traumatic (haemorrhage, fractures, soft tissue injuries) or visceral emergen- cies (bowel obstruction, septic complications). To handle emergencies properly, diagnostic and basic curative equipment must be available at least at routine level, After initial emergency treatment a patient may be referred for specific procedures (ie. nerve sutures, vascular surgery) to a higher level Emergency treatment has to be carried out by a General Medical Officer or even by a Clinical Officer (= a medical professional non-academically trained such as manager for health facilities ‘below hospital level) in the absence of a surgeon: treatment schedules and equipment should be simple and effective. Decisions on equipment specifications have to be made at national level, taking into consideration that other disciplines (gynaecology, orthopaedics) may need the same equipment. This mainly refers to diagnostic means and equipment of theatres. The use of disposable materials (drapes, scalpels) should be minimized. The use of more labour- intensive re-usable materials is feasible at all levels of health care, also in view of disposal problems. The standard of anaesthetic facilities must match the standard of surgical procedures. Surgery at Level I: Minor out-patis t surgery: = splinting of fractures and sprains = abscess incisions = suture of cuts = dressing of wounds and small bums Recognition of acute and chronic surgical disease, first emergency treatment and/or referral -31-Surgery at Level 1: Trauma: = fracture setting and plastering = skeletal traction = treatment of complicated wounds General surgery: = scheduled routine operations (je. hemias, thyroidectomy, appendectomy, cholecystec- tomies, bladder stones) = soft tissue operations (septic and aseptic) = skin grafting Surgical emergencies: = bowel obstruction, intestinal perforations, splenectomy, revision of internal haemorrhage (chest, abdomen, cranium) = amputations Surgery at Level ITI: All above tasks plus: General surgery: = major scheduled operations (stomach resection, intestinal resection for malignancy and urological procedures), -32-nt for Treatment Section 1. 11.3.3 Equipment 1133.1. General Equipment Specifications of theatre installations like operating tables, lights and sterilization which can be used by various disciplines are described in the appendix "Theatre equipment" and will not be listed in the following Equipment requirements for surgery at different levels of health institutions: Surgery at Level I: Diagnostics: = stethoscope, = reflex hammer, = measuring tape, = domestic light source (electric or alternative energy) Therapy: ~ examination and treatment bench = tourniquet ~ small surgical instrument set (for suturing and control of haemorrhage, see also section “Theatre equipment") disinfectant = local anaesthesia = bandages, plasters, splints Sterilizati = steam pressure autoclave (pot, 10 1 volume, is sufficient, variable energy source: electric, ‘gas, paraffin)Equipment for Treatment Section II Surgery at Level 1: All equipment as at basic level I plus: Diagnostics: basic radiography and/or ultrasound Therapy: at least 2 operating theatres (one for minor procedures, fracture setting and septic proce- dures, one for clean major surgery) theatre table (manually operated) theatre light (cold light with stand-by battery) foot-operated suction pump basic surgical instrument set (see section "Theatre equipment") basic orthopaedic set (chisels, drills, traction pins) skin graft knife instruments for craniotomy optional: electrocautery equipment Sterilization: (Clectric) steam autoclave (size according to workload, 10-20 1) Surgery at Level HII: All equipment as at routine level II plus Diagnostics: fluoroscopy image intensifier ultrasound (linear array 3.5 MHz) optional: endoscopy equipment‘Equipment for Treatment jection II Therapy: 2 operating theatres, one of them highly aseptic 2 operating tables (titable and height adjustable) with attachments to suit specific needs (Chogoria’ leg supports for hip abduction and an arm board) electrocautery instrument sets including instruments for microsurgery, intestinal staplers emergency power generator air conditioning (active or passive) Sterilization: steam sterilizer, size according to workload (20-60 |) (see also Section III) 1.3.3.2. Surgical Instruments: ‘Types of surgical instruments vary from one country to another and depend on the different rou- tines used at the different surgical training centres as well as on the personal preferences of the surgeon. However, to reflect the range of "maximal" (developed countries) and “minimal” (developing countries) equipment for the practice of general surgery, levels I & III are given as examples Equipment for "First Aid - Minor Surgery Dressing" (Health Centre Level without theatre) 1 1 1 1 instrument tray tracheal catheter for adults, rubber urethral catheter set urethral catheter (female), metal jar forceps tourniquet bandage scissors, angular, 18 cm ‘gauze scissors, straight, 21em sponge forceps, serrated jaw, 22 em forceps, 21 cm tissue forceps, toothed, 15 cmEquipment for Treatment Section 1 knife handle and blade set 1 grooved director, round point 1 dressing forceps, non-toothed 15 em 1 haemostatic forceps (Kocher), 14 em 1 haemostatic forceps (Kelly), 14 em 1 operating scissors, straight 14 cm 1 needle holder (Mayo Hegar), 15 cm 1 suture set 1 probe 1 splinter forceps Others: syringes splint kit suture clips gloves intravenous rehydration set Optional: maternal care 1 breast pump 3° vaginal specula, small, medium, large 1 haemostatic forceps (Rochester Pean), 16 cm paediatric: 1 nasal aspirator, infant-sized 1 tracheal catheter, infant-sized 2. tubes for nasal feeding, $.8 Fr 1 rectal syringeEquipment for Treatment "Minimum" surgical instrument set and equipment needed for laparotomy at district hospi- tal level (Level [1 or IID), (Aesculap or Martin, Germany): 2 curved dissecting scissors scalpel handle and 1 blade 1 2. dissecting scissors, short 2 dissecting scissors, long 2. stitch scissors 12 artery forceps, curved, small 12 antery forceps, straight, small 12 artery forceps, curved, long 12 artery forceps, straight, long 1 needle holder, short 1 needle holder, long 1 retractor (Langenbeck), medium 1 retractor (Langenbeck), narrow | retractor (Deaver), medium 1 retractor (Deaver), narrow self-retaining retractor dissecting forceps, toothed dissecting forceps, non toothed, long tissue forceps (Allis) tissue forceps (Duval) sponge forceps malleable retractors (spatulae) ‘occlusion clamps, straight ‘occlusion clamps, curved syringes (10 and 20 ml) and needles sutures catgut, chromic catgut (with different sizes and needles) 1 2 al 4 4 4/ tissue forceps (Babcock) 8 2 2 2 2 1 suction nozzle and suction apparatus 1 diathermy electrode, lead and apparatus 1 probe flexible, round -37-Equipment for Treatment Section I 1 crafty director/administrator 1 nasogastric tube 6 towel clips Others: bows, kidney dishes, gallipots, swabs, antiseptic solution, adhesive tape, drainage tubes, colos- tomy bags. Example of a "sm: 5 towel clips 1 pair of stitch scissors 2 pairs of small curved (Mayo) scissors 2 scalpel handles 10 small curved (mosquito) artery forceps 10 large tissue forceps (one pin) 3 small, non-toothed dissecting forceps small, toothed dissecting forceps small, toothed dissecting forceps et of instruments applicable to hospitals at national level | 1 1 small, fine pointed, non toothed dissecting forceps small, fine, toothed dissecting forceps 1 medium length, fine, pointed, non toothed dissecting forceps 1 medium length, fine, pointed, toothed, dissecting forceps 5 sponge holding forceps 10 artery forceps (Roberts) 5 gall bladder forceps (Moynihan's) 1 double-ended retractor (Morris) 2 large retractors (Langenbeck) 2 small retractors (Langenbeck) 2 double-ended retractors (Czemny/'s) 1 aneurysm needle 1 malleable silver probe 1 sinus forceps -38-Equipment for Treatment Section IT double-ended scoop curette double-ended dissector (Mc Donald) double-ended dissector (Watson-Cheyne) blunt-ended diathermy electrode handle needle-ended diathermy handle diathermy cable diathermy quiver sucker needle holders suction tube The “large set" of instruments commonly used in industrialized countries contains all the instruments from the "small" set plus: large, single-bladed retractor (Morris) intestinal forceps with fine blades extra long needle holder (Mayo-Hegar) Jong toothed dissecting forceps Jong non-toothed dissecting forceps extra long-toothed dissecting forceps extra long non toothed dissecting forceps extra long handled scissors, curved tip 11.3.3.3 Endoscopic Instruments ‘Technical equipment for endoscopic procedures for level IN (optional, only in places where the technical and personnel infrastructure is suitable) 1. Proctoseopy: The simplest form of endoscope, a tube of about 8 cm. Lighting can be provided by a small low voltage bulb or by a fibre-light cable. = proctoscope, light source + lubricant -39-2. Sigmoidoscopy: The sigmoidoscope is essentially an elongated version of the proctoscope (about 30 cm). Light is provided by a small low voltage bulb or through a fibre-light cable. Air is insufflated into the sig- moidoscope and into the bowel to improve the view. = sigmoidoscope = bellows = light source biopsy forceps = lubricant Flexible sigmoidoscopes with a fibre-light source are also used for inspection of higher parts of the terminal bowel section 3. Cystoscopy: Endoscopy of the urethra and bladder can be used either for diagnostic or therapeutic procedures Equipment can therefore vary depending on the aim of the procedure The cystoscope consists of an optical system through which the bladder can be examined internally For optimal view, the bladder is filled with clear sterile water. The cystoscope carries a light source asi the case with all the other endoscopic instruments Modifications of the basic diagnostic cystoscope are usually seen when surgical procedures (such as biopsies, coagulation of bleeding vessels) are required Simple, diagnostic cystoscope: = circular sheath = obturator = oval sheath telescope = double or single catheterizing scope faucet = light source, including cable = three-way tap + sterile water4 Equipment for Treatment ~ Surgical cystoscope: = sheath = obturator - catheterizing mechanism - telescope = 30 telescope = TO telescope ~ water tap = bridge = diathermy electrode = biopsy forceps = light source incl, cable 4, Esophago-duodeno-gastroscopy: Section It Gastroscopes are designed for diagnosis (incl. biopsies) and therapeutic procedures (haemostasis of bleeding vessels). The set consists of a flexible fibre optic gastroscope ~ _pharyngoscope with light carrier ‘gastroscope (adult and child size) = mouth gag = dental props = tongue depressor = sucker and suction tubing = light source and lead = Ryle's ube = dilator for cardiospasm (Negus) = forceps (set) = dilators (Chevalier-Jackson) 5, Bronchoscopy: Bronchoscopes are designed for diagnosis (incl. biopsy) and therapeutic procedures such as hae- mostasis The formerly commonly used rigid set is being gradually replaced by flexible fibre optic equipment. = laryngoscope = bronchoscope -41-Equipment for Treatment ection II ~ mouth gag = dental prop = tongue depressor = set of forceps = light source and lead = suction apparatus and tubing, ~ biopsy forceps 6. Laparoscopy: This endoscopic procedure is commonly used in the field of gynaecology, especially in female sterilization (tubal ligation), but also in routine diagnostic and curative surgery. - laparoscope = trocar - Vertes needle cannula = light source and cable = insufflator (CO> ges) 11.4 ANAESTHESIA 11.4.1 Overview 11.4.1.1 Role of Anaesthesia in Developing Countries In developing countries, anaesthesia is frequently applied by medical assistants, clinical officers or other paramedical staff with little or no training in anaesthesia Good anaesthesia depends more on skills, training and standards of the anaesthetist than on the availability of expensive and sophisticated equipment. ‘The spectrum of the most commonly performed surgical procedures under anaesthesia at the rou- tine level includes primarily obstetric/gynaecological emergencies and minor operations like hernia repairs, cataract extractions, etc. Within the curative services, surgical procedures requiring general anaesthesia play a minor role (in many countries less than 20% of all admissions). In view of logistical problems as well as financial -42-‘Equipment for Treatment Section 1 and personnel constraints, it is therefore usually not justified to purchase complicated and so- phisticated equipment which is expensive and difficult to maintain, and to run. Most anaesthetic equipment depends on a regular supply of medical gases. Spare parts for anaes- thetic machines are often not stocked and have to be imported ffom abroad. Due to lack of these and trained technicians, anaesthetic equipment is irregularly or never serviced. Failures with fatal ‘outcomes are common. ‘Anaesthetic apparatuses used in developing countries must therefore be as simple as possible. Considering the costs and unreliable supply of compressed gases (oxygen, nitrous oxide) and the side-effects of the administration of nitrous oxide (hypoxic mixture), inhalational anaesthesia based on a continuous flow of nitrous oxide and oxygen (Boyle's machine) is not adequate. 11.4.1.2 Draw-over Anaesthesia Draw-over anaesthesia is the system of choice up to referral and even national level. Draw-over techniques are economical and capable of producing a very good anaesthesia, they are simple to understand and use and can be serviced locally The most practical equipment under these circumstances consists of a combination of the EMO vaporizer or the Afya (Drager) vaporizer, the OMV (Oxford miniature vaporizer), equipped and calibrated for both halothane and trichloroethylene (Trilene), Cyprane Pac vaporizer or the Malawi model/triservice anaesthetic machine together with a means of inflation such as a manual resuscita- tor (self inflating bag) or Oxford bellows, an Ambu or similar valve (Ruben, Laerdal), and a face- ‘mask or endotracheal connector. 1.4.1.3 Oxygen Oxygen is needed in addition to agents which cause cardio-respiratory depression such as halothane, and for very young, very old and critically ill patients. Oxygen concentrators are a safe and affordable alternative to the use of gas cylinders (e.g, the Malawi model anaesthetic machine). Oxygen concentrators can be run by solar energy/rechargeable batteries or from the mains electricity. Oxygen concentrators work very economically and do not depend on susceptible supplies with gas cylinders. Thus oxygen can save the health budget more than 50% as compared to the supplies with gas cylinders. -43-Equipment for Treatment Section I 11.4.1.4 Mechanical Ventilation Mechanical ventilation isa life-sustaining technology that is costly and that requires highly trained staff and regular servicing Not only purchase and initial installation of the ventilators are very expensive. The additional costs for monitoring equipment, e.g pulse oximeter, an automated oscil- Tometer, CVP manometer, central venous catheter, a ventilator disconnection alarm, respirometer, ccapnograph, blood gas and acid-base status machine mean a continuous unnecessary drain on the hospital budget. Referral hospitals in many developing countries give evidence that even at higher levels of the health system good anaesthesia for all clinical purposes can be provided without mechanical ventila- tors and nitrous oxide. At larger referral centres, mechanical ventilation may be feasible. In such ceases ventilators (e.g. TC-50) in combination with the above equipment may be affordable and safe. Ideally, all hospitals in one country should be equipped with the same type of anaesthetic appara- tus/facilities, Standardized equipment reduces capital expenditure and lowers the costs of servicing, ‘maintenance and spare parts. It also enables students at teaching hospitals to become familiar with the apparatus they will be using later. 1.4.1.5 Anaesthetic and Recovery Room A recovery room or ward and an anaesthetic room with a responsible nurse would be ideal even at the routine level. Recovery rooms should be equipped with ~ beds = oxygen concentrators = cupboards to store equipment and drugs = 2 trolleys and worktops to allow preparation of syringes, needles, cannulae and drugs = 2 blood pressure machines (tonometre) 11.4.2 Treatment Anaesthesia at Level I: ‘Anaesthesia for the management of wounds, episiotomies, biopsy excisions, incision and drainage of abscesses. Suitable anaesthetic methods are: local infiltration, field block, surface anaesthesia (spray). Essential monitoring required: pulse (palpation), blood pressure (sphygmomanometer)‘Equipment for Treatment Section II Essential moritoring required: pulse (palpation), blood pressure (sphygmomanometer) Most conditions requiring anaesthesia (Caesarean sections, evacuations, hernia inguinal, hydro- celes, fractures, trauma, cataract, tumours) are referred to the next level Anaesthesia at Level If: ‘Anaesthesia for the management of Caesarean sections, dilatation and curettage, hemia repair, laparotomy (mainly for treatment of ruptured ectopic pregnancies, tubo-ovarian surgery) hydro- celectomy, amputations, reduction of closed fractures, cataract extraction, skin graft, circumci- sions, foreign body removal. Suitable anaesthetic methods are: local infiltration, field block, surface anaesthesia (spray), general anaesthesia (with inhalational anaesthetic agents, intrave- nous anaesthetic agents or intramuscular agents), regional anaesthesia (epidural and subarach- noid anaesthesia), nerve blocks. Continuous monitoring should include the following parameters: pulse (palpation), ventilation/breathing (observation/perception of the patient's colour, respira tory rate, adequacy of chest movement and the movement of the reservoir bag, auscultation), blood pressure (sphygmomanometer), Hb (laboratory) Anaesthesia at Level II: In addition to the management of all operations performed at routine level, anaesthesia is re- quired for orthopaedic surgery, ENT surgery, more advanced general and gynaecological surgery, and ophthalmic surgery. In many countries, anaesthetic departments at referral level also serve as training institutions for anaesthetic assistants and are also responsible for supervi- sion of anaesthetic equipment and personnel at lower levels. ‘At the referral level, mechanical ventilation is necessary for very long, surgical procedures in theatre, long-term ventilation in recovery rooms or even in intensive care wards. Suitable anaesthetic methods at referral level: local infiltration, field block, surface anaesthesia (spray), general anaesthesia (with inhalational anaesthetic agents, intravenous anaesthetic agents or intramuscular agents), regional anaesthesia (epidural and subarachnoid anaesthesia), nerve blocks, mechanical ventilation, -45-ment for Treatment 11.4.3 Equipment Anaesthesia equipment at Level I: selection of needles and syringes (2 mi, 5 ml, 10 ml), stethoscope sphygmomanometer sterilization apparatus (pressure cooker type) clock torch mini-swabs or cotton wool skin disinfection Anaesthesia equipment at Level II: (including special equipment for paediatric anaesthesia) selfinflating bags of the Ambu type intubation cushion anaesthetic facemasks (sizes infant to large adult, 2 of each size) oropharyngeal airways: Guedel airway (size 000-5), Philipps airway 4 nasopharyngeal airways endotracheal tubes (Oxford or Portex [Magill] size 2 5-10 mm (intemal diameter) in 0.5 ‘mm steps with cuffs only on sizes >6 mm) and connectors gumelastic bougie (introducer) ‘endotracheal tube connector (15 mm plastic) breathing hose and connectors (lengths of | metre antistatic tubing, 30 em tubing for connection of vaporizers, T-piece for oxygen enrichment) breathing valves (Ambu El, Ruben, Laerdal and Ambu E2 for resuscitation for adult and paediatric) nasogastric tube straight-blade laryngoscopes (e.g, Magill) (infant to adult sizes, one of each size) curved-blade laryngoscopes (four sizes) including infam blades universal battery charger and tester (also solar energy) adhesive tape tongue forceps mouth gag, -46-‘Equipment for Treatment Section 1. = laryngeal spray ~ lubricants = scissors = breathing tubes = artery forceps (Kocher’s and Spencer Wells’) = Mayo's tongue and towel forceps = Magill's forceps - T-piece breathing system for infants, oxygen delivery tube for T-piece = reservoir and rebreathing tubes = toumiquet hose = Oxford inflating bellows = selPinflating bag = resuscitator = oxygen concentrator (oxygen cylinder only as back-up and for emergencies) - anaesthetic machine with complete breathing attachment and preferably a compensated vaporizer (draw-over apparatus: EMO, triservice apparatus, continuous flow/draw-over apparatus: Malawi mode! anaesthetic machine) ~ anaesthetic vaporizers (draw-over type, e.g, EMO) for either halothane (e.g. OMV or Cyprane Pac Vaporizer) or trichloroethylene equipment for intravenous use: needles and cannulae, including paediatric sizes and an umbilical vein catheter, infusion sets, infusion sets for blood transfusion, butterfly nee- dies = flowmeters for both oxygen and air suction equipment (2 foot-operated suction pumps as well as electrically operated suction pumps) = abrush for cleaning endotracheal tubes thermometer anaesthetic record sheets = equipment cupboards ~ drug cupboards, worktops ~ trolleys, resuscitation trolley -47 -Equipment for nt Secti Local anaesthesi = spinal needles (size 25G and 22G) = Touhy needles (size 17G), sterilization containers for autoclaving, tourniquet, gallipot ‘Special equipment needs for dental anaesthes = anaesthesia required for tooth extractions, filings, driling, dental surgery ~ methods used: mainly local anaesthetic blocks, sedation techniques, rarely general anaesthesia = essential equipment: selection of needles, syringes (size 5 and 10 mi), stethoscope, sphygmomanometer, manual resuscitator. If general anaesthesia is required, the proce- dure should be performed in the theatre. Anaesthesia equipment at Level ITI: Equipment needs for anaesthesia at referral level are very similar to the equipment needs at routine level. Looking at the audit of operations performed at referral level, ventilators for anaesthesia in the theatre are usually not required. However, ventilators often have to be em- ployed for respiratory failure in paralysed or apnoeic patients, who need long-term ventilation in the intensive care ward. Equipment needed: = ventilator, e.g, TC SO, Penlon Nuffield anaesthetic ventilator = pulse oxymeter = central venous pressure set (not electrical) = central venous catheter (optional) ILS OBSTETRICS (also refer to II.3 Surgery) 11.5.1 Overview Reducing maternal morbidity and mortality is essentially linked to routinely performed antenatal health care for mother and child, The introduction of a basic, routine screening programme - 48 -sment for Treatment dion starting in early pregnancy with regular! follow-up visits is the key to success in improving maternal and fetal health The introduction of a documentation system such as a patient card for every pregnant woman has considerably improved the survey of pregnancy and focussed the attention on possible risk factors or previous complications, The basic but essential work of recognizing potential risk factors for mother and child must be complemented by a well-functioning referral system. The referral system starts at the level of traditional birth attendants and extends up to the national referral hospital in a set-up where each level fullfils clearly defined functions in a well-planned system of matemal and neonatal care. One important task of maternal care is to filter patients and make sure that all mothers at risk have access to higher levels of the health system in time, Antenatal care and observation during "uncomplicated labour do not require highly sophisticated equipment. In developing countries with their high birth rates and limited resources, ultrasound and car- diotocography are usually not used for routine screening but, if they are available, they should be applied to the examination of special high risk cases which have been identified by other ‘means before In most developing countries, about 50% of all operations at levels II and ITI of health care (district and provincial hospitals) are obstetrical and gynaecological ones. The requirements of these obstetrical operations therefore determine the design and equipment of the operating theatre. Essential laboratory needs for maternal care are urine examination, Hb and blood grouping and ‘ctoss-matching. All hospitals with large maternity units should keep a blood bank. In countries with a high prevalence of venereal diseases, serological tests for syphilis should be performed routinely, and HIV tests are today compulsory for all blood banks in the world. IL5.2 Treatment Maternal care and obstetrics at Level I: This comprises health education, cooperation with communities and community health workers (TBAS), screening of antenatal and postnatal cases, referral of risk cases in time, management of normal labour, care of the newbom, as well as prevention, catheter treatment and referral of vvesico-vaginal fistulas (VVFs), and, where experienced staffs present, vacuum extraction in the third stage -49-‘Equipment for Treatment ection Maternal care and obstetrics at Level II: ‘This comprises planning, coordination and supervision of health education and preventive and ‘curative services, and, in addition to the basic level, antenatal and postnatal care of mothers at risk, management of complicated labour, obstetrical operations (Caesarean sections, hyster- ectomies, forceps deliveries, etc.) ‘Complicated cases must be referred according to national policy (eg. 2 and more previous operations, decompensated diabetes, etc.). Prevention, catheter treatment and referral of VVFs. Maternal care and obstetrics at Level TI: Planning, coordination and supervision of health education and preventive and curative services are the main tasks at this level as well as the development of guidelines for management of antenatal and postnatal care and management of labour. Multidisciplinary management of very sick mothers, management of elective obstetrical opera- tions, referred emergency operations (difficult cases of ruptured uteri), rehabilitation of mothers after professional malpractice or negligence, management of vesico-vaginal fistulas and care of the premature and small for date neonate are further important task. Optional activities comprise: amnioscopy, amniocentesis and simple tests on amniotic fluid such as the shake test as a simplified method of assessing the lecithin:sphingomyelin ratio; staining of fetal cells with Nile blue sulphate. 11.5.3 Obstetrics Equipment I1.5.3.1 General Equipment Proceedings in obstetrics vary considerably between industrialized and developing countries and between anglophone and francophone countries. Arguments about the advantages and disad- vantages of certain delivery forceps, about the use of destructive operations and about the use of symphysiotomies will continue forever ‘The authors believe that cranioclasts are dangerous and should not be used any more. Traction forceps like Tamier's axis traction forceps have been rendered obsolete. Forceps deliveries should only be done by an experienced person and with the kind of forceps she is most familiar with. The vacuum extractor has many advantages over the forceps but needs experienced personnel. Episiotomy and Symphysiotomy have an important place in obstetrical practice in all developing countries where craniopelvic disproportion (CPD) is com-Equipment for Treatment 200111 Section TE ‘mon. The best methods for recognition of CPD in developing countries are: past obstetric history, measurement of mother’s height, measurement of the diagonal conjugate, the use of the labour graph and - if available - ultrasound, Cleanliness and sterility are a prerequisite at all places where operative deliveries or intrauterine procedures are performed Failure of electric power can be fatal at locations where all equipment depends on electricity Additional light sources (e.g, battery-operated), hand-operated vacuum extractors and foot ‘operated suction pumps are essential equipment, For busy matemity units, separate sterilizers are recommended. There is no place for baby incubators where supplies of oxygen are only sporadic. Drop counters or infusion pumps are regarded as essential equipment in obstetrics in developed countries. However, break-downs and unqualified operation by paramedical staff are common. Since they are mainly used for precise administration of tocolytic or utero-tonic preparations, the malfunction of drop counters and infusion pumps can be very hazardous. In most develop- ing countries estimation of drip rate with a watch, observation of patient and infusion by a quali- fied nurse/midwife consistute the better choice. Essential equipment for obstetrics at Level I: sufficient supplies with antenatal charts and partograms = good light source (eg, small spot lamp, adjustable) > adult scales + baby scales ~ blood pressure machine(s) = _fetoscope (wood) = simple delivery beds according to expected number of deliveries per day (preference given to delivery beds which are able to be tipped into head-down position) = 1 foot suction pump ‘gag and airway + selfretaining catheters + metal catheters + neonatal mouth sucker = sufficient number of instrument sets plus linen according to expected number of deliver- ies per day. The composition of the instrument sets may vary from country to country and should be in accordance with national preferences and surgical tradition = sterilizer (cooker type will do for most centres) -51-Equipment for Treatment Section Ht = laboratory facilities for testing Hb and urine for protein and glycosuria (simple methods will do, e.g. Sahli method for Hb, Nylander’s reagent for protein) = gloves Optional (depending on national policy): = vacuum extractor (with hand pump) with adequate spare parts (particularly chains, seals, rubber tubing) to be kept in labour ward Essential equipment for obstetrical care at Level II: As for basic level plus: = sufficient number of instrument sets in labour ward, ideally twice as many sets as expected ‘number of cases per day. The instrument sets must include: ~ vaginal specula of various widths and retractors = obstetrical forceps = scissors, perforator, cranioclast, dilators (Hegar) ~ straight clamps = knives and knife blades of different sizes = needles and suture material = curettes of different sizes ~ self-retaining catheters = metal catheters = obstetric forceps (only if obstetrician or experienced medical officer stationed in maternity) = fetal stethoscope, monaural = Hb meter = an autoclave or a simple pressure cooker = delivery beds with retractable foot parts = device for back plate and pelvis elevation (manually) = device for instantaneous adjustment of Trendelenburg position (manually), adjustment to gynaecologic position provided by knee crutches (e g Goepel knee crutches) = good light source in labour ward to perform obstetrical operations, preferably - operation light, ceiling or wall-mounted, swing type = one operation light, stand type with battery, mobile -52-‘Equipment for Treatment Section = simple anaesthetic machine in labour ward: in many developing countries, the EMO vapor- izer and the OMV (Oxford miniature vaporizer), both equipped and calibrated for halothane or trichloroethylene and combined with a means of manual resuscitation (Ambu bag), are the best choice. = infant warming beds = vacuum extractor (with hand pump) with adequate spare parts (particularly chains, seals, rubber tubing) to be kept in labour ward = ultrasound with linear array transducer (3.5 MHz) Essential support services: = operating theatre, basic laboratory with blood bank, laundry, sterilization (radiology is desirable but not absolutely necessary) Optional: = [hand ultrasound fetal heart detector = baby incubator (only where maintenance and supply of oxygen can be guaranted) Essential equipment for obstetrical care at Level III: As for routine level plus: ~ bilirubinometer in the maternity unit = 1 stopwatch for infusion drop counting + ultrasound with linear array transducer (3.5 - 5.0 MHz) and the following transducer op- tions: annular array or curved linear array, transvaginal array. It is generally advisable to have both a linear and an annular array - the linear array is necessary to measure fetal di- mensions and proportions. The annular array is useful in the detection of gynaecological problems and for diagnostics in intemal medicine. However, if resources are so limited that only one transducer can be purchased, a linear array is advisable = essential support services as above plus expanded laboratory services for more serological examinations, fibrinogen and clotting factors, electrolytes, blood pH in umbilical artery (see under laboratory services) - ECG +L ultrasound fetal heart detector -53-Equipment for Treatment Section Optional - conical specula for amnioscopy = hormone laboratory for oestriol and HPL = infant incubator(s) IL5.3.2 Instruments necessary for Obstetric Procedures ‘Common procedures in obstetrics are: = episiotomy - dilatation and curettage ~ Caesarean section 1. Episiotomy: 2. episiotomy scissors 8 artery forceps, small 2. dissecting forceps, toothed 2. dissecting forceps, non-toothed 1 needle holder 4 sponge forceps 1 syringe incl. needle sutures and ligatures catgut or chromic catgut 1 urinary catheter 2. Dilatation and curettage (D & C) 1 vaginal speculum 2 Vulsellum forceps 1 uterine sound 1 uterine dilators set 1 uterine curette, sharp 1 uterine curette, bhunt 4 sponge forcepsEquipment for Treatment Section Th 3. Caesarean section: Laparotomy set plus the following instruments: 8 uterine haemostatic forceps (Green Armitage) 1 obstetric forceps, small 1 vaginal speculum 1 urinary catheter 11.6 GYNAECOLOGY 11.6.1 Over In developing countries, gynaecology is mainly a surgical speciality. Operations include ectopic stations, evacuations and dilatation and curettage, tubal ligations, operations of vesico-vaginal or recto-vaginal fistulas, operations on pelvic abscesses, hysterectomies and operations for cancer, ‘especially for cancer of the cervix. Most of these operations can be done with the normal equip- ‘ment/instruments of general surgery. In conservative gynaecology there is usually a big demand for the following services: + diagnosis and treatment of sexually transmitted diseases (STDs), including pelvic inflamma- tory disease (PID) - family planning = examinations for infertility = diagnosis and treatment of infectious diseases affecting the female genital tract. Examinations for infertility and treatment are common gynaecological procedures in many indus- twialized countries. These procedures are very time-consuming and often very expensive In many developing countries female inferti diagnosed and treated in time. is caused by pelvic infections which have not been -55-Equipment for Treatment, Section I 11.6.2 Treatment Gynaecological care at Level I: (as part of MCH-programmes) Gynaecological care at basic level comprises family planning counselling, early diagnosis and treat- ment of sexually transmitted diseases (STDs) and pelvic inflammatory disease (PID), health educa- tion on STD and AIDS prevention, as well as early diagnosis and referral of any possible gynaeco- logical cancer, such as breast cancer, suspicious lower abdominal masses and referral of vesico- vaginal (VVF) of recto-vaginal fistulas (RVF). Gynaecology at Level I: ‘At routine level, gynaecology comprises supervision of family planning services, clinical supervision ‘on management of STDs and PID at the basic level, planning and supervision of health education, screening of infertility patients, setting up a tentative diagnosis, and deciding on prospects of further treatment, Further diagnostic procedures and treatment or referral of: = family planning clients who need special attention = gynaecological oncology (cervical cancer, breast cancer and other suspicious lower ab- dominal masses) = vesico-vaginal (VVF) or recto-vaginal fistulas (RVF) Surgical treatment at this level should include: = dilatation and curettage (D & C) = surgery of ectopic pregnancies = drainage of intra-abdominal abscesses = uncomplicated operations of lower abdominal masses not involving other structures of the pelvis (e g fibroids, ovarian cysts). Gynaecology at Level III: ‘At referral level, the main tasks consist of overall planning and management of family planning services, planning and management of contro! programmes (eg. STDs and AIDS) or preventive services (VVF prevention, cervical screening), publishing guidelines on management of STDs and PID at all levels of health care, treatment of infertility patients, as well as further diagnosis and ocEquipment for Treatment Section treatment of gynaecological oncology cases, such as cancer of the cervix, breast cancer and others which could not be treated at lower levels of health care, treatment of complicated vaginal or recto-vaginal fistulas 11.6.3 Equipment 11.6.3.1 General Equipment Equipment for conservative gynaecology must provide satisfactory conditions for bimanual pelvic examination and speculum examination (examination chair and good light source), Cervical smears should be taken at all levels of health care, Colposcopy and further treatment of cervical diseases require an experienced gynaecologist and should therefore be reserved for the higher levels of health care. Nearly all operations in this speciality (ectopic gestations, operations for vesico-vaginal and recto- vaginal fistulas, operations on pelvic abscesses, hysterectomies and operations at the adnexae) can be done with general surgical equipment and instruments The equipment and instruments for mini-laparotomies are easy to handle, and the costs are lower ‘compared to the equipment needed for endoscopic procedures such as laparoscopy. The surgical technique of laparotomy is usually familiar to all staff working in developing countries. However laparoscopy usually can be performed as day surgery, and no admission of patients may be neces- sary (tubal ligation) Gynaecological equipment at Level I: = couch or chair for bimanual pelvic examination and speculum examination = good light source = specula, forceps Gynaecological equipment at Level I: Consultation room(s) for gynaecological examination should be equipped with the following: = gynaecological examination chair with proper leg holders (foot plates, stirrups for knee crutches) and pelvis elevation -57-Equipment for Treatment Section ~ good light source + microscope = instrument sterilizer (pressure cooker) Theatre: = operating table with knee crutches for abdominal-vaginal procedures = general surgical set = set for mini-laparotomy Optional: = ultrasound at least linear scan (3.5 MHz) Gynaecological equipment at Level III: = consultation room(s) with gynaecological examination chair as above, light source = microscope = instrument sterilizer (pressure cooker) = colposcope ultrasound linear (3.5 MHz) and sector scan (3.5 - 5 MHz) Optional: = ultrasound vaginal sector scan = equipment for laparoscopy (see surgical equipment) 11.6.3.2 Gynaecological Theatre Equipment For gynaecological surgical procedures a general surgical set is usually sufficient. (See section "general surgery"equipment). ‘Additional instruments for gynaecological examinations and specialized gynaecological-surgical procedures at district hospital level (II or Ill): 1 vaginal speculum (Sims), small | vaginal speculum (Sims), large -58-‘Equipment for Treatment Seti TT aes Hee wo aati ‘vaginal speculum (weighted) forceps (Vulsellum), 28 cm episiotomy scissors uterine sound, 30 cm (set) of uterine dilators (Hegar) (et) uterine curettes hysterectomy forceps (straight), 22.5 em haemostatic forceps (Green Armitage), 20 cm retractor (Doyen) vaginal wall retractors punch biopsy forceps set of suction cannulae amniohooks vacuum extractor cranial perforator craniotomy forceps obstetric forceps, low, curved obstetric forceps, high, straight (Kjelland) colposcope microscope Special procedures: Dilatation of the cervix and uterine curettage (D & C) 1 1 1 vaginal speculum, weighted ‘Vulsellum forceps ‘Sims vaginal speculum uterine sound set of dilators (Hegar) uterine curette, sharp uterine curette, blunt urinary catheter -59-Equipment f tment jon I ‘Abdominal hysterectomy, surgery of the adnexae, ectopic pregnancies: Laparotomy instruments and: diathermy self-retaining abdominal retractor additional hysterectomy clamps (4) Vulsella forceps (2) myomectomy screw urinary catheter 11.7 OPHTHALMOLOGY 11.7.1 Overview Prevention and treatment of eye diseases play an important role at health institutions in most parts of the third world Many countries have trained cadres of paramedical staff for tasks which, in industrialized coun- tries, are performed by general practitioners or even ophthalmologists. The following staffs necessary for comprehensive eye care within the referral system = opticians with basic knowledge (grinding and fiting lenses into frames) = ophthalmic opticians with broader knowledge and better skills - ophthalmic clinical officers or medical assistants and general medical officers with basic knowledge of eye care - ophthalmologists Because of the delicate instruments and equipment used in ophthalmology, the training of ophthalmic staff must include handling and maintenance of equipment Eye care in developing countries requires a functioning referral system. In many countries a system of travelling ophthalmic clinical officers and/or ophthalmologists has been successfully established Certain national support services appear to be important for eye programmes. These services include production of eye drops production of spectacles -60-Equipment for iment i IL.7.2 Treatment Eye care at Level I: Health education and execution of preventive services (e.g, Vit A programmes), assistance in control programmes (e.g. onchocerciasis) Diseases managed at this level: conjunctivitis, easily removable foreign bodies, chalazion (Conservative treatment), trachoma, Diseases dingnosed and referred: cataract, glaucoma, tumours, posterior segment disease, liseases affecting the comea, trauma, diminished visual acuity. Ophthalmology at Level II: Planning, coordination and supervision of health education, preventive services (e.g, Vit A programmes), control programmes (e.g, onchocerciasis) Diseases managed: extraocular eye diseases, enucleations, lid surgery (entropion, tarsor- thaphy). Diseases diagnosed and referred: all intraocular diseases, cataract, glaucoma. Exceptions: In some developing countries, clinical officers and general medical officers have ‘been trained to perform cataract surgery. These operations would then be performed at routine level, Ophthalmology at Level IH: Overall planning and management of health education, planning of preventive services (eg. Vit A programmes), control programmes (e.g. onchocerciasis), Medical training for medical/ health personnel working at level 1 Diseases managed: intra- and extraocular eye diseases including trauma. -61-Equipment for Treatment ection II 11.7.3 Equipment 11.7.3.1 General Equipment Sophisticated equipment and instruments for ophthalmology should only be procured if mainte- nance, repair and adequate training of users can be guaranteed The library should contain adequate manuals on eye care and eye surgery at each level Equipment at Level I: light source lid retractor cotton-tipped sticks visual acuity board (reading chars) near-vision testing card Equipment at Level II: Same equipment as at basic level plus: minor eye surgical set (if cataract surgery is performed at this level: basic cataract surgeon's, kit) direct ophthalmoscope light source ‘magnification lens (2.3x) or operating loupe with head band eye tonometer basic refraction set of spherical lenses organized use of major operating theatre separate small sterilizer (autoclave) for eye instruments Ishihara colour vision charts -62-Equipment for Treatment Section 11 Equipment at Level I: ‘Same equipment as at basic and routine levels plus: indirect ophthalmoscope slit lamp full intraocular surgical kit operating loupe perimeter lens meter full refraction set retinoscope refractometer Optional: ‘operating microscope with coaxial light, special operating stool, photocoagulation system (light) 11.7.3.2. Equipment for Essential Support Services for Ophthalmology Spectacle production: electric edger frame heater (hot air blower) lens meter set of tools (pliers, rulers, screwdrivers) start set of lenses and frames Production of eye drops precision balance pipette press or dropper tops and sealing machine set of basic chemicals (preservatives, buffers, drugs, stains) autoclave water still eae1 TI1.2 THL3 TL4 TLS TIL6 SECTION II SUPPORT SERVICES LABORATORY RADIOLOGY STERILIZATION PHYSIOTHERAPY LIBRARY HOSPITAL WORKSHOP 65 4sae Geiger eter street gecieg 1.1 LABORATORY TIL1.1 Overview In many developing countries the availability of good laboratory services still present the bottleneck in clinical diagnosis, Trained personnel is scarce, supplies with reagents limited, equipment often ‘out of order. Clinicians therefore weigh up carefully which examinations are essential and restrict themselves to a limited number of reliable tests, Decisions on necessary laboratory examinations depend not only on diagnostic needs but also on the workload and availability and skills of laboratory technicians, and the laboratory equipment in working order at their disposal. To request the whole spectrum of laboratory examinations as a routine or to ask for three- and fourfold confirmation of a known diagnosis - a wasteful and often unnecessary practice in western medicine - is irresponsible in developing countries and may overtax all of the laboratory services. Each test requested should be justified, and it might be necessary to choose one parameter out of many as an indicator for certain ailments (e.g. only to examine blood urea as an indicator for urinary retention and to leave out creatinine, uric acid, ete.) When deciding which tests are appropriate for a particular level of health care the following questions should be considered. + Which level of skill is required for the test? = How much of the precious time of the laboratory technician does the test consume? - How sophisticated is the equipment the test asks for? ~ How many supplies does the equipment need? = Who will maintain the equipment? = How reliable and accurate are the test results? = Are constant and regular electricity supplies guaranteed” If not, how can laboratory services be maintained during power failure (stand-by batteries, generator, simpler methods)? The following poims are generally valid = Static methods are more reliable than dynamic methods (substrate tests vs. enzyme tests) = White-cell counts, red-cell counts and especially platelet counts are very time-consuming and often unreliable. = Flame photometers require constant supplies of gas, adjustment and maintenance require experienced personnel = Sticks methods and ready-for-use test-kits are often more expensive than ordinary labora- tory tests, regular supplies must be guaranteed, and expiry dates must be observed. = Digital display at colorimeters facilitates direct reading of results which is much more reliable and superior to any methods requiring manual calculation of values. = 66-Support Services. jection IIE = Wherever regular and frequent microscopic examinations have to be done binocular microscopes with electric illumination are essential. Monocular microscoping with sunlight soon leads to fatigue and cannot yield reliable results oil immersion microscopy requires binocular microscopes with electric illumination, ~ For practical work reliability of results is more important than accuracy. Each laboratory must have manuals and posters in a language understood by the users. A. setup of trained laboratory technicians acting as responsible staff and less qualified rmicroscopists/laboratory assistants for the routine work has proved successful in many developing countries. 11.1.2 Services Laboratory services at Level I: Simple laboratory tests to serve curative and preventive care at this level and to assist in decision ‘making as to which patients/clients should be referred to higher levels of health care. The following examinations are required: - Hb = ESR’ (erythrocyte sedimentation rate) = urine: protein, glucose, sediment = stool, ova, entamoeba cysts, giardia = smear on gonorrhea (methylene blue stain/Gram stain) In addition to these examinations the following tests might be necessary according to regional characteristics: ~ Sickling test = microscopy for malaria parasites, trypanosomes, flaria, acid-fast bacilli ~ qualitative urine tests on DDS and Rifampicin = basic chlamydia tests ‘When more specific tests are needed for proper diagnosis patients and not specimens are referred to the higher level | Some experienced doctors doubt the diagnostic value of ESR in the tropics. -67-Servi es ion 1H Laboratory services at Level II: ‘Supervision and in-service training of laboratory staff in the health district concemed. Training has to include care of equipment, especially the care of microscopes. Control of laboratory equipment, procurement of supplies Provision of routine laboratory tests to serve curative and preventive care at this level and to assist in making the decision as to which patients/clients are to be referred to higher levels of health care. In addition to the examinations performed at the basic level the following tests are required: = full blood count (WBC, diff, WBC, RBC, PCV) = full urine report (bile salt, glucose, protein, specific gravity, pH, sediment) = examination of CSF (microscopy, glucose, protein) Blood chemistry: ~ bilirubin - sGoT - SGPT alkaline phosphatase + urea glucose total plasma protein serum electrolytes ( Na’ ,K’, ...) bleeding time clotting time Serological examinations: = blood grouping and cross-matching - HIV(ELISA test) - VDRL = microscopic examination of smears, sputum, rectal biopsy. ete. = preparation of specimens for dispatch to reference laboratories where feasible (problems: transport, time, temperature) ‘The following are usually not required: = blood enzyme tests = plasma lipids -68-Support Services ‘Seetion IT = serum osmolality clotting factors = culture and sensitivity = histology Optional tests: = Hepatitis B - serology Laboratory services at Level ITT: Supervision and in-service training of laboratory staff working at lower levels, The training must include care of equipment, especialy the care of microscopes Control of laboratory equipment, management of maintenance and repair of equipment, procurement of supplies including consumables, production and distribution of reagents. Provision of a comprehensive spectrum of reliable basic, routine and specialized laboratory tests to serve curative and preventive care at this level Laboratories at this level often serve as reference laboratories. Organizational structures to receive specimens and to send the results to referring health institutions have to be operational Haematology: - ESR = Hb (colorimetric) - PCV = red cell count = leucocyte count = reticulocyte count ~ thrombocyte count = differential count + sickle cell test = bleeding time = clotting time = specimen preparation and dispactching of bone marrow aspirates -69-‘Support Services. Colorimetric Tests: haemoglobin glucose urea creatinine total protein bilirubin alkaline phosphatase SGOT/SGPT Enzyme tests: Plasma li cPK amylase lipase SGOT/SGPT LDH y-GT alkaline phosphatase and other enzyme tests according to specific diagnostic needs ids: cholesterol triglycerides Serology: Gruber-Widal H+O VDRL. blood grouping rhesus determination ccross-match rheuma serology hepatitis serology (A, B, C) Weil-Felix (Ox 19 / Rickettsia) specimen taking and dispatching for other serologic tests -70- Section 1deposits nitrate (test strip) PH (test strip) protein ghicose ketones urobilinogen bilirubin Dregnancy test occult blood ‘worm eggs protozoas Cerebrospinal fluid: Pandy test total protein cell count deposit staining acc. GramvZiehl-Neelsen culture Swabs: Gram stain Ziehi-Neelsen stain methylene blue stain Blood parasitology: malaria parasites borreliosis trypanosomes -n-‘Support Services Section Examination for: schistosomiasis amoebiasis filariasis toxoplasmosis trypanosomiasis brucellosis microfilariae Sputum: Zichl-Neelsen stain Skin snip: Ziehl-Neelsen stain microfilariae Optional tests: HIV confirmatory test (ELISA) serological tests for endemic viral diseases (e.g. Dengue) radio-immuno assay or enzymatic tests for TSH, T3, T4, sex hormones (enzymatic tests ‘appear more appropriate because no radioactive substances are needed) resistance tests for malaria parasites TI.1.3 Equipment Laboratory tests must yield reliable and reproducible results. Precise results require more sophisticated equipment. Exaggerated precision does not necessarily lead to better diagnosis and treatment (e.g. the accuracy of Hb levels of +1 g% is more than sufficient in most cases). Well-functioning laboratory services demand at least: well-trained and supervised staff (training and supervision must include care of equipment) constant supply of laboratory reagents ‘constant supply of electricity with voltage fluctuations not exceeding +/- 10% -72-Support. = constant supply of water = regular maintenance and repair of equipment. : In countries where a regular supply of laboratory reagents cannot be maintained any discussion on laboratory equipment will remain purely academic. Break-down of electricity supplies is not only a problem at the lower levels of health care but also in many capitals of developing countries where referral hospitals and central laboratories are located. The voltage sometimes fluctuates between 150 and 250 V. Ways must be found to keep laboratories working despite these problems. One way could be to connect the laboratories to an emergency power supply (which often fails as well) or to use the buffer capacity of batteries. Mi- ccroscopes and colorimeters can be connected to a 12 V DC source; batteries can be charged by the mains or by solar panels, All laboratories in developing countries must have equipment on stand-by which does not depend on electricity, e.g, a manually operated centrifuge, foot suction pumps, a mechanical precision balance, a kerosene or - better still - gas reftigerator. Vulnerable equipment must be connected to voltage stabilizers, In countries where the water supply is a problem, laboratories must have their own elevated water tank. Potential errors and fatigue of laboratory staff must be minimized, Colorimeters which give a direct reading are therefore preferable to those colorimeters which require calculations. For laboratory staff working on microscopes for long hours, binocular microscopes with electric illumination are essential The list of essential equipment mentioned below does not give required numbers, the numbers of, e.g. microscopes, needed depend only on the number of specimens examined per time unit and number of staff available and not on the level of health care. Some laboratory equipment (like scintillation counters and autoanalysers) has only a limited life ‘expectancy even under the best maintenance conditions. Procurement of such equipment should only be considered if replacement at the end of ts lifetime can be guaranteed Laboratory equipment at Level I: = binocular microscope with electric illumination (where there is no electricity, solar or battery-powered), 10x wide field oculars, objectives 10x. 40x, 100x_ (alternatively. objectives 5x, 12.5x, 50x, 125x) = plastic cover for microscope - ESR stand = centrifuge, hand-driven, table model, swing-out head (6x15 ml) = stopwatch = haemogiobinometer set (Sahli type) eae‘Support Services Laboratory equipment at Level II: As above plus: centrifuge, electrical centrifuge, hand-driven, table model, swing-out head decentralized additional haemoglobinometer sets (maternity, MCH clinics, paediatric wards) colorimeter sterilizer, hot air (for destruction of infection samples a separate autoclave may be required) haematocrit bilirubinometer pH meter mechanical balance small water still water Biter staining equipment counting chamber hand tally counter bunsen bumer / spirit amp interval timer watch ‘Sundries: dispensing and pipetting devices (4 to 20 ml) racks and trays syringes needles blood lancets forceps markers thermometers plass and plastic ware containers for dispatching specimens blood bank with refiigerator all blood grouping sera 74+‘Support Services ‘Section 111 Laboratory equipment at Level III: As above plus: = flame photometer = electronic balance = incubator for culture and sensitivity = spectrophotometer = water still / deionizer capable of producing 10-12 ! distilled or deionized water per day Histology and cytology section equipped with rotary microtome, microscopes, staining equipment. Optional: = microscopes with + phase condenser ~ dark field observation - UV fluorescence. Those microscopes should best be used in sp clinics and dermatological clinics. S offices, e.g. gynaecology clinics, STD 11.2 RADIOLOGY TI1.2.1 Overview Level I: No radiological examinations. Patients requiring X-ray examination are referred to higher levels. Level I: Radiological examination of skeleton, chest, abdomen should be possible. -15-‘Support Services Section 111 Level I: ‘The whole range of classical radiological examinations should be offered: = fluoroscopy of the stomach, intestines, thorax - intravenous pyelograms where country specific health needs - eg. high prevalence of nephrolithiasis - and possible medical intervention at this level - e.g. operations on the urina- ry tract - make this necessary = radiological examination of the gall bladder where countryspecific health needs - eg high prevalence of cholelithiasis - make this feasible [At present the investment and running costs of computer tomography (CT), Digital Subtraction ‘Angiography (DSA) and Nuclear Magnetic Resonance Imaging (NMR) cannot be met by the health budgets of most developing countries without seriously cutting back on more basic health most developing countries the logistical support for successful operation of this icated equipment is not to be found either in government services or in the private National or other acceptable regulations on radiological protection (safety of equipment, X-ray ‘measuring devices, etc.) and on routine inspection of radiological equipment (for radiation leakage, scatter radiation, shock-proof properties) must be observed. ‘The following types of X-ray units exist - fixed units / mobile units = single phase / three phase / multipulse / multiphase units = mains supply / battery-generated / capacitor discharge Attention: Before selecting / purchasing an X-ray unit, the technical features of the power supply of the radiology department must be assessed, Relevant data are: mains voltage and fluctuations, power, capacity of power supply (kW), or maximal current (A). Impedance must be below 0.32 ‘Ohms. Examples for specification of X-ray systems: 1. Simple radiographic system (e.g. from India) X-ray generator (Pleodor 60): stationary anode tube, single phase, mains supplied, fixed unit Output, $ kW max. 100 kV at 25 mA max, 60 mA at 40-70kV exposure time; 0.1 sec to 6 see Mains connection: AC, single phase, 240 V (200-270 V), 15 A fused, at 50 Hz, or three- phase current, 380 V -76-‘Support Services ection IT Fluoroscopy possible, but not advisable, 2. Basic radiographic system ‘Multipulse generator, rotating anode tube, fixed system Generator output: not less than 11 kW S4kV-125kV max, 150 mA. exposure time: 0.003 sec shortest exposure time Mains connection: AC, single phase, 220 V (automatic mains compensation), 10 A fused, battery-charged (capacity 11 Ah, 6 h charging time), altemative connection to solar panels (olar technology because of high energy requirements is still very expensive to buy and to run and therefore generally not recommended) No fluoroscopy. 3. Medium power three phase unit Three phase, 6 pulse generator. Fixed system (ceiling- mounted) Output 50-70 kW 125 kV - 200 kV 150 mA - 800 mA exposure time: 0.003 sec shortest exposure time Mains connection: AC, three phase, 380 V (automatic mains compensation), >10 A fused (operation with batteries, solar panels or capacitors not possible) Darkroom requirements: ‘Manual processing of films in common darkrooms is advisable. ‘Automatic processing machines are lable to frequent break-downs and should only be used where regular service and maintenance can be guaranteed. Automatic processors also need air conditioning and special provision for water supply and drainage -17-Support Services ‘ection 1M. Ti1.2.2 Equipment X-ray facilities at level I are usually not required Radiographic equipment at Level I: ‘Simple radiographic system (see above) and/or Basic radiographic system (see above) Manual film processor Radiographic equipment at Level ITI: As for the routine level and/or = agood "medium power three phase unit” with: fluorographic/radiographic table image-intensifier set manual film processor Optional: = multisection casette with screens (capacity 3-7 films) = dental X-ray unit = processing machine (if necessary and sustainibly feasible) III.2.3 Diagnostic Imaging - a Comparison ‘The following table gives a comparison between X-ray and ultrasound equipment with reference to the requirements of typical health institutions in developing countries: -78-‘Support Services Area capital investment running costs expenditure for ‘maintenancelrepair installation expenditure space energy requirements record keeping darkroom chemicals size of record store risks for patients Xray easy considerable Usefulness in diagnostic areas: Area chest skeleton joints abdomen liver kidney Pregnancy intestinal obstruction internal haemorrhage bowel perforation foreign bodies X-ray very useful very usefil very useful usefil very limited useful very limited very useful limited useful useful section MT Ultrasound low small small small difficult in absence of examination records absent Ultrasound very limited very limited limited useful very useful useful very useful less useful useful useful limited Sonography cannot yet replace radiography but is gaining increasing importance both in internal medicine and in obstetrics and gynaecology.‘Sumport Services Scot Three months of supervision in a busy ultrasound department will allow an experienced doctor, medical assistant or paramedic to recognize most of the important obstetric and gynaecological problems as well as any large tumour, cyst or abscess in the liver, spleen or kidney, gall bladder. ‘The inexperienced can more easily recognize human anatomy and pathology in the linear array than in the curved array. Transvaginal screening is very valuable for early pregnancies and changes at uterus and adnexae, but is more difficult to interpret than abdominal ultrasound images. Because of the many fields ultrasound can be used in, a small hospital in a developing country should first be equipped with a sonographic unit and not with an X-ray unit, 111.3 STERILIZATION TIL.3.1 Overview Sterilization stands for the destruction of all infective organisms: vegetative microorganisms, spores and viruses. Disinfection refers to the destruction of vegetative organisms, but not necessarily spores. Methods of sterilization 1, Hot air ovens ‘Ovens are electrically heated and usually an internal fan provides even distribution of the heat. Sterilizing time takes about 2 hours at 170°C. This method is best suitable for glassware, ‘ophthalmic instruments, and metal containers which are not soft-soldered. It is not suitable for eg. tissues, plastics and rubber. 2, Steam autoclaves Moist heat acts by producing a coagulation of the enzymes and protein within the bacterial cell Using hot steam at high pressure, sterilization takes 15 minutes at 130°C or 25 minutes at 120°C. 3. Chemical sterilization There are a number of chemicals with antibacterial properties. The instruments must be in contact, with the solution or gas for an adequate period of time. 4, Sterilization by radiation The total destruction of bacteria including spores can be achieved by exposing the articles to the action of y-rays. The radiation interferes with the mitotic activity of the microorganisms.This process is not suitable for use in hospitals but is employed commercially. -80-Support Services Section HI 5, Disinfection and antisepti Disinfectants have serious limitations and they are ineffective if pus or blood is present. However they are necessary in daily routine work, especially in articles where heat may not be applicable (Grains, rubber, suture materials). Some chemical disinfectants are chlorhexidine, glutaraldehyde, cresol and sodium hydrochloride (Eau de Javelle). Attention! Proper sterilization of instruments and other equipment is crucial in preventing HIV transmission. TI1.3.2 Equipment Autoclaves The pressure and temperature in an autoclave (pressure cooker) must be held constant for a certain length of time to achieve its effect. Standard time is 25 min. at 120°C. At the district hospital leve! sterilization should largely be based on autoclaving. For efficient use an ‘autoclave requires a trained operator and good maintenance. One common problem in developing Countries is the unreliable electrical supply. A (second) simple autoclave heated by kerosene or gas may therefore be suitable in many cases. The selection of the right autoclave requires many considerations such as expected workload, servicing needs, maintenance costs, size, energy (clectricity or gas-operated) Desirable features for an autoclave are a horizontal or vertical cylindrical drum and a short cycle The chamber capacity should not be larger than required. Sterilizers with excessive capacities are ‘more expensive to operate and need longer cycles. The requirement is calculated as follows, necessary capacity [ltrs] = average daily workload [ltrs] / daily number of cycles x 1.5 Single-Walled Autoclaves ‘These are metal containers with some water on the bottom part to boil. They act just like pressure cookers used for cooking Disadvantages: often no thermometer, articles still moist after sterilization. Double-Walled Autoclaves The steam kept in the jacket round the chamber enters the chambers through a pipe when needed and pushes the air out. Therefore operating cycles are short and energy consumption is relatively low. Also, the sterilized articles are less moist after sterilization. “The decision whether to choose a horizontal or vertical autoclave depends largely on whether piped steam is available or not and on the necessary autoclave capacity -81-‘Support Services Section II 1.4 PHYSIOTHERAPY ILL4.1 Overview Major general, traumatic and orthopaedic surgery cannot be successfully undertaken without physiotherapeutic aftercare. Physiotherapy services in poor countries are determined by Jack of specialists and lack of equipment. Frequently, nurses or medical assistants will have to work in the capacity of a physiotherapist. There is a tendency to compensate for lack of knowledge and training by using sophisticated equipment (ie. electrostimulation, microwave, electric extension tables). Therefore training is essential. Adequate services rely on knowledge, skill and dedication. Most of the equipment of a physiotherapy unit can be produced locally. Long-term rehabilitation treatment requires interdisciplinary cooperation and should be planned at national level. Support services to a physiotherapy unit ar: = orthopaedic workshop staffed with orthopaedic technicians production of sophisticated braces assembly of pre-manufactured prostheses and aids = wheelchair production TI1.4.2 Treatment Physiotherapy at Level I: No physiotherapy services required, Relevant cases will be referred for medical/surgical treatment to higher level (see orthopaedics/surgery) Physiotherapy at Level II: = postoperative respiration stimulation and thrombosis prophylaxis = rehabilitation training of hemiplegia and paraplegia = remobilization of fractures + _ stretching of contractures (polio, burns) = remobilization of joint contractures (polyarthritis) manipulations of the spine Optional: = treatment of cerebral paresis (only if expertise is available) -82-Su Physiotherapy at Level III: Same services as at routine level plus: treatment of cerebral paresis fitting and supply of braces crutches pads orthopaedic footwear. 11.4.3 Equipment: Locally produced equipment should be used, as industrially manufactured equipment is expensive and therefore cannot be provided in sufficient numbers. Blueprints for manufacturing appropriate rehabilitation equipment are available from various international organizations. Physiotherapy equipment at Level I: No equipment necessary. Optional: stock of crutches in various sizes. Physiotherapy equipment at Level I: crutches parallel bars treatment bench gymnastic mattresses, pulley apparatus hot/cold packs (including heater and fridge) Optional: bath tubs for hydrotherapy Buildings: ‘one gymnastic hall, one office and one storeroom, -83-Support Services Section Physiotherapy equipment at Level III: Same equipment as at routine level plus: = electrotherapy equipment (short-wave, infrared, electrostimulation) = pool for hydrotherapy = thermoplast equipment (production of splints) Support services: = workshop for production of low cost crutches, braces, pads, sandals. 11.5 LIBRARY Books and journals are essential tools of the medical profession. Libraries should therefore exist at all levels of health care and the contents of the libraries must relate to the health needs of the target population, to the standard of health care and to the specific information needs of the personnel. The different information needs should lead to standardized reference lists of books and journals for the different levels of health care. The provision of the same handbooks and journals to identical levels of health care can contribute to achieving a comparable standard of medicine at all health institutions in a country Libraries at higher levels should have at least the following sections: = general medical library including handbooks and journals general library for paramedical staff (nurses, laboratory staf, etc.) = general library for management and administration = technical library with manuals on radiography, sonography, laboratory equipment, and do- cumentation and operating instructions of all technical equipment, Support structures are just as import as a good selection of books and journals: = a good library system (this includes a functioning lending system of a lending library, an appropriate arrangement of a reference library, etc.) = control system of the inventory = adequate facilities with sufficient shelves, desks, seats + trained staff (e.g at least one trained librarian supervising the medical libraries in the country) For ease of information flow and ordering literature, cooperation with a national library service should be sought.‘Support Services Section 11 IIL.6 HOSPITAL WORKSHOPS 11.6.1 Overview ‘With regard to organization, management and maintenance of equipment, a national policy is required. This policy has to describe the structure, function and responsibilities of workshops at different levels. Due to economic constraints, workshops at level are not recommended. A tool box may be considered. Maintenance workshop at level II In addition to maintenance and repair of the equipment found at this level the staff of the workshop has to perform the following functions: = training of users = advising hospital administrator / medical staff as a member of a "technical committee" on replacement of equipment, procurement of new equipment and spare parts, inventory = maintenance of health institutions at lower level = keeping record of all equipment, maintenance activities (time and expenditure of maintenance and repair, securement of all technical information and manuals, information on availability of spare parts, etc.) = stock keeping of important spare parts = management of extemal services. Maintenance of. = water supply, waste water, sanitary installation ~ buildings, fixtures, furniture ~ electrical supply, emergency generators = cooling devices, = sterilization = medical equipment of low sophistication. Maintenance workshop at level IIT Workshops at central level maintain and repair equipment found at this level. Workshops at this, level provide specialized services for sophisticated equipment and specialist service support for equipment at lower levels. Limitations of maintenance and repair of equipment must be defined by the national policy. In addition, workshops at this highest level are responsible for: -85-Support Services Section 111 continuous training and supervision of engineers, technicians, and craftsmen at lower levels national publications on issues concerning technical equipment counselling national policy makers and purchasers of equipment as a member of a "national technical committee" on replacement of equipment, procurement of new equipment and spare parts, inventory, etc. collecting and compiling information on all types of equipment in use (problems and expenditure of maintenance and repair, securement of all technical information and ‘manuals, information on availability of spare parts, etc.) stock-keeping of important spare parts ‘supervision of workshops and health institutions at subordinate level. 11.6.2 Workshop Equipment ‘The workshops should be equipped for heavy metalwork light metalwork plumbing electricity electronics carpentry masonry Tool box for level I | ocksmith hammer, 200 g 1 set screwdriver, 3, §, 8, 10 mm 1 set star screwdriver, 3 pieces 1 slide rule, 150 mm 1 adjustable spanner up to 24 mm 1 water-pump pliers 1 grip pliers 1 combination pliers 1 round nose pliers 1 hatffound file, smooth, 250 mm 1 set double open end spanner, 6-26 mm -86-‘Support Services Section 1 = padlock = 1 set Allen keys, 2- 14mm = 1 set dill bits, 1 - 13 mm (1/10 fractions) HSS = 1 set concrete drill bits, 4, 6, 8, 10, 12 (long) mm = centre punch = 1 (elec.) drilling machine incl, set of = tool box = L combination sharpening stone = 1 set splint pin driver, 3 pes. ~ I metal tape measure, 3m = 1 Swiss army knife (biggest version) = I pair ofheavy duty scissors = long nose pliers = 1 inspection lamp = 1 set needle files - 1 fret saw & 20 blades = 1 set cold chisels = 1 set watchmaker's screwdrivers = 1 set twist gimlets = I pair of leather gloves = 2 pipe wrenches up to 2.5" ~ 1 side cutter = 1 elec. soldering iron, 50 W /240 V = | phase tester = V multimeter - 1 panel saw, 500 mm - 2 wood chisels, 10,20 mm = 1 glass cutter = 1 spirit level Tools for Level 11 = [parallel vice, 130 mm - [locksmith hammer, 200 g = Locksmith hammer, 500 g -87-Support Services 1 set screwdriver, 3, 5, 8, 10 mm 1 set star screwdriver, 3 pes. 1 square, 250x 165 mm 1 compass, 150 mm I steel scriber 1 hacksaw, 300 mm and 15 blades 1 adjustable spanner up to 24 mm. 1 water-pump pliers 1 grip pliers 1 combination pliers 1 round nose pliers 1 tinner snip 1 flat file, rough, 350 mm_ 1 flat file, smooth, 250 mm 1 halfround file, smooth, 250 mm 1 round file, smooth 1 triangular file, smooth, 150 mm 1 set double open end spanners, 6 - 26 mm. 1 set do., equivalent inch 1 set ring spanners, 6 - 27 mm 1 set do., equivalent inch 4 padlocks (various) 1 set socket spanners 6 - 22 with ratchet, etc. 1 set Allen keys, 2- 14 mm 1 set do., equivalent inch 1 set taps & dies, 3 - 12 mm 1 set do.. equivalent inch 1 set drillings, | - 13 mm (1/10 fractions) HSS J set concrete drill bits, 4, 6, 8, 10, 12 (long) mm. 1 set screw extractors, 5 pes. | centre punch | safety gogeles 1 wire brush 1 grease gun, 300 mm -88-support Services jection IIT = 1 elec. drilling machine inc, jigsaw, grinding & polishing attachments = 1 drilling stand + Vhand angle grinder = 1 kerosene blowlamp = 1 soldering iron for above = 1 gas welding set (complete) = 1001 box = 1 combination sharpening stone = 1 scraper (3-edged) = 1 set splint pin driver, 3 pes. = 1 metal tape measure, 3m = 1 Swiss army knife (biggest version) + 1 pair of heavy duty scissors ~ oil can, 350 cc = set hollow punches, 3 - 30 mm = blind rivet pliers ~ 1 pair vice flaps = 1 gas eylinder trolley = anvil = ong nose pliers = 1 inspection lamp = I set needle files | calipers - Tpanga +L workbench = cupboard = | wall shelf = Hadder = 1 fret saw and 20 blades = 1 set taps and dies, | - 3 mm = 1 set cold chisels = 1 small machine vice = 1V-block - lair blower attachment -89-Support Services 0 Section SIT 1 set watchmaker’s screwdrivers 1 tweezers 1 sheet metal stand shears 1 probing magnet 1 set countersinks, 3 pes. 1 set twist gimlets, 1 conical reamer, 3 - 25 mm 1 set hole cutter for sheet metal, 10 - 30 mm. 1 set balance weights, | mg - 250 g 2 snap ring pliers (internal / external) 1 nut splitter 1 set special wrenches for microscopes 1 micrometer 1 metal detector 1 stopwatch 1 pair leather gloves 1 fridge refiling set 1 set drawing equipment (DIN Aa) 2 pipe wrenches up to 2.5" 1 pipe vice and stand 1 sewerage cleaning rod 1 pipe cutter & flaring tool 1 sink drainage sucker 1 set ratchet die, 1/2" - 2" 1 set spare knives for above | side cutter 1 elec. soldering iron, 50 W / 240 V 1 phase tester 1 battery charger 1 multimeter 1 extension cable for power supply, 25 m 1 soldering iron, 16 W/ 240 V 1 plane, 350 mm, and spare blade | rebate plane & spare knife -90-‘Support Services 1 wood & planing vice 1 bow saw, 700 mm 1 panel saw, 500 mm 1 tenon saw 1 saw set pliers 2 wood chisels, 10, 20 mm 1 hand drill, 10 mm 1 wood rasp 2.G-clamps, 120 mm 2.do., 250 mm 2.do,, 1250 mm 1 brace 3 brace bits, 10, 14, 22 mm 1 claw hammer 1 pincer 1 sliding bevel 2 paint scrapers, 20, 50 mm 3 brushes, 1/2", 1", 2" 1 mitre box I mortice gauge | canvas awl | glass cutter | flat chisel 1 pointed chisel | spirit level 1 mason’s trowel 1 mason’s float 1 sledge hammer 1 wind-up tape, 30 m 1 tyre pump (manual) 3 tyre levers 1 pressure gauge 1 feeder gauge, 0.005 - | mm 3 funnels 1 crimp pliers -91- Section 11‘Support Services Workshop equipment at level [II As for level II plus 1 lathe (small) 1 mill (small) 1 bending machine (for sheet metal) 1 do. (for pipes) 1 universal circular saw 1 standing driling machine 1 compressor 1 set paint sprayer 1 set precision measuring tools 1 set elec. welding 1 oscilloscope 1 insulation tester 1 3-phase tester ] function generator -92- ‘Section INSECTION IV LISTS OF EQUIPMENT IV.1 INVESTMENTS IV.2,. MAINTENANCE REQUIREMENTS IV.3. INSTRUMENT SETSLists of Equipment ‘Section IV ‘The following lists are based upon data from 1992. “Investment Costs in US$" ‘These prices are calculated without transport, insurance, customs, and other extras. Depending on the receiving country concemed these extras may amount to up to 20% of, investment costs. "Additional investment Costs" Some apparatus need special installation preparation and installation work. These additional costs, which may be between 2% and 25% of investment costs, depend on Jocal circumstances. "Rumning Costs per Year in USS" They constet of consumables, reagents and chemicals, medical gases, and regular maintenance (cleaning, inspection, preventive maintenance). Not included in these prices are Xray tubes, ultrasonic transducers, fibre optics, energy and water supply, as these depend on local prices, salaries for operators, ete. "Main Cost Factors" The usual main contributor to the yearly running costs is marked by "x". Some cost factors cannot be exactly differentiated; the main factor may vary. This is marked by "(x)" in the table Maintenance, esp. repair, costs (see above) which don't occur periodically per year are not included here. Possible costs of this type are marked by /x/. “Lifetime in Years" Information is given conceming to the average life span, which depends on ~ type of apparatus - installation - quality of power supply - instrument quality + care in operation, maintenance ete = frequency of use.IV.1 List of Equipment: Investments ae Rex x & Prereeey ae xHoe ost oe sxeayyy “Tour 058 3 asegee gagee age 2 e3ee somos auBrr uayn “slgpest) "donB)dccooee sennacc, sate FERRE or s0001 i -97-Boxes Bx falda HenntheeGa Heeeeeba & Rank x88 | (aFedez 3noy3t4) GHYINoAY SONYNALNIVH sted 3003 eTqeqoerjez YATM peq AreaTTep (Azebims eatseaut ‘utw) adooso3séo atduys ‘adosso3sAo voTqeutuexe oTATed 103 TTeyD 70 yonoD ‘adoosodtoo seyauTAOTOO yrzoojeuery ‘abngT7qUE. Teopaqoate ‘eBnjt4Ue0 (uaaTzp-puey) ebnjtzqued eomos IYETT WITH ‘eTqTXeTJ ‘edoosoyouozq snjeredde ainsseid poor sexs rOnATEU Seb BOOTS soqereby1yez WITH poorg Faesousorssud “yousd quow e923 pue uoTIeUTMEXs ‘YoU AdezeyjorpAy 203 sqn3 yqeq (wotjonpoid dozp-ake) uoTsyoazd ‘eouepeq (Azoqer0qeT) aTUOTIaTS ‘aoueTeq (AzoqerogeT) TeoTueyoau ‘eoueTeq weays oT73908T@ ‘eaeToo3Ne (aod T-01) aansserd weeis ‘anetooqne auTYORU oT yISseUe atduys ‘auTypen oTIeuaseeuE aoinos qUSTT yatm edossorme WALL Suauarmbay soueuayuteyA] Z'AL