Healthcare Technology Management (HTM) guide 1 How to Organize Dealkalizers Fleck Model 2850 SXT Series Operation and Service Manual

‘HOW TO MANAGE’ SERIES

FOR HEALTHCARE TECHNOLOGY

Guide 1
How to Organize

a System of Healthcare
Technology Management

Management Procedures for
Health Facilities and Health Authorities

TALCTALC

Teaching-aids At Low CostTeaching-aids At Low Cost

Dedicated to baby Nathan and Trevor, for their patience and help.

Published by TALC, PO Box 49, St. Albans, Hertfordshire, AL1 5TX, UK
Tel: [phone], fax: [phone], email: [e-mail],
website: www.talcuk.org

Copyright © 2005 Ziken International

Ziken International (Consultants) Ltd,
Causeway House, 46 Malling Street, Lewes, East Sussex, BN7 2RH, UK
Tel: [phone], fax: [phone], email: [e-mail],
website: www.ziken.co.uk

‘How to Manage’ Series for Healthcare Technology

Guide 1:How to Organize a System of Healthcare Technology Management

Guide 2: How to Plan and Budget for your Healthcare Technology

Guide 3: How to Procure and Commission your Healthcare Technology

Guide 4: How to Operate your Healthcare Technology Effectively and Safely

Guide 5: How to Organize the Maintenance of your Healthcare Technology

Guide 6: How to Manage the Finances of your Healthcare Technology

Management Teams

Keywords: healthcare technology, management procedures,

health service administration, district health services, developing countries,
organization, maintenance team, equipment

Any parts of this publication, including the illustrations, may be copied, reproduced, or adapted to
meet local needs, without permission, provided that the parts reproduced are distributed free or at
cost – not for profit. For any reproduction with commercial ends, permission must first be obtained
from the publisher. The publisher would appreciate being sent a copy of materials in which text or
illustrations have been used.

This document is an output from a project funded by the UK government’s Department for
International Development (DFID) for the benefit of developing countries. The views expressed
are not necessarily those of DFID.

ISBN: 0-9549467-0-7

All rights reserved

A catalogue record is available from the British Library

Design and layout by Jules Stock (email: [e-mail])

Illustrations and charts by David Woodroffe (email: [e-mail])

Edited by Rebecca Lowe, Swan Media Services (email: [e-mail])

‘How to Manage’ Series for Healthcare Technology

Guide 1

How to Organize a System of

Healthcare Technology Management

by:

Andreas Lenel

Health Economist Consultant, FAKT, Stuttgart, Germany

Caroline Temple-Bird

Healthcare Technology Management Consultant,

Ziken International Consultants Ltd, Lewes, UK

Willi Kawohl

Financial Management Consultant, FAKT, Stuttgart, Germany

Manjit Kaur

Development Officer, ECHO International Health Services, Coulsdon, UK

Series Editor

Caroline Temple-Bird

Healthcare Technology Management Consultant,

Ziken International Consultants Ltd, Lewes, UK

CONTENTS

Section Page

Foreword i

Preface i

Acknowledgements iii

Abbreviations v

List of Boxes and Figures vi

1. Introduction 1

1.1 Introduction to the Series of Guides 1

1.2 Introduction to this Specific Guide 9

2. Framework Requirements for Quality Health Services 15

2.1 Regulatory Role of Government 16

2.2 Establishing Standards for your Health System 19

2.3 Developing Policies for Health Services 23

2.3.1 A Vision for Health Services 24

2.3.2 Standardization of Healthcare Technology 25

2.3.3 Provision of Maintenance 26

2.3.4 Finances 28

2.4 The Importance of Introducing a Healthcare Technology
Management Service 30

2.5 How to Manage these Changes 35

3. How to Determine Your Technical Requirements 39

3.1 A Summary of Technical Requirements for HTM 40

3.2 Skill Requirements at Different Levels of the Health System 41

3.2.1 Understanding the Skill Requirements 41

3.2.2 Determining Your Skill Requirements 46

3.3 Workload Requirements 47

3.3.1 Understanding the Workload Requirements 47

3.3.2 Determining Your Workload Requirements 48

Contents

4. How to Choose the Model for Your HTM Service 57

4.1 Providers of HTM Activities 57

4.1.1 Possible Sources 57

4.1.2 Strategies to Consider 64

4.2 Incorporating HTM into Health Management 66

5. How to Develop an Organizational Structure for the
HTM Service 71

5.1 Relationship between the Health Delivery System and
the HTM Service 72

5.2 Placing Staff at the Different Levels of the HTM Service 75

5.3 Responsibilities at Each Level of the HTM Service 83

6. How to Determine the Human Resources Required 91

6.1 Types of Staff Required 91

6.2 Numbers of Staff Required 97

6.3 Establishment Posts and Career Progression 100

6.4 Terms and Conditions of Employment 103

7. How to Set Yourself Goals and Monitor Progress 107

7.1 Setting Goals for Organizing a System of HTM 109

7.2 Monitoring Progress 113

7.3 Gathering Data 118

Annexes 121

1. Glossary 121

2. Reference Materials and Contacts 126

3. Sample Job Descriptions 149

4. Source Material/Bibliography 155

Contents

Foreword

This Series of Guides is the output from a project funded by the UK government’s
Department for International Development (DFID) for the benefit of developing
countries. The output is the result of an international collaboration that
brought together:

◆ researchers from Ziken International and ECHO International Health Services in

the UK, and FAKT in Germany

◆ an advisory group from WHO, PAHO, GTZ, the Swiss Tropical Institute, and the

Medical Research Council of South Africa

◆ reviewers from many countries in the developing world

in order to identify best practice in the field of healthcare technology management.

The views expressed are not necessarily those of DFID or the other
organizations involved.

Garth Singleton

Manager, Ziken International Consultants Ltd, Lewes, UK

Preface

The provision of equitable, quality and efficient healthcare requires an extraordinary
array of properly balanced and managed resource inputs. Physical resources such as
fixed assets and consumables, often described as healthcare technology, are among
the principal types of those inputs. Technology is the platform on which the delivery
of healthcare rests, and the basis for provision of all health interventions. Technology
generation, acquisition and utilization require massive investment, and related
decisions must be made carefully to ensure the best match between the supply of
technology and health system needs, the appropriate balance between capital and
recurrent costs, and the capacity to manage technology throughout its life.

Healthcare technology has become an increasingly visible policy issue, and healthcare
technology management (HTM) strategies have repeatedly come under the spotlight
in recent years. While the need for improved HTM practice has long been recognized
and addressed at numerous international forums, health facilities in many countries
are still burdened with many problems, including non-functioning medical equipment
as a result of factors such as inadequate planning, inappropriate procurement, poorly
organized and managed healthcare technical services, and a shortage of skilled
personnel. The situation is similar for other health system physical assets such as
buildings, plant and machinery, furniture and fixtures, communication and information
systems, catering and laundry equipment, waste disposal, and vehicles.

Foreword

i

Preface (continued)

The (mis-)management of physical assets impacts on the quality, efficiency and
sustainability of health services at all levels, be it in a tertiary hospital setting with
sophisticated life-support equipment, or at the primary healthcare level where simple
equipment is needed for effective diagnosis and safe treatment of patients. What is
vital – at all levels and at all times – is a critical mass of affordable, appropriate, and
properly functioning equipment used and applied correctly by competent personnel,
with minimal risk to their patients and to themselves. Clear policy, technical
guidance, and practical tools are needed for effective and efficient management of
healthcare technology for it to impact on priority health problems and the health
system's capacity to adequately respond to health needs and expectations.

This Series of Guides aims to promote better management of healthcare technology
and to provide practical advice on all aspects of its acquisition and utilization, as well
as on the organization and financing of healthcare technical services that can deliver
effective HTM.

The Guides – individually and collectively – have been written in a way that makes
them generally applicable, at all levels of health service delivery, for all types of
healthcare provider organizations and encompassing the roles of health workers and
all relevant support personnel.

It is hoped that these Guides will be widely used in collaboration with all appropriate
stakeholders and as part of broader HTM capacity-building initiatives being
developed, promoted and implemented by WHO and its partners, and will therefore
contribute to the growing body of evidence-based HTM best practice.

The sponsors, authors and reviewers of this Series of Guides are to be congratulated
for what is a comprehensive and timely addition to the global HTM toolkit.

Andrei Issakov, Coordinator, Health Technology and Facilities Planning and
Management, World Health Organization, Geneva, Switzerland

Mladen Poluta, Director, UCT/WHO HTM Programme, University of Cape
Town, South Africa

Preface

ii

Acknowledgements

This Guide was written:

◆ with specialist support from:

Juergen Clauss, formerly Consultant in Healthcare Technology, FAKT,
Stuttgart, Germany

Andreas Mallouppas, Director, Service for External Affairs and Projects, University of
Cyprus, Nicosia, Cyprus

◆ with assistance from an Advisory Group of:

Hans Halbwachs, Healthcare Technology Management, Deutsche Gesellschaft für
Technische Zusammenarbeit (GTZ-GmbH), Eschborn, Germany

Peter Heimann, Director, WHO Collaborating Centre for Essential Health
Technologies, Medical Research Council of South Africa, Tygerberg, South Africa

Antonio Hernandez, Regional Advisor, Health Services Engineering and Maintenance,
PAHO/WHO, Washington DC, USA

Andrei Issakov, Coordinator, Health Technology and Facilities Planning and
Management, Department of Health System Policies and Operations, WHO,
Geneva, Switzerland

Yunkap Kwankam, Scientist, Department of Health Service Provision, WHO,
Geneva, Switzerland

Martin Raab, Biomedical Engineer, Swiss Centre for International Health of the
Swiss Tropical Institute, Basle, Switzerland

Gerald Verollet, Technical Officer, Medical Devices, Blood Safety and Clinical
Technology (BCT) Department, WHO, Geneva, Switzerland

Reinhold Werlein, Biomedical Engineer, Swiss Centre for International Health of the
Swiss Tropical Institute, Basle, Switzerland

◆ and reviewed by:

Dr. P. Asman, Head of the Bio-engineering Unit, Ministry of Health, Accra, Ghana

Tsibu J. Bbuku, Medical Equipment Specialist, Central Board of Health,
Lusaka, Zambia

Sue Carr-Hartley, Director of Nursing, Aga Khan Foundation Private Hospital,
Nairobi, Kenya

Ms. Sok Chann, PAM Coordinator at Biomedical Engineering Unit, Ministry of
Health, Phnom Penh, Cambodia

Juliette Cook, Biomedical Engineer, Advisor to Ministries of Health of Mozambique,
and Vanuatu

Acknowledgements

iii

Peter Cook, Biomedical Engineer, ECHO International Health Services,
Coulsdon, UK

Freedom Dellosa, Chief of Hospital Equipment Maintenance Service Division,
Region 9 – Mindanao Peninsula, Department of Health, Zambonga City, Philippines

Pieter de Ruijter, Consultant, HEART Consultancy, Renkum, The Netherlands

Roland Fritz, HCTS Coordinator, Christian Social Services Commission,
Dar es Salaam, Tanzania

Andrew Gammie, Project Director, International Nepal Fellowship, Pokhara, Nepal

Dr. Nichodemus Gebe, Medical Devices Training Coordinator, Biomedical
Engineering Unit, Accra, Ghana

Richard Hudson, Team Leader, Technical Assistance Programme, International
Nepal Fellowship, Nepalgunj, Nepal

Muditha Jayatilaka, Deputy Director General of Health Services (Biomedical
Engineering Services), Ministry of Health, Nutrition and Welfare, Colombo, Sri Lanka

Godfrey Katabaro, Biomedical Engineering Technologist, Kagera Medical Technical
Services, church health sector, Kagera, Tanzania

Timothy Mukoko, Senior Bio-medical Equipment Technologist, University Teaching
Hospital, Lusaka, Zambia

Sulaiman Shahabuddin, Director, Patient Services, Aga Khan Foundation Private
Hospital, Nairobi, Kenya

Birgit Thiede, Physical Assets Management (PAM) Advisor, Ministry of Health,
Phnom Penh, Cambodia

◆ using source material:

as described in Annex 4: Source Material/Bibliography

◆ with financial assistance from:

the Knowledge and Research Programme on Disability and Healthcare Technology,
DFID, government of the United Kingdom

◆ with administrative support from:

all the staff at Ziken International Consultants Ltd, UK, especially Garth Singleton,

Rob Parsons, and Lou Korda, as well as Thomas Rebohle from FAKT, Germany

Acknowledgements

iv

Abbreviations

AHA American Hospital Association

BP British pharmacopoeia

CE European conformity

CEN European Committee for Standardization

CENELEC European Committee for Electrotechnical Standardization

CT computed tomography (scanner)

ECRI Emergency Care Research Institute (of the US)

EFTA European Free Trade Association

EP European pharmacopoeia

ETSI European Telecommunications Standards Institute

EU European Union

FAKT German consultancy company for management, training,

and technologies

FDA Food and Drug Administration

GMP good manufacturing practices

GTZ Deutsche Gesellschaft für Technische Zusammenarbeit

(German Government Technical Aid Agency)

HMIS health management information system

HND higher national diploma

HTM healthcare technology management

HTM-IS healthcare technology management information system

HTMS healthcare technology management service

HTMWG healthcare technology management working group

IEC International Electrotechnical Commission

IP international pharmacopoeia (of the WHO)

ISO International Organization for Standardization

MBEHOMA Mbeya Hospital Maintenance Association, Tanzania

MIS maintenance information system

MOH Ministry of Health

MRI magnetic resonance imaging

NGO non-governmental organization

PPM planned preventive maintenance

US $ United States dollars

USP United States pharmacopoeia

WHO World Health Organization

Abbreviations

v

List of Boxes and Figures

Page

Box 1 Categories of items described as ‘healthcare technology’ 2

Box 2 Benefits of healthcare technology management (HTM) 4

Box 3 The collective responsibility for HTM 13

Box 4 Alternative ways of organizing the health system 17

Box 5 A checklist for your regulatory system 18

Box 6 Examples of important safety and performance standards 21

Box 7 A checklist for improving your standards 23

Box 8 The benefits of standardization 25

Box 9 A checklist for improving your healthcare technology policy 29

Box 10 Savings derived from effective healthcare

technology management 31

Box 11 The financial benefit of maintaining equipment 32

Box 12 A checklist for understanding the importance of HTM

to your country and organization 35

Box 13 A checklist for improving your ability to manage change 37

Box 14 Summary of issues in Section 2 on framework requirements 37

Box 15 Skill levels required according to maintenance needs 42

Box 16 Possible division of time between maintenance and other

HTM activities 48

Box 17 Samples of estimated hours per year at each skill level for

HTM at a typical health centre 50

Box 18 Samples of estimated hours per year at each skill level for

HTM at a typical 100-bed district hospital 51

Box 19 Estimated workload for a workshop at a typical

well-patronized 600-bed hospital 54

Box 20 A checklist for understanding your technical requirements 56

Box 21 Summary of issues in Section 3 on determining

technical requirements 56

Box 22 A checklist for determining the model for your HTM Service 69

Box 23 Summary of issues in Section 4 on choosing the model for

your HTM Service 69

Box 24 A checklist for the organizational structure and staff

placement for your HTM Service 83

Box 25 A checklist for determining responsibilities in your

HTM Service 89

List of boxes and figures

vi

Box 26 Summary of issues in Section 5 on the organizational

structure for the HTM Service 90

Box 27 Basic training requirements 96

Box 28 GTZ and WHO’s suggestions for minimum staff

requirements at different levels of the HTM Service 98

Box 29 Suggestions for staff development needs according to

hospital size from a FAKT international seminar 99

Box 30 Suggestions from various countries of staff requirements 99

Box 31 A checklist for improving your human resources 105

Box 32 Summary of issues in Section 6 on determining your human

resource requirements 106

Box 33 Example of how to measure a goal 111

Box 34 A checklist for improving your planning and

monitoring capabilities 119

Box 35: Summary of issues in Section 7 on setting goals and

monitoring progress 119

Box 36 WHO’s definition of the technology management hierarchy

(Annex 1) 125

Figure 1 The place of HTM in the health system 2

Figure 2 The relationship between the Guides in this Series 6

Figure 3 The healthcare technology management cycle 10

Figure 4 The structure of Guide 1 12

Figure 5 HTM Service inputs and outputs 34

Figure 6 Division of maintenance work by skill level in the

health service 47

Figure 7 Pyramid referral system of government health services 72

Figure 8 Partners working with HTM staff at each level of the

HTM Service 74

Figure 9: Sample organizational chart for the HTM Service 82

Figure 10: Relationship between HTM Service staff skills, numbers

required, and training 96

Figure 11 Daily operational and professional reporting structures for

HTM staff 102

Figure 12 The planning and review cycle 107

Figure 13 Main areas to measure when developing a system of HTM 112

List of boxes and figures

vii

viii

1. INTRODUCTION

Why is This Important?

This introduction explains the importance of healthcare technology
management (HTM) and its place in the health system.

It also describes:

◆ the purpose of the Series of Guides and this Guide in particular

◆ the people the Guides are aimed at

◆ the names and labels commonly used in HTM, in this Series.

The Series of Guides is introduced in Section 1.1, and this particular Guide on how
to organize a system of healthcare technology management in Section 1.2.

1.1 INTRODUCTION TO THE SERIES OF GUIDES

Healthcare Technology Management’s Place in the Health System

All health service providers want to get the most out of their investments. To enable
them to do so, they need to actively manage health service assets, ensuring that they
are used efficiently and optimally. All management takes place in the context of your
health system’s policies and finances. If these are favourable, the management of
health service assets can be effective and efficient, and this will lead to improvements
in the quality and quantity of healthcare delivered, without an increase in costs.

The health service’s most valuable assets which must be managed are its human
resources, physical assets, and other resources such as supplies. Physical assets such
as facilities and healthcare technology are the greatest capital expenditure in any
health sector. Thus it makes financial sense to manage these valuable resources, and
to ensure that healthcare technology:

◆ is selected appropriately

◆ is used correctly and to maximum capacity

◆ lasts as long as possible.

Such effective and appropriate management of healthcare technology will contribute
to improved efficiency within the health sector. This will result in improved and
increased health outcomes, and a more sustainable health service. This is the goal of
healthcare technology management – the subject of this Series of Guides.

1 Introduction

1

What Do we Mean by Healthcare Technology?

The World Health Organization (WHO) uses the broader term ‘health technology’,
which it defines as including:

‘devices, drugs, medical and surgical procedures – and the knowledge associated
with these – used in the prevention, diagnosis and treatment of disease as well as
in rehabilitation, and the organizational and supportive systems within which care
is provided’

(Source: Kwankam, Y, et al, 2001, ‘Health care technology policy framework’, WHO Regional Publications,

Eastern Mediterranean Series 24: Health care technology management, No. 1)

However, the phrase ‘healthcare technology’ used in this Series of Guides only refers
to the physical pieces of hardware in the WHO definition, that need to be
maintained. Drugs and pharmaceuticals are usually covered by separate policy
initiatives, frameworks, and colleagues in another department.

Therefore, we use the term healthcare technology to refer to the various equipment
and technologies found within health facilities, as shown in Box 1.

BOX 1: Categories of Equipment and Technologies Described as ‘Healthcare Technology’

medical equipment walking aids health facility furniture

communications equipment training equipment office equipment

office furniture fixtures built into the building plant for cooling, heating, etc

service supply installations equipment-specific supplies fire-fighting equipment

workshop equipment fabric of the building vehicles

laundry and kitchen equipment waste treatment plant energy sources

For examples of these different categories, see the Glossary in Annex 1.

Figure 1: The Place of Healthcare Technology Management in the Health System

1.1 Introduction to this series of guides

2

Health

System

Policies

Health Sector Organization

and Management

Human Resources

Funds

Healthcare Technology

Consumable Supplies

Facilities

Healthy

Population

Health

Service

Provision

Often, different types of equipment and technologies are the responsibility of
different organizations. For example, in the government sector, different ministries
may be involved, such as Health, Works, and Supplies. In the non-government sector,
different agencies may be involved, such as Health, and Logistics.

The range of healthcare technology which falls under the responsibility of the health
service provider varies from country to country and organization to organization.
Therefore each country’s definition of healthcare technology will vary depending on
the range of equipment and technology types that they actually manage.

For simplicity, we often use the term ‘equipment’ in place of the longer
phrase ‘healthcare technology’ throughout this Series of Guides.

What is Healthcare Technology Management?

First of all, healthcare hechnology management (HTM) involves the organization
and coordination of all of the following activities, which ensure the successful
management of physical pieces of hardware:

◆ Gathering reliable information about your equipment.

◆ Planning your technology needs and allocating sufficient funds for them.

◆ Purchasing suitable models and installing them effectively.

◆ Providing sufficient resources for their use.

◆ Operating them effectively and safely.

◆ Maintaining and repairing the equipment.

◆ Decommissioning, disposing, and replacing unsafe and obsolete items.

◆ Ensuring staff have the right skills to get the best use out of your equipment.

This will require you to have broad skills in the management of a number of
areas, including:

◆ technical problems

◆ finances

◆ purchasing procedures

◆ stores supply and control

◆ workshops

◆ staff development.

1.1 Introduction to this series of guides

3

However, you also need skills to manage the place of healthcare technology in the
health system. Therefore, HTM means managing how healthcare technology should
interact and balance with your:

◆ medical and surgical procedures

◆ support services

◆ consumable supplies, and

◆ facilities

so that the complex whole enables you to provide the health services required.

Thus HTM is a field that requires the involvement of staff from many disciplines
– technical, clinical, financial, administrative, etc. It is not just the job of managers, it
is the responsibility of all members of staff who deal with healthcare technology.

This Series of Guides provides advice on a wide range of management procedures,
which you can use as tools to help you in your daily work. For further clarification of
the range of activities involved in HTM and common terms used, refer to the
WHO’s definition of the technology management hierarchy in Annex 1.

Box 2 highlights some of the benefits of HTM.

BOX 2: Benefits of Healthcare Technology Management (HTM)

◆ Health facilities can deliver a full service, unimpeded by non-functioning healthcare technology.

◆ Equipment is properly utilized, maintained, and safeguarded.

◆ Staff make maximum use of equipment, by following written procedures and good practice.

◆ Health service providers are given comprehensive, timely, and reliable information on:

- the functional status of the equipment

- the performance of the maintenance services

- the operational skills and practice of equipment-user departments

- the skills and practice of staff responsible for various equipment-related activities in a range of
departments including finance, purchasing, stores, and human resources.

◆ Staff control the huge financial investment in equipment, and this can lead to a more effective and

efficient healthcare service.

1.1 Introduction to this series of guides

4

Purpose of the Series of Guides

The titles in this Series are designed to contribute to improved healthcare
technology management in the health sectors of developing countries, although they
may also be relevant to emerging economies, and other types of country. The Series
is designed for any health sector, whether it is run by:

◆ government (such as the Ministry of Health or Defence)

◆ a non-governmental organization (NGO) (such as a charitable or

not-for-profit agency)

◆ a faith organization (such as a mission)

◆ a corporation (for example, an employer such as a mine, who may subsidize

the healthcare)

◆ a private company (such as a health insurance company or for-profit agency).

This Series aims to improve healthcare technology at a daily operational level, as well
as to provide practical resource materials for equipment users, maintainers, health
service managers, and external support agencies.

To manage your technology effectively, you will need suitable and effective procedures
in place for all activities which impact on the technology. Your health service provider
organization should already have developed a Policy Document setting out the
principles for managing your stock of healthcare technology (Annex 2 provides a
number of resources available to help with this). The next step is to develop written
organizational procedures, in line with the strategies laid out in the policy, which staff
will follow on a daily basis.

The titles in this Series provide a straightforward and practical approach to healthcare
technology management procedures:

Guide 1 covers the framework in which Healthcare Technology Management (HTM)
can take place. It also provides information on how to organize a network of HTM
Teams throughout your health service provider organization.

Guides 2 to 5 are resource materials which will help health staff with the daily
management of healthcare technology. They cover the chain of activities involved in
managing healthcare technology – from planning and budgeting to procurement,
daily operation and safety, and maintenance management.

Guide 6 looks at how to ensure your HTM Teams carry out their work in an
economical way, by giving advice on financial management.

How the Guides are coordinated is set out in Figure 2.

1.1 Introduction to this series of guides

5

Figure 2: The Relationship Between the Guides in This Series

Who are These Guides Aimed at?

These Guides are aimed at people who work for, or assist, health service provider
organizations in developing countries. Though targeted primarily at those working in
health facilities or within the decentralized health authorities, many of the principles
will also apply to staff in other organizations (for example, those managing health
equipment in the Ministry of Works, private maintenance workshops, and head offices).

Depending on the country and organization, some daily tasks will be undertaken by
end users while others may be carried out by higher level personnel, such as central
level managers. For this reason, the Guides cover a range of tasks for different types of
staff, including:

◆ equipment users (all types)

◆ maintenance staff

◆ managers

◆ administrative and support staff

◆ policy-makers

◆ external support agency personnel.

1.1 Introduction to this series of guides

6

Framework/structure

Organizing a network of

HTM Teams (Guide 1)

Procurem

g and

Plannin

budgeting

(Guide 2)

Chain of activities

Maintenance

management

(Guide 5)

in the equipment

life cycle

commissionin

(Guide 3)

Daily operation

ent and

and safety

(Guide 4)

g

Ensuring efficiency

Financial management of HTM Teams (Guide 6)

They also describe activities at different operational levels, including:

◆ the health facility level

◆ the zonal administration level (such as district, regional, diocesan)

◆ the central/national level

◆ by external support agencies.

Many activities require a multi-disciplinary approach; therefore it is important to form
mixed teams which include representatives from the planning, financial, clinical,
technical, and logistical areas. Allocation of responsibilities will depend upon a
number of factors, including:

◆ your health service provider

◆ the size of the organization

◆ the number of decentralized levels of authority

◆ the size of your health facility

◆ your level of autonomy.

The names and titles given to the people and teams involved will vary depending on
the type of health service provider you work with.

For the sake of simplicity, we have used a variety of labels to describe
different types of staff and teams involved in HTM.

This Series describes how to introduce healthcare technology management into your
organization. The term Healthcare Technology Management Service (HTMS) is
used to describe the delivery structure required to manage equipment within the
health system. This encompasses all levels of the health service, from the central
level, through the regions/districts, to facility level.

There should be a referral network of workshops where maintenance staff with
technical skills are based. However, equipment management should also take place
where there are no workshops, by involving general health facility staff. We call these
groups of people the HTM Team, and we suggest that you have a team at every level
whether a workshop exists or not. Throughout this Series, we have called the person
who leads that team the HTM Manager.

At every level, there should also be a committee which regularly considers all
equipment-related matters, and ensures decisions are made that are appropriate to
the health system as a whole. We have used the term HTM Working Group
(HTMWG) for this committee, which will advise the Health Management Teams on
all equipment issues.

1.1 Introduction to this series of guides

7

Due to its role, the HTMWG must be multi-disciplinary. Depending on the
operational level of the HTMWG, its members could include the following:

◆ Head of medical/clinical services.

◆ Head of support services.

◆ Purchasing and supplies officer.

◆ Finance officer.

◆ Representatives from both medical equipment and plant maintenance.

◆ Representatives of equipment users from a variety of areas (medical/clinical,

nursing, paramedical, support services, etc).

◆ Co-opted members (if specific equipment areas are discussed or specific interest

or need is shown).

The HTM Working Group prepares the annual plans for equipment purchases,
rehabilitation and funding, and prioritizes expenditure across the facility/district as a
whole (see Guide 2 on planning and budgeting). It may have various sub-groups to
help consider specific aspects of equipment management, such as pricing,
commissioning, safety, etc.

How to Use These Guides

Each Guide has been designed to stand alone, and has been aimed at different types
of readers depending on its content (Section 1.2). However, since some elements
are shared between them, you may need to refer to the other Guides from time to
time. Also, if you own the full Series (a set of six Guides) you will find that some
sections of the text are repeated.

We appreciate that different countries use different terms. For example, a purchasing
officer in one country may be a supplies manager in another; some countries use
working groups, while others call them standing committees; and essential service
packages may be called basic healthcare packages elsewhere. For the purpose of
these Guides it has been necessary to pick one set of terms and define them. You can
then modify them for your own situation.

The terms used throughout the text are outlined, with examples, in the
Glossary in Annex 1.

We appreciate that you may find it hard to pursue the ideas introduced in these
Guides. Depending on your socio-economic circumstances, you may face many
frustrations on the road to achieving effective healthcare technology management.
We recognize that not all of the suggested procedures can be undertaken in all
environments. Therefore we recommend that you take a step-by-step approach,
rather than trying to achieve everything at once (Section 2).

1.1 Introduction to this series of guides

8

These Guides have been developed to offer advice and recommendations only,
therefore you may wish to adapt them to meet the needs of your particular situation.
For example, you can choose to focus on those management procedures which best
suit your position, the size of your organization, and your level of autonomy.

For more information about reference materials and contacts for healthcare
technology management, see Annex 2.

1.2 INTRODUCTION TO THIS SPECIFIC GUIDE

The Importance of Healthcare Technology Management

Healthcare technology is such an important part of healthcare today that it cannot
easily be ignored. It has a very wide application; for example equipment is used to:

◆ help diagnose whether a patient has malaria

◆ treat a patient by removing their gall stones

◆ monitor the condition of a patient’s heart

◆ provide therapy in order to get a patient moving about again

◆ control the environment by supplying heat and light

◆ provide necessities such as running water

◆ transport patients and staff

◆ feed patients and staff

◆ provide clean surroundings.

Healthcare technology management is essential to ensure that such equipment
continues to function effectively in a good working condition. For example, proper
maintenance can extend the life of equipment – this is essential for providing good
health services and saving scarce resources.

This is why maintenance is such a key technical activity. But, in addition to
maintenance, HTM also involves other essential activities which ensure that
equipment is effectively planned and budgeted for, procured, and operated, etc.
Healthcare technology management in fact involves a cycle of activities in the life of
equipment, as shown in Figure 3.

1.2 Introduction to this specific guide

9

Figure 3: The Healthcare Technology Management Cycle

Very often, healthcare technology management is not introduced, because it is
considered to be too costly and too complicated. The aim of this Series of Guides is
to demonstrate how you can introduce healthcare technology management into your
health system. This first Guide explains the reasons why you should undertake
HTM. It describes the general framework that proper HTM requires, and outlines
the organizational set-up needed to implement it, both throughout your health
service provider organization and countrywide.

Who is this Guide Aimed at?

This Guide is particularly suitable for the following:

◆ health planners and policy-makers

◆ government staff in charge of regulating and supervising health systems

◆ technical (maintenance) staff at the different levels of the HTM Service

◆ health management teams

◆ external support agency staff.

1.2 Introduction to this specific guide

10

Planning and
Assessment

Decommissioning
and Disposal

Maintenance
and Repair

Operation
and Safety

Training and Skill
Development

• Create
awareness

• Monitor
and
evaluate

Installation and
Commissioning

Budgeting and
Financing

Technology Assessment
and Selection

Procurement
and Logistics

However, other types of staff involved with healthcare technology management may
also find it useful. For example:

◆ managers and administrators

◆ human resource managers

◆ finance officers

◆ equipment users

◆ purchasing officers.

All of these staff should have a good understanding of the reasons for healthcare
technology management, the activities involved, and the different possibilities for
delivering HTM.

The recommendations and procedures outlined in this Guide are primarily aimed at
policy-makers, planners, and managers at central and decentralized authority levels.
However, the Guide also explains what the responsibilities are for all staff involved in
HTM at all levels of the system, to enable you to see the bigger picture.

What Topics are Covered?

This Guide concentrates primarily upon the organizational set-up for delivering
healthcare technology management. It outlines issues to consider for HTM, such as:

◆ regulations and standards

◆ technical requirements

◆ models for delivery

◆ organizational structure

◆ human resource requirements

◆ monitoring progress.

We recognize that, alongside repair and maintenance, technical staff are also
responsible for the wide range of HTM activities shown in Figure 3.
Recommendations and procedures for all these tasks are provided in Guides 2 – 6 of
this Series. However, in this Guide, maintenance activities are frequently used as an
example to illustrate the technical requirements for your HTM Service.

The Guide aims to:

◆ Encourage those organizations without an HTM Service to begin the process of

developing one.

◆ Help those organizations that have started developing an HTM Service with

strategies for expanding and developing it further.

◆ Clarify the issues for organizations that already have an HTM Service.

1.2 Introduction to this specific guide

11

The system introduced in this Guide provides a solid approach to organizing
healthcare technology management. However, we recognize that there are other ways
of organizing these issues which may be more appropriate for your administrative
system. The important thing is to implement a well-functioning system.

As you read through the recommendations in this Guide, you may find it useful to
refer to advice in other Guides in the Series, as indicated in the text. Additional
useful reference materials and contacts are given in Annex 2.

How is This Guide Structured?

The structure of Guide 1 highlights the justification for undertaking healthcare
technology management and the issues to consider when organizing HTM within
your health system, as shown in Figure 4.

Figure 4: The Structure of Guide 1

1.2 Introduction to this specific guide

12

Introducing the Series, and this particular GuideSection 1

Understanding the framework required for delivering
quality health services, and the justification
and background conditions for HTM

Section 2

Determining the technical requirements for HTM
at different levels of the health system

Considering different models for providing HTM,
and ways of incorporating it into health management

Section 3

Developing the organizational structure for HTM
in relation to your healthcare delivery system

Section 4

Understanding the human resource requirements
of your HTM system

Section 5

Section 7

Monitoring the effectiveness and efficiency
of your HTM system

Section 6

13

Section 1 summary

Who Does What in Organizing HTM?

Since equipment that is well managed lasts a long time and enables you to deliver
the health services required, it is important for HTM to be seen as a collective
responsibility. Thus many people have a role to play, as shown in Box 3.

BOX 3: The Collective Responsibility for HTM

Government

Your health
service provider

Health
policy-makers,
planners, and
managers at central
level of your health
service provider
organization

HTM Managers and
their technical staff
at all levels

HTM Teams at
facilities without
workshops

HTM Teams at
facilities with
workshops

HTM Working
Groups (at facility,
district, regional
and central level)

Working Together

Continued overleaf

◆ provides the regulatory framework for quality health services, including HTM

(Section 2)

◆ conforms to the legislation, regulations, standards, and policies set by government

for health services (Section 2)

◆ decide which providers of HTM activities to use (Section 4.1)

◆ ensure that HTM is incorporated into the health management system (Section 4.2)

◆ determine the best organizational structure for the HTM Service across the

different levels of your health system, according to the technical requirements
calculated by technical staff (Section 5)

◆ ensure annual goals and plans are set and monitored for the improvement of the

HTM Service (Section 7)

◆ determine the different technical requirements for HTM activities, in terms of

skill and workload requirements, in order to help design the HTM Service
(Section 3)

◆ ensure there is appropriate division of labour when placing staff at the different

levels of the HTM Service (Section 5.2)

◆ ensure appropriate responsibilities are undertaken at the different levels of the

HTM Service, including supervision, planning, and monitoring (Section 5.3)

◆ ensure that HTM activities are carried out effectively throughout the HTM

Service (see Guides 2 – 6)

◆ oversee the condition and running of equipment on a daily basis

◆ are the contact point for all equipment and maintenance matters

◆ are responsible for finding the correct solution (for example, calling in technical

support from the workshops, or external contractors)

◆ undertake the maintenance or repair work themselves (if it is a job for which they

have been trained)

◆ deliver all aspects of healthcare technology management (see Section 3.1, and

Guides 2 – 6)

◆ provide a referral network for HTM activities (Sections 4 and 5)

◆ act as a zonal workshop to provide HTM by outreach to the zone, such as a district

or a region, as appropriate (Section 5.2)

◆ advise health management teams at their level on all equipment matters

Section 1 summary

14

BOX 3: The Collective Responsibility for HTM (continued)

Health Management
Teams (at facility,
district, regional
and central level)

Finance Officers

Human Resources
Departments

Equipment Users

Working Together

◆ address the practical issues involved with implementing HTM activities

◆ ensure annual goals and plans are set and monitored for the improvement of HTM

activities (see Guides 2 – 6)

◆ allocate sufficient funds for all HTM activities (see Section 6.3 and Guide 2)

◆ hire suitably skilled technical staff for the HTM Service and offer attractive

packages in order to retain them in post (Section 6)

◆ facilitate in-service training to improve the skills required for HTM (Section 6)

◆ are key to successful HTM since they greatly affect the life of equipment and

form the first level of the HTM Service

◆ take good care of equipment

◆ operate equipment properly and safely

◆ undertake user planned preventive maintenance, and care and cleaning of

equipment

◆ report faults promptly to their Section Heads

◆ educate new users (see Guide 4)

2. FRAMEWORK REQUIREMENTS FOR
QUALITY HEALTH SERVICES

Why is This Important?

In order to deliver quality health services, it is essential to undertake effective
healthcare technology management.

There are various framework requirements to help you do this. These include
legislation, regulations, standards, and policies.

These framework requirements create the boundary conditions within which
you undertake healthcare technology management. They include central or
national guiding principles, policy issues, and high-level assumptions that can
impede or assist you in your work.

It is very difficult to function effectively if these framework requirements do not
exist, and you should lobby your organization to develop them.

Depending on how autonomous your health facilities are, you may be able to
develop these framework requirements at facility, region/district, or central level.

In most industrialized countries, laws, regulations, policies and guidelines form an
indispensable part of health service management. For many developing countries,
however, these regulatory procedures have yet to be developed. By considering them
in this Section, we see that effective healthcare technology management (HTM) is
essential in order to deliver quality health services.

This Section offers advice on:

◆ the regulatory role of government (Section 2.1)

◆ establishing standards for your health system (Section 2.2)

◆ policy issues for HTM, such as a vision, financing, standardization, and

maintenance (Section 2.3)

◆ the importance of introducing an HTM Service (Section 2.4)

◆ managing change (Section 2.5).

This Section provides the justification for undertaking healthcare technology
management. Although some of the ideas proposed may seem idealistic for your own
country’s situation, you should view this as a blueprint to work towards. The best
approach is to start by introducing small changes, but at least to act. The longest
journey starts with the first step.

2 Framework requirements for quality health services

15

2.1 REGULATORY ROLE OF GOVERNMENT

Health systems are organized differently all over the world. For example, they can be:

◆ mainly public

◆ mainly private for-profit (for example, run by a commercial organization), and

private not-for-profit (for example, run by faith organizations, NGOs)

◆ a mixture of government and private organizations.

One of the major distinguishing features of different health systems is the role
played by the government.

The World Health Organization (WHO) identifies four distinct functions for health
systems:

◆ the provision of health services

◆ the financing of health services

◆ the creation of health resources (investment in facilities, equipment, and training)

◆ the stewardship of health services (regulation and enforcement).

The government may be involved to a lesser or greater degree in the provision and
financing of health services as well as the creation of health resources. Alternatively,
these functions may be provided by the private sector alone, or by a mixture of both
government and private sector. However, stewardship is largely the responsibility of
government, either directly or through independent bodies acting under the broad
direction of government.

.

2.1 Regulatory role of government

16

Experience in El Salvador

The health sector of El Salvador is divided into public and private health providers. The

public health sector is run by the Ministry of Health (Ministerio de Salud Pública y

Asistencia Social), the National Social Insurance Agency (Instituto Salvadoreño de

Seguridad Social), and approximately 17 other public institutions.

The MOH regulates the health sector. It also runs a health service network with facilities at

different levels of a referral system, consisting of specialized hospitals in the capital, general

hospitals, and health centres. According to its statutes the MOH should look after the

preventive needs of the total population, and the curative needs of around 85 per cent of the

population. In reality it is covering approximately two-thirds of the population. Approximately

17 per cent of the population is covered by the National Social Insurance Agency.

The remainder of the population is covered by the private sector. This consists of private

professionals and service organizations which work for profit, such as pharmacies,

doctors, dentists, and private health facilities, together with a number of non-governmental

agencies which operate as not-for-profit organizations. This private sector covers some

10 per cent of the inpatient service demand of the population, and a much higher share of

the outpatient demand.

BOX 4: Alternative Ways of Organizing the Health System

Option Health system functions:

2.1 Regulatory role of government

17

Service financing

Government budget
financing, through:

Ministries of Finance
and Health

Private financing,
through:

health insurance
(social security, private
and community
pooling), donations,
direct payments, etc

Mixed financing

Service provision

Government service
provision, through:

government hospitals,
government doctors,
etc

Private service
provision, through:

private hospitals, not­for-profit hospitals,
independent doctors,
etc

Public and private
service provision

Resource creation

Government capital
development and
training

Private investment
in health facilities,
and privately-funded
education

Public and private
investment in health
facilities and training

Stewardship

Government
regulation and
enforcement

Government
regulation, and
quasi-public bodies
enforcing regulations

Government
regulation, and
public or quasi­public bodies
enforcing regulations

1

2

3

Clearly, a wide range of options exists for the financing and provision of health
services, and the creation of resources. In recent years, mixed solutions have become
increasingly common, for example:

◆ Government may provide the majority of health services, but the services

themselves are increasingly paid for by health insurance companies and patients.

◆ Government may finance both public health facilities and some costs of the not-

for-profit facilities, such as mission hospitals.

◆ Other health facilities may be financed by patients, employer contributions, and

insurance companies.

Thus we can see that health service provision and financing, as well as resource
creation may be taken on by both the government and private sector. However, the
government is solely responsible for regulation. The reason for this is that the
government has a duty to ensure the quality of healthcare delivered in order to
protect the safety of the population. These regulations may then be enforced
directly by government bodies or they may be enforced by publicly funded bodies,
such as professional associations, which apply government sanctioned regulations.

Most governments would agree that the protection of health and the guarantee of
safety of health services are vital. However, in many countries this regulatory
function is underdeveloped, with weak legal and regulatory frameworks.

Box 4 shows various options for organizing health systems.

To regulate health services, the government should:

◆ Adopt suitable quality standards for all aspects of health services, including

acceptable international or national standards for healthcare technology, drugs,
and supplies in order to ensure their efficacy, quality and safety (Section 2.2).

◆ Establish systems to ensure standards are met, so that the bodies enforcing

regulations have legal sanctions they can use if standards are infringed (Section 2.2).

◆ Establish wide-ranging polices covering all aspects of the utilization, effectiveness,

and safety of healthcare technology, drugs, and supplies (Section 2.3).

◆ Establish systems to ensure these policies can be implemented (Sections 2.3,

2.4 and 2.5).

For health services, the Ministry of Health is the body most likely to develop these
government regulations. Other health service providers need to be guided by
government laws, and should look to the Ministry of Health for guidance or follow
their direction if required to do so by law or regulation.

It is not possible for this Guide to elaborate on all these steps in detail. However,
Box 5 outlines the steps required to guarantee that the government is able to
regulate health services effectively.

BOX 5: A Checklist for Your Regulatory System

Check whether the system existing in your country meets the following requirements:

◆ Has your government taken responsibility for the regulation of health services?

◆ To regulate health services, has your government:

- adopted suitable quality standards for health services in general?

- specifically adopted acceptable international or national standards for healthcare technology?

- established legal sanctions for infringements of standards?

◆ Which bodies/agencies are responsible for enforcing government regulations?

◆ To enforce government regulations, have these bodies/agencies:

- put in place systems to check whether the standards are being met?

- used the legal system to effectively prosecute infringements of the standards?

◆ Has your government developed:

- wide-ranging health policies?

- specifically policies for healthcare technology?

- established systems for implementing these policies?

◆ Does your health service provider follow the guidance provided by government?

2.1 Regulatory role of government

18

2.2 ESTABLISHING STANDARDS FOR YOUR

HEALTH SYSTEM

The government should agree on which quality standards have to
be met by the health services in general. They will cover areas
such as:

◆ administrative, medical, and surgical procedures and the

training of personnel

◆ construction and operation of health facilities

◆ acquisition and use of healthcare technology, drugs, and supplies

◆ safety and environmental issues

◆ quality management practices.

In practice, the Ministry of Health is most likely to be responsible for undertaking
this task, in collaboration with any other relevant regulatory authorities (for example,
those regulating construction, or environmental impact issues). The body
responsible should ideally be a ministerial multi-disciplinary committee, with
representatives from all health service providers, and which takes technical advice
from any bodies with expertise in healthcare technology management – such as the
HTM Service (Section 2.4).

Since drawing up these standards can be both time consuming and expensive,
governments may often choose to adopt acceptable international standards (such as
ISO), rather than develop their own. However, they must be suitable and applicable
to your country situation and fit in with your country’s vision for health services
(Section 2.3). For example, an international standard may require operating theatres
to have a ventilation system that produces negative pressure air-flow over the
operating table (to promote a sterile environment). But the reality in developing
countries may be that operating theatres do not have a ventilation or air-conditioning
system (other than opening windows) and manage to ensure low levels of sepsis
through other surgical practices. Thus, such an international standard would be both
impractical and costly to enforce.

The adoption of suitable international or national standards for healthcare
technology is of particular relevance to this Guide. These are important since
countries can suffer if they acquire sub-standard and unsafe equipment.

2.2 Establishing standards for your health system

19

Standard

a required or agreed level of

quality or attainment set by a

recognized authority, used as a

measure, norm, or model

A wide variety of formal standards and guidelines now exist which relate to
healthcare technology. They apply to:

◆ design, development, and manufacturing practices for hardware, associated

consumables, and software

◆ safety and performance requirements for certain classes of technologies (such as

radiation or electrical safety)

◆ procedures and training for equipment operators and maintainers

◆ environmental issues such as the disposal of hazardous medical waste (for more

details on this, see Guide 4 on operation and safety).

Again, in the majority of cases ministries of health
would save money and time by adopting suitable
internationally recognized standards (see Annex 2).
Specialist support may be required to assist with this
process. Box 6 provides a summary of the important
standards you are likely to see reference to. For more
information on introducing internationally recognized
standards into your procurement procedures, refer to
Guide 3 on procurement and commissioning.

2.2 Establishing standards for your health system

20

Country Experiences

Many countries do not have a system in place for establishing and enforcing equipment

standards for all equipment purchases and donations. This has led to the supply of sub-

standard equipment. For example:

◆ metallurgy microscopes supplied instead of medical microscopes

◆ infant incubators containing asbestos

◆ suction pumps constructed with poor internal wiring so that they smoke when used

◆ instrument autoclaves not manufactured as pressure vessels which leak, do not sterilize

the contents, and are dangerous

◆ operating tables constructed with such poor tolerances in the hydraulic systems that

they consistently leak oil and sink under the weight of a patient

◆ operating lights manufactured with mains voltage (alternating current) wired into the

lamp-head, instead of the required safe 12 volts (direct current)

◆ veterinary equipment instead of the necessary human equivalent medical ones.

Did you know?

◆ Standards and guidelines are produced

and/or adopted by government agencies,
international organizations, and
professional and specialty organizations
and societies.

◆ The Emergency Care Research Institute

(ECRI) in the United States lists over 13,000
individual standards and guidelines relating
to healthcare technology, produced by over
800 organizations and agencies from North
America alone.

BOX 6: Examples of Important Safety and Performance Standards

All equipment should meet international, regional, or national safety and performance standards (see Annex 2).
The most important standards include:

◆ IEC (International Electrotechnical Commission) – these are international standards for the

electrical safety of any electrical and electromechanical equipment (such as refrigerators). IEC 60101

is the international standard specifically addressing medical electrical safety that manufacturers must

conform to if medical equipment is to be electrically and mechanically safe for use by staff with patients.

As part of their responsibilities, maintenance staff should also safety test equipment to ensure it meets

these standards (see Guide 4 on operation and safety).

◆ ISO (International Organization for Standardization) – these are international standards for

industry, technology and business, with special standard series for quality management and systems

in any field. ISO 9000-9004 is a series of standards covering the quality of manufacturing processes,

design and development, construction, installation, and servicing. ISO standards do not currently exist

for all equipment, but do apply to a range of medical devices (for example, ISO 13485 and ISO 13488).

ISO standards, however, do not have a status of official standards unless they are adopted by a competent

national authority. ISO is made up of its members. A member body of ISO is the national body ‘most

representative of standardization in its country’. Examples are BSI (British Standards Institution, UK),

ANSI (American National Standards Institute, US), DIN (Germany), SAI (Australia).

2.2 Establishing standards for your health system

21

Experience in Indonesia

The Indonesian Government asked the German Technical Cooperation Agency to assist

the Directorate of Cosmetic and Medical Devices Control in establishing a system for

registration/certification of medical equipment. This would involve defining standards for

medical equipment, as well as the relevant test methods which equipment must pass if it

is to be allowed to be imported or used by health institutions.

This task was particularly difficult since the Directorate had, in the past, concentrated its

efforts on the registration/certification of drugs and cosmetics and had only limited

experience with medical equipment. Thus during the assistance project, the Directorate

realized that unique national standards for medical equipment could not be developed

by the Ministry of Health, since the technical requirements for this did not exist in the

MOH. Therefore they decided to register selected equipment based on available

international standards.

As a result of the project, Indonesia introduced the respective internationally accepted

standards for a group of eight types of medical equipment. In addition to the standards,

the Directorate also took responsibility for registering all medical devices that met the

selected standards and passed the tests, and providing the operational permits for them.

Continued overleaf

2.2 Establishing standards for your health system

22

BOX 6: Examples of Important Safety and Performance Standards (continued)

◆ EU standards are developed through the organs of EU, EFTA, and the three European standardization

organizations CEN, CENELEC and ETSI. Directives are issued by the EU authorities and the

standardization organization prepares the technical standards according to the directives. These become

standards to be adopted nationally. There are three main medical devices directives for Europe. These

are: i) 90/385/EEC for active implantable medical devices; ii) 93/42/EEC covers vigilance and

compliance in general for medical devices; iii) 98/79/EC for in-vitro diagnostic medical devices.

CE markings indicate that a product meets European Union directive standards of performance and

safety and, for example, apply to all sterile medical supplies.

◆ American Standards are adopted from the international work of organizations like the IEC and ISO, or

are developed nationally. ANSI is the national organization that facilitates national standards

development by accrediting procedures of standardization organizations. All new medical equipment has

to be approved by the Food and Drug Administration (FDA-approval) before it can be commercialized.

◆ Pharmacopoeia specifications – quality specifications for the most commonly used drugs and some

medical supplies, such as bandages, tape, and swabs. Important pharmacopoeias include the British

(BP), European (EP), United States (USP), and the WHO’s International Pharmacopoeia (IP).

◆ Manufacturer’s Certificates – these are validated by the government of the exporting country confirming

that the exported device is approved for domestic use in the exporting country. In this way, the

importing country can be assured of the same risk exposure as the citizens of the exporting country

◆ Export Certificates – allow manufacturers to export equipment that is not manufactured for the

exporting country’s domestic sale or use. At present, there is no uniform certificate for different

countries, so it is wise to be cautious in interpreting such ‘export certificates’. (Note: the WHO export

certificate at present only applies to pharmaceutical products).

◆ Good Manufacturing Practices (GMP) – where this has been introduced, a manufacturer’s Quality

System is audited and monitored to ensure standards of production and safety are maintained and

are consistent. GMP has recently been established for manufacturers of equipment. (For example,

quality system standard for medical devices: 1128 in Japan, and 21 CFR part 820 in USA)

◆ Registration or Licensing – of manufacturers, wholesalers, importers, and retail outlets by a local

regulatory authority.

Note: be aware that:

◆ apparently standard quality certificates may indeed be based on varying parameters

◆ export certificates and GMP are both issued by authorities in the country of

origin, and their value depends upon the capacity and diligence of the issuing

Regulatory Authority.

It is not enough simply to establish these standards; they also need to be adhered to.
For this reason, you should establish a national supervisory body that has the power
to ensure that health service providers comply with the standards in force. To be
effective, such an enforcement agency must be allocated sufficient financial and
personnel resources. It should also be linked or networked with corresponding
international bodies.

23

2.2 Establishing standards for your health system

Much healthcare technology in developing countries is received through foreign aid
and donations, but such products do not always meet international standards.
Therefore, your country will need to negotiate with external support agencies. The
best way to do this is to develop regulations for donors that supply equipment (see
Annex 2, and Guide 3 on procurement and commissioning).

The legal system plays an important role in enforcing such standards, by ensuring
that any infringements can be effectively prosecuted. It is therefore essential that
the legal system is allocated sufficient financial and human resources to enforce
claims against any institution operating equipment that does not meet the
prescribed standards.

Box 7 outlines the issues to consider if you wish to improve your standards.

BOX 7: A Checklist for Improving Your Standards

Check whether the following requirements have been met by your country:

◆ Which quality standards has your government defined for health services in general?

◆ Which international or national standards has your government defined for healthcare technology,

relating to:

- manufacturing?

- safety?

- use?

- disposal?

◆ Which national supervisory bodies in your country are responsible for ensuring the different sets of

standards are complied with?

◆ Do these supervisory bodies use the legal system to enforce claims against any institution operating

equipment that does not meet the prescribed standards?

◆ Does your health service provider conform to these government standards?

2.3 DEVELOPING POLICIES FOR HEALTH SERVICES

Every country needs to establish wide-ranging policies covering all aspects of health
services. National health policies are usually developed by the Ministry of Health (or
its equivalent). If these policies are linked to regulations, then other health service
providers must also follow them. Each health service provider can expand them
internally, and must establish systems that ensure they are implemented.

Of relevance to this Guide, are the necessary policies for the utilization, effectiveness,
and safety of healthcare technology. One key framework requirement for this Series of
Guides is that your health service provider should have started work on a Healthcare
Technology Policy. Healthcare technology policies have been developed by many
countries, and there are several written resources and agencies which offer guidance
(see Annex 2). You may need specialist support with this process.

A Healthcare Technology Policy usually addresses all the healthcare technology
management (HTM) activities involved in the life-cycle of equipment, as shown in
Figure 3 (Section 1.2). Here we will consider just four issues that provide key
background conditions for this Guide:

◆ a vision for health services

◆ standardization

◆ the provision of maintenance; and

◆ finances.

Ultimately you will need an HTM Service to ensure that you can deliver HTM
throughout your organization. Its organizational structure will also be part of your
policy document. This is discussed in Section 5 of this Guide.

2.3.1 A Vision for Health Services

Every health service provider needs a realistic vision of the service it can offer. This
should include a clear understanding of its role in relation to other health service
providers in the national health service. Only when this vision is known can the
health service provider decide what healthcare technology is needed, and prioritize
the actions required to develop its stock of equipment.

It is unhelpful if lots of individual health facilities pull in different directions, with
no coordinated plan for the health service as a whole. The central authority of each
health service provider should be responsible for considering what sort of healthcare
should be offered at each level of their health service. Preferably they will collaborate
with the Ministry of Health, or follow their guidance if regulated to do so.

Your country and health service provider may already have developed central level
guidance such as ‘Essential Service Packages’. In many other countries and
organizations, the definition of the functions for each level of healthcare delivery
may not, as yet, be written down in a policy document. If there is no health service
plan, there is no framework on which to base decisions. Guide 2 provides further
information on developing a vision and planning your healthcare technology stock.

To develop strategies for healthcare delivery, health service providers should take
into account:

◆ healthcare trends

◆ demographic data

◆ epidemiological profiles

◆ priority health problems

◆ clinical and referral features of the target area

◆ the available infrastructure, finances, and human resources.

2.3.1 A vision for health services

24

The standards you adopt (Section 2.2) must necessarily be linked to the type of
health services you decide to offer.

2.3.2 Standardization of Healthcare Technology

Having developed a vision for health services, many health
service providers find it helpful to introduce an element of
standardization for healthcare technology in order to limit the
wide variety of makes and models of equipment found in their
stock. In this way, they benefit from technical, financial, logistic,
and training viewpoints, as shown in Box 8.

BOX 8: The Benefits of Standardization

Standardization helps you to improve:

Quality:

◆ by ensuring that only products which meet the defined standards are acquired, without the need for

additional cumbersome tests and checks.

Procurement and logistics:

◆ by limiting the number of types of spare parts, accessories, and consumables that you have to keep in

stock for different types of equipment.

◆ by helping you to rationalize your sources of supply and supply routes, and make savings through bulk

purchasing.

Skill development and performance:

◆ by enabling staff to become more knowledgeable about the operation and maintenance of the products,

as it limits the variety of items they have to be familiar with.

After sales support:

◆ by giving suppliers greater incentives to provide after-sales services and establish long-term relationships

with you due to the bulk sales.

It is easier to achieve standardization if equipment is planned and ordered on a
country-wide, district-wide or health service provider basis. Procurement by one
facility at a time almost certainly generates singular types of equipment that are
unaffordable to maintain. It is therefore important to combine forces with other
facilities or health service providers, and it may be wise to collaborate with or follow
the standardization strategies of the Ministry of Health (see Guides 2 and 3).

2.3.2 Standardization of healthcare technology

25

Standardization

(also known as rationalization,

normalization, and harmonization)

– the process of reducing the

range of makes and models of

equipment available in your

stock, by purchasing particular

or named makes and models.

To ensure that you standardize to safe well-made makes and models, it is usual to
standardize equipment to the healthcare technology standards you have set, as
described in Section 2.2. In fact, introducing standards for healthcare technology
automatically starts the process of introducing an element of standardization as it
restricts purchases to those items that meet the standards.

Tip

•

To achieve standardization you need to go through a tender process that ensures the
limited range of makes and models eventually selected are consistent with agreed
specifications and conform to existing standards you have set.

It is important that standardization efforts do not just apply to products purchased
by the health service providers, but also to donations. To achieve this, it is important
that regulations for donors have been established (see Annex 2 and Guide 3).

Standardizing your healthcare technology may be difficult for a number of reasons.
Your country and local businesses may have their own trade practices and interests.
National donors may have tied-aid practices, while the procurement procedures of
international funding agencies, health service institutions, and individuals may act
against your standardization strategies (see Guide 3 on procurement and
commissioning).

You may need to hold discussions with organizations such as the Ministry of Industry
and/or Trade, the chambers of commerce or specific business associations, as well as
external support agencies. However, it is well worth persevering, as standardization
offers many benefits, both in terms of cost and efficiency.

2.3.3 Provision of Maintenance

Having established standards for the equipment you purchase, you need strategies to
ensure it continues to meet the standards required throughout its entire working
life. Maintenance is a key activity for achieving this.

Undertaking maintenance belongs to the service provision function of health
systems (Section 2.1). Therefore, this means that the government is not necessarily
directly involved in carrying out maintenance. Maintenance could, in principle, be
carried out by the government, the private sector, or by a mixture of the two.

2.3.2 Standardization of healthcare technology

26

It is useful to organize the maintenance system along similar lines to the health
service provision already existing in your country. For instance, if the health system is
predominantly run by the government, it is probably simplest to let the government
run the maintenance organization as well. In contrast, if private organizations run the
health services, it makes little sense for the maintenance activities to be carried out
by a government body. In the majority of cases, a mixed system is most likely.

However, the government may wish to take a regulatory role and establish
regulations that will guarantee that healthcare technology performs effectively,
accurately, and safely. The rules established should be valid for all health service
providers, irrespective of their type of organization – applying equally to centralized
and decentralized public health systems, private health providers, or NGOs running
their own health services.

Details of how maintenance is organized would not need to be prescribed by the
regulatory body. Instead, it is up to individual health service providers to decide how
maintenance activities are to be delivered. Maintenance services can be organized in
many different ways. However, the nature and the complexity of some maintenance
services often call for partnerships between the public and private health service
providers. Partnerships may also exist between health service providers and private
sector sources of maintenance support. Such partnerships are discussed further in
Sections 3 and 4.

To provide maintenance services, you will normally need to establish good links
between maintenance workshops. This will create a network that supports the needs
of all your health facilities. Maintenance is, of course, only one of many HTM
activities that need to be carried out. However, the fact that maintenance workshops
usually already exist in most countries serves as a useful starting point for
establishing a physical HTM Service across your health service provider organization
and across your country (Section 5).

2.3.3 Provision of maintenance

27

Country Experiences

Some countries, such as Germany and Austria, have introduced a medical products law

(Medizinproduktegesetz) which regulates that planned preventive maintenance (PPM),

and many other healthcare technology management activities, must be undertaken in

order to guarantee the safety of medical products. An advantage for maintenance

departments is that as a result finances are automatically allocated for PPM as it is

prescribed that it must be undertaken. Such examples of strict regulations are a crucial

pre-requisite for the safety of medical products, provided that they can be enforced.

2.3.4 Finances

28

2.3.4 Finances

To ensure that healthcare technology is utilized effectively and safely throughout its
life, your health service provider will need to plan and allocate adequate budgets.
These budgets need to cover all expenditure requirements:

◆ Capital investment for new and replacement equipment, as well as training.

◆ Recurrent costs for consumables, maintenance, administration, etc.

Guide 2 of this Series provides advice on how your health service provider can plan
and budget for all activities relating to your healthcare technology.

In a government-organized system these funds are mainly provided by government
budgets, while private systems or mixed systems must generate the required funds
from their customers, or from benefactors and donors (see Box 4).

Depending on your health service provider and country, your HTM Service may be
able to generate income by charging for services provided. Whether this income can
be used to further improve the HTM Service depends on the policies of the
responsible financing authority, such as the treasury (in the government sector) or a
central finance office. Guide 6 of this Series provides advice on how to manage the
finances of the HTM Service, including the possibilities for generating income.

Experience in Malawi

The government of Malawi has recognized that the establishment of a National Physical

Asset Management System is crucial, in order to meet the objective of the National

Health Plan ‘to improve efficiency and equity in resource allocation’.

As a first step, the Ministry of Health and Population in 1998 created a Physical Assets

Management Division within the Department of Health Technical Support Services. In

November 2002, as a next important step, the Malawi National Health Physical Assets

Policy was launched. This comprehensive policy regulates the organizational structure of

physical assets management, the planning and budgeting of funds for maintenance

activities, equipment procurement policies including donation policies, maintenance

management guidelines, information policy, and staff development.

The policy specified a referral system under the Physical Assets Management Division

consisting of three regional maintenance units at strategic locations in the country

(Lilongwe, Blantyre, and Mzuzu). These regional maintenance units are responsible for

healthcare technology management (including inventories, planning, repair, etc) in all

health facilities. Their maintenance and repair attention is especially targeted at

equipment that requires special skills, test equipment, and tools not usually available at

health facilities. Below the regional maintenance units, hospital maintenance units are

to be established at central and district hospitals. Hospital maintenance units will carry

out maintenance and repair services on buildings, plant and utilities for all facilities in

their respective catchment areas.

2.3 Developing policies for health services

29

Box 9 outlines the issues to consider if you wish to improve aspects of your
Healthcare Technology Policy.

BOX 9: A Checklist for Improving Your Healthcare Technology Policy

Check whether the following requirements have been met by your country:

Existence of a policy

◆ Does your government have a National Healthcare Technology Policy?

◆ Are there regulations that require your health service provider to follow the national policy?

◆ Has your health service provider developed its own Healthcare Technology Policy?

◆ Does your policy cover all healthcare technology management activities?

◆ Does your policy cover the necessary organizational structure for an HTM Service?

Check whether the following aspects are adequately covered in your policy:

Developing a vision

◆ Has your health service provider established a vision for its health services, which details the type of

healthcare to offer at each level?

◆ Does this vision conform to the national vision for health services?

◆ Is the vision used to help you plan what healthcare technology your health service provider should own?

Standardization strategies

◆ Has your health service provider set up policies to introduce an element of standardization in the

purchase of healthcare technology (equipment and equipment-related supplies)?

◆ Is your standardization policy closely linked to the international or national standards set by your

government for healthcare technology (equipment and equipment-related supplies)?

◆ Has your health service provider introduced systems which ensure that even items supplied through

foreign aid and donations also meet your standards, as well as your standardization and purchasing

policies?

◆ Does your standardization policy conform to the standardization strategies of government, and other

health service providers in your country?

Continued overleaf

2.3 Developing policies for health services

30

BOX 9: A Checklist for Improving Your Healthcare Technology Policy (continued)

Providing maintenance

◆ Does your government require that maintenance takes place, in order to ensure the continuous

effectiveness and safety of healthcare technology?

◆ Does your health service provider, therefore, provide sufficient resources so that maintenance can

take place?

◆ What sanctions are imposed if maintenance does not take place?

◆ What different maintenance organizations are involved in assisting health services in your country, and

what activities do they undertake?

◆ Are all health facilities in your country being supported by these national maintenance organizations?

◆ Are the staff in your health facilities sufficiently qualified to undertake maintenance?

◆ Does your health service provider collaborate with other agencies in order to provide maintenance?

◆ What are the major constraints to maintenance in your health service provider organization?

Finances

◆ Does your health service provider have adequate capital and recurrent budgets for all healthcare

technology management activities, such as planning, procurement, operation, maintenance, training,

safety, disposal?

◆ Does your health service provider finance the running of an HTM Service?

◆ Do these funds come from government budgets, or do you generate the required funds from

customers/donations?

◆ Can your HTM Service generate income?

◆ Can this income be used to further improve the HTM Service?

2.4 THE IMPORTANCE OF INTRODUCING A
HEALTHCARE TECHNOLOGY MANAGEMENT
SERVICE

We have established the importance of:

◆ adopting standards for healthcare technology, in order to ensure they are safe and

perform effectively (Section 2.2)

◆ developing healthcare technology policies which cover all aspects of healthcare

technology management activities (Section 2.3)

◆ establishing systems to ensure the policy is implemented (Section 2.3).

All these aims could be achieved if each health service provider practised healthcare
technology management (HTM) as part of the everyday life of their health service.
The best way to do this is to have an HTM Service incorporated into each health
service provider organization.

Box 2 (Section 1.1) shows that HTM provides a wide range of benefits. It helps you
to provide quality health services and meet health service standards by, for example:

◆ ensuring the safety of equipment

◆ developing operational skills

◆ disposing of equipment without harming the environment

◆ planning equipment purchases that are cost-effective

◆ running services economically.

It is difficult to express this in financial terms, but Box 10 gives an idea of the sort of
savings that can be made if HTM is effectively carried out.

BOX 10: Savings Derived from Effective Healthcare Technology Management

Adapted from: Mallouppas, A, 1986, ‘WHO: Strategy and proposed action concerning maintenance of

hospital and medical equipment’, WHO, Geneva, unpublished document

2.4 The importance of introducing a healthcare technology management service

31

Problems that effective HTM could avoid

Policy/planning:

◆ lack of standardization

◆ purchase of sophisticated equipment for which

operating and maintenance staff have no skills

Procurement:

◆ impact on equipment and buildings during

installation, unforeseen at the initial tender stage

◆ inability to correctly specify and foresee total needs

when tendering and procuring equipment

Training:

◆ improper use of equipment by operating and

maintenance staff

Operation and maintenance:

◆ excessive equipment down-time due to absence of

preventive maintenance, inability to repair, and lack of
spare parts

Resulting waste you could save

◆ 30–50% additional cost for extra spare-

parts and extra maintenance workload

◆ 20–40% of equipment remains

underutilized or unused

◆ extra modifications or additions required

for 10–30% of equipment

◆ 10–30% additional unplanned costs

◆ loss of 30–80% of the potential lifetime

of equipment

◆ 25–35% of equipment out of service

Taking maintenance as an example, we can examine the benefits of carrying out
effective healthcare technology management in greater detail. Maintenance not only
has a positive impact on the safety and effectiveness of healthcare technology, but
also has two important economic benefits:

◆ It increases the lifetime of equipment and thus helps to save scarce investment

resources.

◆ It enhances the demand for health services, since demand for services is crucially

dependent upon the availability of functioning healthcare technology.

Healthcare technology that is out of order quickly leads to a decline in demand, which
will in turn reduce the income and quality of services of the health facilities. You will
lose clients if, for example, it becomes known that malfunctioning of sterilization
equipment may endanger the health of the patients. Similarly, patients will avoid
visiting health facilities that do not possess functioning diagnostic equipment.

Box 11 provides two examples that illustrate the financial benefits of extending the
lifetime of equipment as a result of proper maintenance.

BOX 11: The Financial Benefit of Maintaining Equipment

Example 1: An electrically operated autoclave, horizontal bench-top model

2.4 The importance of introducing a healthcare technology management service

32

Continued opposite

With maintenance

◆ Average lifetime is 12 years if

properly maintained

◆ One new autoclave is

required after 12 years =
US$3,500

◆ Maintenance of medical

equipment (such as this
model with sophisticated
electronic controls) requires
an average of 5% of purchase
price per year = US$2,100
over 12 years

◆ Total cost = US$5,600

Without maintenance

◆ Obsolete after 5 years

according to a study by the
German Technical
Cooperation Agency (GTZ)

1

◆ 2.4 new autoclaves required

over that 12 year period =
US$8,400

◆ No cost incurred for

maintenance

◆ Total cost = US$8,400

Effect

◆ Without maintenance, you

lose 7 years of potential life
of the equipment.

◆ Maintenance allows you to

postpone reinvestment for 7
years. Without maintenance
the additional autoclaves you
require over that period =
US$4,900.

◆ Maintenance costs are less

than the cost of the
additional replacement
autoclaves required if no
maintenance is carried out.

◆ Even when funding

maintenance, you still obtain
considerable economic
benefit =US$ 2,800.

33

2.4 The importance of introducing a healthcare technology management service

With maintenance

◆ Average lifetime is 15 years if

properly maintained

◆ One new generating set is

required after 15 years
= US$6,500

◆ Maintenance of plant (such

as a quite sensitive petrol
model which needs regular
maintenance) requires an
average of 4% of purchase
price per year = US$3,900
over 15 years

◆ Total cost = US$10,400

Without maintenance

◆ Obsolete after 7.5 years

◆ 2 new generating sets

required over that 15 year
period = US$13,000

◆ No cost incurred for

maintenance

◆ Total cost = US$13,000

Effect

◆ Without maintenance, you

lose half the potential life of
the equipment.

◆ Maintenance allows you to

postpone reinvestment for 7.5
years. Without maintenance
the additional generating set
you require over that period
= US$6,500.

◆ Maintenance costs are less

than the cost of the
additional replacement
generating set required if no
maintenance is carried out.

◆ By undertaking maintenance

you obtain a net saving =
US$2,600.

BOX 11: The Financial Benefit of Maintaining Equipment (continued)

Example 2: A stand-by generating set, 8 kVA petrol model

Since foreign exchange is very precious in developing countries and local currencies depreciate against hard
currencies all the time, such savings are even more valuable.

1. H. Halbwachs, 2000, ‘Maintenance and life expectancy of healthcare equipment in developing economies’,
Health Estate Journal, Vol.54, No.2, p. 26-31, Portsmouth, UK

Thus, the justification for introducing an HTM Service is that it will benefit you
economically and clinically, by ensuring that healthcare technology continues to
meet the standards required throughout its working lifetime.

The activities of an HTM Service belong to the service provision function of health
systems (Section 2.1). However, the government may wish to take a regulatory role
and establish regulations that guarantee that HTM occurs. To achieve this, it will be
necessary to have:

◆ a government body to provide regulations which will ensure the continued

performance and safety of healthcare technology throughout its life

◆ a control mechanism to check that all health service providers pursue these

healthcare technology management activities effectively

◆ legal or other sanctions that are enforceable if the rules are infringed.

2.4 The importance of introducing a healthcare technology management service

34

The government body responsible for providing regulations could be the central
level of a national HTM Service. Each health service provider could then develop its
own HTM Service. It should involve a network of teams and committees that enable
HTM to be practised in all facilities. The process for developing such an HTM
Service is discussed in the remainder of this Guide.

In order to establish an effective HTM Service, you will need to provide sufficient
inputs. Only in this way will you get the outputs and benefits that you require.
Figure 5 illustrates these requirements.

Figure 5: HTM Service Inputs and Outputs

Source: WHO, 1987, ‘Inter-regional meeting on the maintenance and repair of health care equipment:

Nicosia, Cyprus, 24–28 November 1986’, Geneva, Switzerland, WHO/SHS/NHP/87.5

INPUTS

Spare parts

Service infrastructure

(staff posts, salaries, career, etc.)

Training

Facilities (workshops,

tools, equipment)

Installation and

Commissioning

Selection and procurement of

equipment and spares

Planning

OUTPUTS

Budget

Inventory

Policy

Healthcare

Technology

Management

Service

Maintenance

Planning

Coordination with other Departments

Logistics (Medical Store) Support

Transport support

Telecomms/ Posts

Decommissioning

Training

Budgeting

Repair

SafetyRoutine

2.4 The importance of introducing a healthcare technology management service

35

Box 12 outlines the issues to consider if you wish to see how important an HTM
system is to your country and organization.

BOX 12: A Checklist for Understanding the Importance of HTM to Your Country

and Organization

Check whether the HTM system existing in your country meets the following requirements:

◆ Has your government set up regulations that require health facilities to undertake healthcare

technology management?

◆ Is there a government HTM Service whose central level provides guidance on HTM activities?

◆ Does your government demand that private and non-governmental health service providers also

practise HTM?

◆ Has your government set up mechanisms that fine, sanction or sue health facilities that do not provide

efficient and safe healthcare technology?

◆ Does your health service provider have its own HTM Service made up of a network of teams

and committees?

◆ Does your health service provider allocate sufficient resources for the implementation of HTM

activities in its own facilities?

2.5 HOW TO MANAGE CHANGE

The regulatory requirements presented in this Section may appear somewhat
idealistic, compared to the reality in many health systems. However, the aim is not
to highlight the deficiencies of existing systems, but to provide a blueprint for a
functioning healthcare technology management system. Hopefully, this will enable
you to get the right framework conditions in place, and thus improve the
effectiveness and the safety of your health services.

We are not recommending that your health service provider:

◆ throw out all their current HTM strategies and start again

◆ make sudden and sweeping changes that are likely to fail if they are over-ambitious.

Rather, it is better to take a step-by-step approach, introducing changes gradually,
with a careful review process. To implement an HTM system with all the
complexities described in this Series of Guides will take several years, and to try to
achieve everything at once could be disastrous. However for healthcare technology
management to improve, it is important to act.

36

2.5 How to manage change

It is possible to write down all the correct procedures and yet still fail to improve the
performance of staff. To ensure that your HTM procedures are effective, it is
important for there to be good managers who can find ways to motivate staff
(Sections 6 and 7). Simply ordering staff to implement new procedures usually does
not work. It is much better to discuss and develop the procedures with the staff who
will implement them. This could take the form or discussion, working groups or
training workshops. People who are involved in developing ideas about their own
work methods are more likely to:

◆ understand the objectives

◆ understand the reasons why processes are necessary

◆ be encouraged to change their way of working

◆ be more interested in making changes which result in improvement

◆ see that the aim of the HTM procedures is to improve their delivery of healthcare.

We recognize that many readers will face difficulties such as staff shortages, poor
finances, lack of materials, a lack of influence and time, and possibly even corruption.
Introducing new rules and procedures into a system or institution that has no real
work ethic, or which possibly employs dishonest workers, will not have any
significant effect.

Therefore, strategies may be required to bring about cultural and behavioural
change. For example:

◆ When materials are short, instead of focussing upon breakages and loss, place more

emphasis upon the importance of staff working hard and putting in the hours.

◆ Favour good managers who are seen to be present and doing what they preach.

◆ Encourage an atmosphere where staff are praised for good work, rather than a

culture of judgement and criticism.

Introducing rules and administrative procedures alone will not be sufficient to bring
about cultural change. You will also need to find ways of increasing performance and
productivity, and acknowledging/rewarding good behaviour is essential. For example:

◆ it is better to break a tool while actively undertaking maintenance, rather than

breaking nothing but never doing any work

◆ it is better to break a rule in an emergency (such as withdrawing stocks from

stores), rather than stick to the rules and risk the possible death of a patient.

Annex 2 has some examples of useful reference materials. To bring about such
changes, you will require skills in:

◆ managing change

◆ staff motivation

◆ effective communication

◆ encouragement, and

◆ supportive training with demonstrations.

2.5 How to manage change

37

All parties involved in the network of HTM Teams and HTM Working Groups need
to participate in developing the HTM Service. This will encourage a sense of
ownership of the Service and its responsibilities, and will lead to greater acceptance
and motivation among staff. If you are short of skilled staff (such as technicians,
managers, planners or policy-makers), you may need to obtain specialist support to
assist with some of these tasks.

Box 13 outlines the issues to consider if you wish to improve the management of
change within your organization.

BOX 13: A Checklist for Improving Your Ability to Manage Change

Check whether your organization meets the following requirements:

◆ As a staff member in your organization, in your opinion, do you face problems with shortages of staff,

finances, and materials, a lack of influence and time, or corruption?

◆ In your opinion, is there no real ‘work ethic’ in your organization?

◆ Does your health service provider employ strategies to bring about cultural and behavioural change, in

order to improve performance and productivity in your organization?

◆ To develop and introduce rules and procedures, does your health service provider use strategies such as

discussion, working groups, and training workshops with the staff that will implement them?

◆ Does your organization have skills in managing change, staff motivation, effective communication,

encouragement, and supportive training with demonstrations?

◆ Did all parties involved in the network of healthcare technology management teams and working groups

(committees) participate in developing the HTM Service?

◆ Does your health service provider introduce changes gradually, step-by-step, with a careful review process?

Box 14 contains a summary of the issues covered in this Section.

BOX 14: Summary of Issues in Section 2 on Framework Requirements

Government

Public or
quasi-public bodies

All Health Service
Providers

Regulatory Role

◆ actively regulates health services whether they are delivered by public providers,

private providers, or a mixture of the two

◆ develops checking systems and legal sanctions for infringement of health

regulations

◆ enforce government regulations

◆ conform to regulations and guidelines provided by government

Continued overleaf

Section 2 Summary

38

BOX 14: Summary of Issues in Section 2 on Framework Requirements (continued)

Government

All Health Service
Providers

Ministry of Health

Other Health
Service Providers

Ministry of Health

Other Health
Service Providers

All Health
Service Providers

Manage Change HTM Service Develop Policy Establish Standards

◆ adopts suitable standards for quality health services, including those for:

- procedures and training of personnel

- construction and operation of health facilities

- supply and use of healthcare technology, drugs, and supplies

- safety and environmental issues

- quality management

◆ specifically for healthcare technology, adopts standards for:

- design, development, and manufacturing

- performance and safety

- use and training

- waste disposal

◆ develops donor regulations to ensure all equipment received through foreign aid

and donations also complies with the standards

◆ establishes a supervisory body to enforce the standards

◆ conform to the standards set by government

◆ develops national policies for health services

◆ specifically develops a Healthcare Technology Policy to cover all healthcare

technology management activities including:

- a vision of the function of each level of healthcare delivery

- an element of standardization in equipment purchases and donations

- provision of maintenance through partnerships between public and private bodies

- provision of finances for all HTM activities (capital and recurrent)

- the organizational structure for an HTM Service (Section 5)

◆ regulates on these issues (if required)

◆ establishes a system that ensures the policies are implemented

◆ follow the policies of the Ministry of Health if regulated to do so

◆ develop their own internal Healthcare Technology Policy and expand strategies on

a vision, standardization, provision of maintenance, finances, and an HTM Service

◆ establish a system that ensures the policies are implemented

◆ develops an HTM Service made up of a network of HTM Teams and HTM

Working Groups (Sections 3 to 7)

◆ uses the central level of the HTMS as the national regulatory body, if necessary

◆ provides sufficient inputs to ensure the HTMS is effective

◆ develop their own HTM Service made up of a network of HTM Teams and

HTM Working Groups (Sections 3 to 7)

◆ follow MOH regulations concerning the HTM Service if regulated to do so

◆ provide sufficient inputs to ensure the HTMS is effective

◆ implement strategies to develop skills in managing change, staff motivation, effective

communication, encouragement, and supportive training with demonstrations

◆ introduce rules and procedures using discussion, working groups and training

workshops, with the staff that will implement them

◆ include all parties involved in the network of HTM Teams and HTM Working

Groups in the development of the HTM Service

◆ introduce changes to the HTMS step-by-step, with a careful review process.

3. HOW TO DETERMINE YOUR
TECHNICAL REQUIREMENTS

Why is This Important?

Very often health facilities fail to introduce healthcare technology management
because they believe the technical requirements are too difficult. However, if
we break down the technical requirements into different levels of complexity,
we can see that many tasks can already be undertaken with relatively limited
skills. We can also determine which activities are too complex for health
service technical staff with few qualifications, and what the workload
implications might be.

The following presentation will help you to evaluate the technical
requirements of your particular health facility, and for different levels of the
health system.

To help you design your HTM Service, we need to consider the technical
requirements for each level of healthcare delivery.

In this Section, the term ‘technical requirements’ refers to:

◆ the range of activities involved in healthcare technology management

◆ the different types of technical staff required to complete this range of tasks –

such as, general member of health staff trained to carry out maintenance activities
(handyman), artisan, technician, technologist, engineer, manager (see Section 6
for an explanation of these terms)

◆ the maintenance (preventive) and repair (corrective) needs of different types

of technology

◆ the workload due to the different tasks.

This Section investigates these needs by looking at:

◆ a summary of technical requirements for HTM (Section 3.1)

◆ skill requirements (Section 3.2)

◆ workload (time) requirements (Section 3.3).

3. How to determine your technical requirements

39

3.1 A summary of technical requirements

40

3.1 A SUMMARY OF TECHNICAL REQUIREMENTS

FOR HTM

As Figures 3 and 5 show, healthcare technology management covers a wide range of
activities. Here are just some of them:

◆ providing technical advice ◆ planning and costing work

◆ selection and procurement ◆ installation and commissioning

◆ training users and maintainers ◆ operating equipment

◆ maintenance and repair work ◆ monitoring contracts

◆ decommissioning and disposal ◆ managing workshop facilities

◆ managing staff ◆ record-keeping

◆ managing the inventory ◆ stock control of parts, consumables, etc

◆ managing waste ◆ implementing safety protocols.

All these activities require different technical skills. It is important, first, to
determine the particular skills required for the various different activities, at each
level of healthcare delivery. Next, you need to consider the workload required for
different skill levels. This will help you to decide how to provide the HTM services
required (Section 4).

Tip

•

The calculation of skills and workload requirements will only be of use if central
planners commit to providing HTM Teams with sufficient resources (such as spare
parts and transport) to carry out the identified workload.

Who Should Calculate the Technical Requirements?

Preference

The expertise of technical staff should be used to determine the skill and workload
requirements for HTM activities.

Takes what action?

Should study and estimate these requirements, then
pass the information on to senior planners so that
the model and organizational structure for the HTM
Service can be designed (Sections 4 and 5).

Takes what action?

Central level staff should take responsibility and
collaborate with staff at region/district and facility
level, to estimate these requirements.

Who?

Senior technical staff or
existing HTM Teams
(Section 1.1)

Which level?

All levels of technical staff
working together

3.2 Skill requirements at different levels of the health system

41

To assist with this estimation process, HTM staff need to use Sections 3.2 and 3.3
to help them determine the skill and workload requirements for HTM activities.

3.2 SKILL REQUIREMENTS AT DIFFERENT LEVELS

OF THE HEALTH SYSTEM

3.2.1 Understanding the Skill Requirements

Since maintenance and repair tasks require the greatest amount of technical skills we
will concentrate on them here as a key example. A brief summary for other healthcare
technology management skills is also given, that you can then expand upon.

Maintenance Skills

For simplicity, the term ‘maintenance’ is used to cover both the preventive
maintenance tasks and the corrective repair tasks that are required.

It is important to maintain all healthcare technology, including medical equipment,
plant, service supply installations, the fabric of buildings, vehicles, office equipment,
and furniture. This may not be limited to those items of equipment found in health
facilities, but could also include those in staff accommodation and training facilities.

Failure to appropriately maintain the physical assets of the health service is often
blamed on lack of financial resources, lack of qualified personnel, or organizational
and managerial deficiencies. These reasons would be perfectly understandable if
very sophisticated equipment was being used, as this would require highly skilled
staff and expensive spare parts. The reality, however, is that only a very limited
percentage of equipment is that sophisticated.

The argument that maintenance is too costly can be countered by looking at the
specific maintenance and repair requirements of your health facility. There are likely
to be different technical levels of skills required, depending on the type of
maintenance problem and the types of healthcare technology you use, as shown in
Box 15.

3.2.1 Understanding the skill requirements

42

Level of complexity

Skill level 1

Skill level 2

Skill level 3

Skill level 4

Type of technology and maintenance task

Basic maintenance tasks on basic equipment –
for example, oiling castors on beds.

Basic maintenance tasks on more complex
technologies – for example, cleaning and
replacing the air filter of an infant incubator.

Medium-level maintenance tasks on basic
equipment – for example, adjusting scale
balances.

Medium-level maintenance tasks on more
complex technologies – for example, checking
the integrity of electrical grounding.

High-level maintenance tasks on medium-level
technologies – for example, overhauling the
hydraulic system of an operating table.

High-level maintenance tasks on more
complex technologies – for example, fault­finding problems with diathermy machines.

Sophisticated-level maintenance tasks on high­level technologies – for example, calibrating
flowmeters on anaesthetic machines.

Sophisticated-level maintenance tasks on
sophisticated technologies – for example,
repairing CT scanners.

Service provision by:

Equipment users, with
training – clinical, medical
and paramedical staff, general
health personnel, plant
operators, attendants,
patients, in-house
maintainers, patient
caretakers, administrative
staff, drivers.

Local artisans – private sector
artisans and in-house artisans.

In-house craftspeople and
technicians – maintainers with
polyvalent skills (in other
words, skills that cover a range
of engineering disciplines).

Maintenance specialists
– technologists, engineers.

Specialized firms
– manufacturers’
representatives, independent
private companies.

BOX 15: Skill Levels Required According to Maintenance Needs

Depending on the size of your health facility, a broad spectrum of skills may be
required to cover the maintenance needs for the whole range of equipment.
However, not all of these skills need to be permanently present and some may be
required only very rarely. Thus, it is often more cost-effective for specialists to be
spread across a number of different facilities, rather than devoting all their time to
the needs of one facility. These workload issues are discussed in Section 3.3.

The various different skill levels for maintenance can be further defined as follows:

3.2.1 Understanding the skill requirements

43

Skill Level One – Semi-skilled

The skills required at this level are simple, so maintenance can be carried out:

◆ either by local private sector artisans and any in-house ones

◆ or, often, by the equipment users themselves, with some additional training.

Examples of these kinds of maintenance activity include:

◆ changing an ophthalmoscope bulb

◆ changing cracked tubing

◆ changing a compressor’s engine oil

◆ replacing a tap washer

◆ replacing the castors on a wheelchair

◆ replacing rubber seals on sterilizers

◆ changing a microscope bulb.

Skill Level Two – Skilled

The tasks at this level require some further skills which existing in-house technical
staff may have (such as craftspeople and technicians with informal training,
certificates, or diplomas). If they do not have these skills, they can be relatively
easily taught via retraining programmes.

The trained staff can then work as ‘polyvalent’ maintainers (with multi-disciplinary
engineering skills) for these medium technology tasks. Examples of this type of
maintenance activity include:

◆ replacing a heating element in an autoclave

◆ replacing brushes in a centrifuge

◆ checking the mechanical integrity of items

such as switches, controls, connectors, and
meters in any equipment.

Tip

•

Maintenance activities at both skill levels one and two can often be carried out by
existing staff within the health facility, without the need to hire new or highly
trained staff. In spite of this, very often these tasks are ignored by health
management teams, claiming a lack of staff or financial resources. This situation can
be resolved by securing the required funds and establishing a retraining programme
for existing staff.

Skill Level Three – Highly Skilled

These jobs should be reserved for highly skilled maintenance specialists
(technologists, engineers). They would normally require:

◆ either a higher national diploma (HND) or degree in a suitable engineering

subject (such as electronics or mechanics) which they have applied to the work in
the health service

◆ or an HND or degree in clinical or hospital engineering, if a dedicated course

is available.

Examples of this type of maintenance activity include:

◆ calibrating the light source of a photometer

◆ fault-finding problems with autoclaves

◆ replacing photocells on solar panels

◆ replacing rubber fittings on anaesthetic machines.

Tip

•

If your facility does not have the resources to employ such a specialist, you could
consider getting together with other health facilities to jointly run a maintenance
service with specialists. For example, in some countries, specialists at large central
facilities also provide sophisticated services to smaller facilities. In others, the specialists
might be based at district or regional workshops and care for all facilities in their area.
Sections 4 and 5 discuss various options for the organization of such services.

Skill Level Four – Specialized

The maintenance skills required for level four activities are so specific that they
cannot be performed by technologists or engineers who work in multi-disciplinary
maintenance services. Instead they require the intensive training and experience
that comes from specializing on particular equipment makes and models. Very often,
these services can only be provided by:

◆ either the equipment manufacturers and possibly their representatives in

your country

◆ or independent private sector maintenance companies.

Examples for this type of maintenance activity include:

◆ repairing MRI equipment

◆ resolving computer software problems

◆ repairing ultrasound machines.

3.2.1 Understanding the skill requirements

44

Other HTM Skills

Alongside maintenance skills each level of healthcare delivery will have varying needs
for skills for other HTM activities. These are the types of skills used to manage
issues such as work, equipment, people, and money. These requirements are discussed
further in Section 5 on responsibilities, and in the job descriptions provided in
Annex 3. Examples of the skills required can be defined briefly as follows:

At Skill Level One

The following sorts of activities are required:

◆ planning the work and materials required

◆ keeping a record of work

◆ reading manuals and drawings

◆ training equipment users.

At Skill Level Two

In addition to the tasks at skill level one, activities such as:

◆ making work schedules and drawings

◆ advising on selection and procurement

◆ planning and costing work

◆ training other maintenance staff

◆ monitoring and ordering stores

◆ monitoring contracts.

At Skill Level Three

In addition to the tasks at skill level two, activities such as:

◆ managing the equipment database

◆ financial management

◆ installation and commissioning

◆ writing reports and keeping statistics

◆ managing and supervising other technical staff.

3.2.1 Understanding the skill requirements

45

At Skill Level Four

It is unusual to hand over control of the other HTM activities relating to
management of work, equipment, people, and money to private sector companies
(except when you have asked them for help with installation, commissioning, and
training). Thus for other HTM activities, the skills at level four are required by your
most senior technical staff at the central level of your health service provider
organization. In addition to the tasks at skill level three, they will take on overall
planning and supervising roles, including the development of contractual
relationships with the private sector (Section 4.1).

3.2.2 Determining Your Skill Requirements

It is useful for you to determine what your own skill requirements are at your
particular health facility. A number of countries have used their equipment
inventories to help make a methodical calculation of the skills requirements for each
type of health facility. To do this, you would:

◆ look at the different types of equipment you own in your facility or service level

◆ for each type of equipment, determine the maintenance tasks required under the

four skill levels, using your experience of:

- typical operator errors

- common problems and repairs

- planned preventive maintenance needs

◆ assess the other HTM activities required at each skill level for your facility or

service level

◆ lay out the information in some form of spreadsheet.

By carrying out this process, you will begin to see the number of tasks required at
each of the four skill levels. The process of translating this into workload
requirements is discussed in Section 3.3.

Tip

•

One advantage of having an equipment inventory, is that you can use it to forecast
your budget, manpower, contract, spare parts, and replacement needs. For more
information on preparing and using equipment inventories, see Guide 2 on planning
and budgeting.

3.2.2 Determining your skill requirements

46

3.3 Workload requirements

47

3.3 WORKLOAD REQUIREMENTS

3.3.1 Understanding the Workload Requirements

Box 15 (Section 3.2) describes a wide variety of skills to cover the maintenance
needs for the whole range of equipment. However, not all of these skills need to be
permanently present in your health facility, and some may be required only very
rarely. Figure 6 provides an illustration of how much of the maintenance work is
undertaken at each skill level, across your whole health service (not necessarily at
each health facility).

Figure 6: Division of Maintenance Work by Skill Level in the Health Service

Adapted from: Raab, M, 1999, ‘Maintenance strategies’, Swiss Center for International Health,

Basel, Switzerland, August 1999

Figure 6 shows us that, as the skill level increases, the workload for the maintenance
required decreases. As much as 40–70 per cent of the maintenance requirements for
your health service could be undertaken by people with skill levels one and two
(equipment users, existing in-house craftspeople and technicians, and artisans).
Technologists and engineers are only required for about a quarter of the work, and
specialist private sector support is required rarely. Thus, in order to make maximum
use of resources, the more expensive specialists should be shared across your health
service in such a way that their skills are put to good use and benefit as many
facilities as possible. A suitable organizational structure for achieving this within the
HTM Service is discussed in Section 5.

Level 4

5 – 10%

Level 3

Level 2

Level 1

10 – 25%

20 – 40%

20 – 30%

Specialized technical support
from external service companies

Maintenance by technologists
and engineers from a referral
network of workshops

Maintenance by in-house
craftspeople and
technicians

Maintenance by
equipment users
and local artisans

3.3.1 Understanding the workload requirements

48

Also, as the skill level increases, the workload includes a greater amount of the other
HTM activities, as shown in Box 16.

BOX 16: Possible Division of Time Between Maintenance and Other HTM Activities

(Section 3.2.1)

Skill level one

– equipment users, private sector and in-house artisans

Skill level two

– craftspeople and technicians

Skill level three

– technologists and engineers

Skill level four (specialized maintenance)

– specialized firms

Skill level four (other HTM activities)

– central level managers

3.3.2 Determining Your Workload Requirements

To determine your workload requirements, you first need to consider the hours
required for carrying out the HTM activities. Next, you need to analyze the
implications in terms of staff numbers.

Hours Required for the Tasks

Using Section 3.2.2 you can break down the technical tasks for your health facility or
service level, according to their level of complexity and the skills required to perform
them. Armed with this information, you can now calculate the probable working
hours required to carry out these HTM activities.

Look at the typical problems and work requirements you identified in Section 3.2.2,
and consider the typical time it takes to attend to them. This is a useful tool for
HTM Managers as it can be used to convince planners of the need for different types
of staff (Section 6).

As an illustration, below we have given some examples based on a large number of
samples of government and mission facilities in various West and East African
countries. The hours required for maintenance were calculated by considering all the
likely problems which could occur.

80% on maintenance

20% on other HTM activities

70% on maintenance

30% on other HTM activities

60% on maintenance

40% on other HTM activities

80% on maintenance

20% on other HTM activities

20% on maintenance

80% on other HTM activities

In Box 17, the amount of time required for the maintenance of a sample of different
equipment is calculated for a typical health centre (a small facility with several beds
– see Annex 1). Time estimates are also given for the other HTM activities, using
the percentages from Box 16.

Box 18 presents the situation for a typical 100-bed district hospital. Thus, these
boxes reflect primary care requirements.

We recognize that the size of your country, health system, and health service provider
will affect the size of your health facilities and their equipment contents. A health
centre in one country may require the same amount of equipment as a small hospital
in another. Our equipment contents for a 100-bed district hospital may be suited to a
smaller hospital in some countries, or a secondary level facility in others. However,
the figures given in Boxes 17 and 18 are intended to provide you with a realistic
example of typical equipment needs.

In Boxes 17 and 18, we have grouped together a selection of major equipment
items and maintenance needs, under the generic heading ‘technical functions’. This
is not intended to be an exhaustive list, but provides an example of some typical
maintenance needs. To determine the needs of your own health facility, you would
need to carry out your own inventory identifying your specific equipment and
maintenance requirements.

However, the examples here provide a useful illustration of the different technical
needs of such facilities, and the trends in workload. In particular, they are useful in
highlighting the fact that most technical tasks required are at the lower (less
skilled) levels.

3.3.2 Determining your workload requirements

49

BOX 17: Samples of Estimated Hours per Year at Each Skill Level for HTM at a Typical

Health Centre

The findings from Box 17 for a typical health centre are that:

Conclusions:

◆ 93 per cent of the maintenance requirements of a typical health centre are at the

first and second skill level and could be performed by equipment users (with
some additional training), private sector artisans, or retrained health service
craftspeople and technicians.

3.3.2 Determining your workload requirements

50

Skill level one =

Skill level two =

Skill level three =

48% of the total

45% of the total

7% of the total

82 hours

78 hours

12 hours

172 hours per year

=

=

=

=

Total maintenance needs for the sample:

Health centre (typical, several beds)

Hours per year (estimated)

A. MAINTENANCE

Technical functions

Facilities, infrastructure

Building structures Roofing, furniture

Power supply

Water supply, sewerage

Sanitation

Waste management

Equipment for basic medical services

Sterilization

Cooling, air condition.

Basic diagnostic eqp.

Basic laboratory eqp.

Sub-total maintenance hours/year

B. OTHER HTM ACTIVITES (Section 3.2.1)

Work hours (based on percentage of work time, as shown in
Box 16)

Total hours/year

Sample equipment

Generators, solar plants

Storage tanks

Latrines

Incinerators

Autoclaves

Refrigerators

Sphygmomanometer

Microscopes

172

235

Skill
level 1

28

16

82

21 834

103

Skill
level 2

2

8

6

8

6

4

4

18

16

Skill
level 3

8

46

4

8

8

8

46

Skill
level 4

01278

0

020112

3.3.2 Determining your workload requirements

51

◆ Only seven per cent would require skills of the third level (in order to undertake

work such as servicing the microscopes and the power generating equipment).

◆ No skills at the fourth level are required.

Box 18 shows the example of a typical 100-bed district hospital. Here, the
maintenance needs are much more extensive.

BOX 18: Samples of Estimated Hours per Year at Each Skill Level for HTM at a Typical

100-Bed District Hospital

District hospital (typical 100-bed)

Hours per year (estimated)

A. MAINTENANCE

Technical functions

Facilities, infrastructure

Building structures

Power supply

Water supply, sewerage

Sanitation

Waste management

Equipment for basic medical services

Sterilization

Cooling, air condition.

Basic diagnostic eqp.

Basic laboratory eqp.

Basic surgical eqp.

Sophisticated equipment for treatment and diagnosis

Other hospital support services

Sub-total maintenance hours/year

B. OTHER HTM ACTIVITIES (Section 3.2.1)

Work hours (based on percentage of work time, as shown in
Box 16)

Total hours/year

Sample equipment

Roofing, furniture

Generators, solar plants

Storage tanks

Latrines

Incinerators

Autoclaves

Refrigerators

Sphygmomanometer

Microscopes

Suction pumps

Operation table 92 208Surgery

Anaesthesia app. 304Anaesthesia

Foetal heart detector 16 84Obstetrics

Ultrasound equipment. 106Gynaecology

Slit lamp 244Ophthalmology

Photometer 88Laboratory

X-ray apparatus 2416Radiology

Vehicles 500 20300Transport

Telephone system 145 735Communication, data processing

Measuring equipment 80

4,888

Skill
level 1

960

170

100

120

160

120

12

48

20

20

Skill
level 2

192

425 42

300

120

50

120

26

100

120

40

Skill
level 3

14

13

8

4

20

2

16

20

15

1612Technical department

Skill
level 4

20

14

24

56

1143212,3262,127

456214997532

5705353,3232,6597,087

3.3.2 Determining your workload requirements

52

The findings from Box 18 for a typical 100-bed district hospital are that:

Conclusions:

◆ The majority of maintenance requirements relate to the two basic skill levels.

◆ 44 per cent of all maintenance requirements belong to the first level and could

therefore be performed by local private or in-house artisans, and equipment users
with some additional training.

◆ Another 48 per cent of activities need to be undertaken at the second skill level

and could be performed by retrained in-house craftspeople and technicians, with
proper supervision by the health service maintenance specialists from
maintenance level three. Due to the time input, this work could be undertaken by
a small number of craftspeople and technicians based at the district hospital (see
section below on implications for staff numbers).

◆ Only seven per cent of the maintenance requirements have to be undertaken by

health service technologists and engineers at maintenance level three. Due to this
low time input, a single maintenance specialist could serve several district
hospitals and health centres simultaneously. The engineers are also needed to
supervise technical staff throughout the HTM Service and to maintain the high
technology equipment. Thus, technologists and engineers should be based at a
higher level of the HTM Service (such as regional level) in order for their skills to
benefit as many facilities as possible. The skills of each of these costly specialists
can then be utilized across all levels of the health service, thus spreading the
workload and sharing the costs for technologists and engineers among various
facilities or across a larger area. This would help to reduce the financial burden for
each facility.

◆ Sophisticated maintenance operations account for just two per cent of the time

requirements, and these would have to be purchased from the private sector.

Skill level one =

Skill level two =

Skill level three =

Skill level four =

44% of the total

48% of the total

7% of the total

2% of the total

2,127 hours

2,326 hours

321 hours

114 hours

4,888 hours per year

=

=

=

=

=

Total maintenance needs for the sample:

3.3.2 Determining your workload requirements

53

The examples given above show that, to a large extent, maintenance at the primary
care level does not depend on highly skilled staff, and therefore does not necessarily
need to be extremely costly. Depending on the human resources available in your
organization, the majority of the maintenance activities could be undertaken by
existing technical staff with support from general health staff. However, you may
need to provide some additional retraining to ensure they can cover the bulk of
general maintenance needs.

Next, we need to find a way of examining the implications of the technical needs we
have already identified, in terms of staffing numbers.

Implications for Staff Numbers

Once you have an understanding of the hours required for HTM activities, you can
use that information to calculate probable staff numbers.

However, this is not a straightforward calculation that is uniform around the world.
How the hours of work required are converted into probable numbers of staff will
depend on:

◆ how many days a year and hours a day your staff work

◆ the productivity of your staff (how much of the time available is used for work)

◆ how far staff have to travel to reach the job

◆ how long staff have to wait for the necessary inputs, such as spare parts, finances

and transport

◆ quantity and age of equipment items.

One issue to consider when looking at workload is the full range of HTM activities
that staff must undertake. Sometimes traditional maintenance tasks (such as
carrying out repairs) are mistakenly considered to be of higher value than other
HTM activities (such as administration, planning or management activities). This is
mostly due to the fact that they produce more tangible results and are therefore
‘chargeable’. However, all HTM activities are valid and important if you want to
improve the condition of healthcare technology, the health service’s ability to use it,
and the efficiency of the HTM Service. Thus workload estimates should be based on
all HTM activities and not simply maintenance alone.

The second issue to consider when estimating workload is the productivity of your
staff. Productivity reflects the time that staff work compared to the total time
available for work, and depends upon factors such as cultural work practices,
distances to travel, and constraints to undertaking work. Such a ‘percentage
efficiency’ for the use of time is specific to your country. Therefore, you should not
compare your productivity to international figures but to the performance of other
public and private sectors in your country.

Issues such as chargeable tasks and productivity are discussed in more detail in
Guide 6 on financial management.

As an illustration, we present an example that has taken these workload factors into
account. The example is based on a study of large hospitals (ranging from 100 to
1000-beds) in Ghana, Nigeria, and Kenya. They used an alternative method for
calculating the hours required for maintenance, and considered the typical number
of job requests. They were, however, looking at busy and effective maintenance
departments.

Tip

•

There is a danger of basing your calculation of the required hours on numbers of job
requests. If staff in your health facility typically do not report faults and your
maintenance staff do not attend to many jobs per month, your estimate of the
necessary workload will be artificially low.

In Box 19, the amount of time required for the maintenance and repair of healthcare
technology is calculated for a typical 600-bed hospital. Thus, this box reflects
secondary or tertiary care requirements.

3.3.2 Determining your workload requirements

54

Box 19: Estimated Workload for a Workshop at a Typical Well-Patronized 600-bed Hospital

Things to consider

◆ A typical well-patronised

hospital with 600-beds

◆ Hours required to do

maintenance

◆ Hours required for all

HTM activities

◆ Allowance for staff

productivity levels

◆ Calculation of staffing levels

Assumption

◆ Has on average approx. 1,000

outpatients per day and 110
per cent bed-occupancy

◆ Each job takes about three

hours to do and check
thoroughly

◆ Maintenance and repair job

requests account for only
60 per cent of all technical
activity

◆ The ‘percentage efficiency’

of the use of total available
staff-time can reach 50 per
cent (as achieved by the
public and private sectors in
these countries)

◆ Staff working hours are 150

hours per person per month

Outcome

◆ The predicted number of

maintenance and repair job
requests per month to the
on-site workshop is 130

◆ About 390 hours of technical

input is required per month
to deal with repair jobs and
other requests for
maintenance

◆ The total for all technical

activity would then be 650
hours per month

◆ Thus, a total of 1,300 hours

per month of technical staff
input is required to service
such a hospital.

◆ This is equivalent to 8–9

full-time competent staff for
such a hospital

The study found that the amount of maintenance work required relates to:

◆ the size of a health facility

◆ how busy it is

◆ whether it has an on-site maintenance workshop.

A busy facility will cause more wear and tear on assets than a quiet one. Also around
80 per cent of the requests for service made to the maintenance department relate
to facilities and technologies primarily involved with inpatient care. On this basis,
Box 19 shows how technical requirements have been calculated, and how local
workload factors affected the conversion of hours into numbers of staff.

We can use this technique of converting hours of work into staff numbers for the
primary care examples which were given in Box 17 and Box 18. The countries
concerned estimated, for example:

◆ 3,323 hours per year for HTM at skill level two for a 100-bed district hospital

◆ 535 hours per year for HTM at skill level three for a 100-bed district hospital.

Using the same percentage efficiency and staff working hours assumptions as used in
Box 19, the total hours for technical input per year become:

◆ 6,646 hours per year at skill level two – this translates to three craftspeople/

technicians to cover one district hospital, or four to cover one district hospital and
7 health centres

◆ 1,070 hours per year at skill level three – this translates to one

technologist/engineer to serve two district hospitals, or one technologist/engineer
to serve one district hospital as well as many health centres, and the supervision of
other technical staff.

Further information about how to calculate your personnel needs for the HTM
Service is given in Section 6.

These examples are useful as they illustrate that the trend is for few staff at the
primary care level, with the majority at the lower skill level. Staff at the higher skill
level are used to support many health facilities.

The example in Box 19 also highlights that larger hospitals need larger HTM
Teams. For secondary and tertiary care facilities with large numbers of hospital beds,
a greater percentage of the equipment is complex or sophisticated. Also, not all
manufacturers’ representatives in your country will have the technical capacity to
support this equipment. So for many countries, one solution is to increase the
numbers and levels of technical staff within their HTM Service for these large
facilities (Section 6.1).

Box 20 outlines the issues to consider if you wish to determine the technical
requirements for your organization.

3.3.2 Determining your workload requirements

55

Section 3 summary

56

BOX 20: A Checklist for Understanding Your Technical Requirements

Check what your technical requirements are:

◆ Do your facilities have equipment inventories that would help you to determine the major maintenance

requirements?

◆ Using the examples highlighted, would you be able to determine the major maintenance and other HTM

requirements at your facility or district?

◆ Which of these requirements could be covered by the staff which currently exist in your facility, district,

or region?

◆ Which of these requirements could be covered by technical staff which exist in other facilities or in the

private sector?

◆ Using the examples highlighted, would you be able to determine the workload requirements at your

facility or district?

◆ What are the personnel resources available for HTM in your facility, district, or region?

◆ Can these staff cover the workload requirements?

◆ Which parts of healthcare technology management could already be introduced in your facility/district

or region?

◆ What deficiencies are there in your HTM system?

Box 21 contains a summary of the issues covered in this Section.

BOX 21: Summary of Issues in Section 3 on Determining Technical Requirements

Senior technical
staff, or existing
HTM Teams,
at all levels

Senior planners
in health service
provider
organizations

Senior technical
staff, or existing
HTM Teams,
at all levels

Senior technical
staff, or existing
HTM Teams,
at all levels

Workload Skills Needed HTM Activities

◆ collaborate to determine the technical requirements for HTM at different levels

of the health service

◆ use estimates of skill and workload requirements (Section 3.1–3.3) for this

purpose

◆ pass on the information to senior planners

◆ use the technical requirements to design the model and organizational structure

for the HTM Service (Sections 4 and 5).

◆ use the equipment inventory to determine the skill requirements for

maintenance and other HTM activities, in order to help design the HTM Service

◆ ensure that HTM activities are carried out effectively throughout the HTM

Service (see Guides 2–6)

◆ determine the hour requirements for maintenance and other HTM activities

◆ translate the hour requirements into probable staff numbers according to local

workload factors, in order to help design the HTM Service

4. How to choose the model for your HTM service

57

4. HOW TO CHOOSE THE MODEL FOR
YOUR HTM SERVICE

Why is This Important?

There are several different models for providing HTM activities. It is useful to
understand the options that may be available to you when developing your HTM
Service, and to choose the most appropriate model that suits your situation.

For HTM to be effective, it needs to be seen as a normal part of general health
management activities. HTM activities need to be integrated into the health
management system. There are a number of strategies for doing this.

Having determined the technical requirements for different levels of your health
system (Section 3), you can investigate the best model for satisfying those needs.
In this Section, we discuss:

◆ different providers of HTM activities (Section 4.1)

◆ ways to incorporate HTM into the health management system (Section 4.2).

4.1 PROVIDERS OF HTM ACTIVITIES

4.1.1 Possible Sources

In any country, a range of HTM activities can be provided in different ways. The key
providers of HTM activities are outlined below:

i. Individual ‘In-house’ Skills

In a number of developing countries, individual facilities have invested in technical
staff (such as artisans, technicians, engineers), as well as the resources they need
to function effectively. In these instances, the facilities greatly benefit from having
in-house technical skills for healthcare technology management.

health facility health facility

workshop

technical

support

or

no technical

support

4.1.1 Possible sources

58

Advantages: Having your own technical staff available on site is invaluable for
providing advice and a quick response. Thus there is a crucial role for in-house
providers of HTM activities.

Disadvantages: If each health facility develops separate individual in-house skills,
the technical staff on site may become isolated, with no back-up or support, and
many activities and skills have to be duplicated across the health service.

Also, in many developing countries the reality is that health service providers rarely
provide an adequate maintenance service within their facilities, let alone the
broader HTM role. In many cases some maintenance services are planned, but
cannot be implemented properly due to lack of financial and personnel resources. In
these instances, you may need to retrain existing staff, employ staff, or contract
additional technical support from the private sector.

ii. Existing Technical Referral Networks in the Health Sector

In a number of countries, different health service providers have already set up a
referral network of maintenance workshops to cater for the technical needs of their
own health facilities. In this way, the in-house skills at individual health facilities are
linked in an overall HTM Service.

Advantages: A referral network offers a greater range of skills to health facilities by
outreach from other locations, as well as support and supervision for individual
maintenance staff from their colleagues.

B

Health service provider A Health service provider

A

B

possible technical support

technical

support

A

B

A

4.1.1 Possible sources

59

Since small health service provider organizations may not find it economical to
develop such a network (see disadvantages below), an attractive idea for those with
an existing HTM Service is the possibility of expanding their network to cover, and
sell services to, facilities owned by other health service providers. Thus,
government, NGO, and private health service providers could all consider an
expansion of their role.

For health service provider organizations with an existing HTM Service, expanding
their coverage to facilities of other providers would be relatively easy, since they
already have an organization in place, together with some qualified staff and a
support structure.

Disadvantages: The capital investment required to establish a referral network of
workshops may not be economical for health service providers that only have a few
health facilities.

For health service provider organizations with an existing HTM Service, expanding
it to cover facilities of other providers would introduce an extra workload which, at
the beginning, may not generate sufficient additional income to cover the cost
increases. This may be the case for a number of years, and may even require some
subsidies.

iii. Collaborative Arrangements

An alternative approach to creating a referral network would be for a number of
health facilities under different ownership to collaborate to form a new organization,
which is jointly owned. This would then provide an HTM Service for them all. For
example, there could be collaboration between:

◆ the government and the mines

◆ one church organization and another

◆ groups of facilities under different ownership in one region.

Workshop of
health service

providers A, B and C

C

technical

A

B

support

4.1.1 Possible sources

60

Advantages: Such networking is very important. It may be the only way to obtain an
HTM Service, due to the high capital investment involved in its establishment.
Such a collaboration between organizations enables the various health facilities to
have an influence over the way the HTM Service is run. Such a joint venture could
also generate significant savings compared to running an independent HTM Service
in each health service provider organization.

Disadvantages: When creating such a partnership there would be a lack of any
supporting services and structures in the beginning. These would subsequently have
to be jointly developed. In addition, it may be necessary to hire technical and
administrative staff.

Experience in Tanzania

The Mbeya Hospital Maintenance Association (MBEHOMA) is a non-profit organization

that installs, maintains, and repairs hospital and other technical equipment. In the 20

years of its existence, it has proved that a regional maintenance service can be operated

without large subsidies.

Currently, most of its operating cost is covered by the income obtained from the sale

of services. MBEHOMA’s income is composed of different fees. The annual membership

fees of the member hospitals help to cover overheads. In return, members are served first

and charged reduced fees for actual service and mileage. In addition to service and

mileage fees, MBEHOMA also charges a fee for procuring equipment or spare parts. Only

hospitals are accepted as members of MBEHOMA. By 1999 it had eight members – seven

church hospitals of different denominations and one private hospital of a tea company.

Due to the good reputation of MBEHOMA, members of the MBEHOMA team work 40 per

cent of their time for private customers such as schools, hotels, or local entrepreneurs.

As they are charged more than the member hospitals, the fees from private customers

amount to 60 per cent of the total income. As well as medical equipment, the technicians

are able to plan for and maintain a wide range of other equipment – for example

electrical installations, water pumps, cars, and even solar-powered systems.

4.1.1 Possible sources

61

iv. Maintenance Services From Other Sectors

In some countries, other agencies have been given the authority for the maintenance
and procurement of certain types of equipment. For example:

◆ In the government sector, the Ministry of Works may be responsible for health

buildings, plant, and service installations, the Ministry of Supplies may be
responsible for furniture and office equipment, and the Ministry of Transport
for vehicles.

◆ In the non-government or private sectors, there may be a Maintenance Service or

a Logistics Division separate to the Health Division that has authority over
different types of equipment.

◆ There will also be national electricity supply, water supply, and telecommunication

authorities with varying responsibilities for different types of equipment.

Therefore these agencies also run HTM Services, and will need to organize and
improve their management skills accordingly.

Advantages: If these other agencies are effective, they carry out important work for
your health service provider. You need to follow their policies and guidelines for the
types of equipment they are responsible for, and should not interfere with any
equipment outside of your responsibility.

Disadvantages: These agencies usually have lots of other clients besides your
health service provider and may not give you the response and time that you require.
If you are unhappy with the service provided, your health service provider may need
to re-negotiate the responsibilities of the different agencies, in order to ensure that
all the equipment the health service relies upon is in good working condition.

Ministry

of Works

Utility

Authority

technical

support

Logistics

Division

4.1.1 Possible sources

62

Ideally, the health service provider should have overall management control of all its
equipment. In reality, you have no control over the finances allocated by these other
maintenance agencies for your needs. It can often be difficult to coordinate and
control staff from other maintenance agencies working on health facility sites. With
many agencies involved, there is often a duplication of skills on site (such as welders,
electricians, carpenters).

For this reason, it is sensible to ensure your in-house HTM Service is multi­disciplinary, and includes technical skills for all different types of equipment. The
staff members of such a multi-disciplinary service have one boss only (the health
service provider), work together for the good of all the physical assets of a health
facility and not just some of them, and pool their skills.

v. Private Sector Companies and Individuals

Most countries need to count on private sector support for some, if not all, of the
following:

◆ maintenance and repair

◆ supplies of spare parts

◆ technical advice

◆ installation and commissioning

◆ training.

Experience in Zambia

As in many developing countries, Zambia had established a Public Works Department

(PWD). This was responsible for maintaining the buildings, plant, service supply

installations, and furniture of all government facilities including health facilities. But the

PWD had a large workload, and had a financial system that did not transparently show

money per client (for example, the Ministry of Health). Thus, the government decided to

disband the PWD and allow individual ministries to take on their maintenance

responsibilities and the management of all their physical assets.

The Ministry of Health absorbed many of the PWD plant technicians to join their existing

medical equipment technicians. In this way, they created multi-disciplinary maintenance

teams at hospital workshops for all technical needs, under the control of a single

authority – the hospital.

Private sector companies may include the manufacturers of equipment,
representatives of the manufacturers, or enterprises that should contain suitably
skilled personnel and resources. Private sector individuals may include artisans
acting as sole traders, who should have recognized certified skills and their own tools.

Advantages: Private sector companies and individuals (such as artisans) can have
substantial technical skills, plus extensive knowledge about the equipment they
make or sell. Before appointing them, however, you should make sure they are
skilled, reputable, and have sufficient resources to carry out the job (such as a
workshop, technical staff, and spare parts).

Disadvantages: Private sector individuals may have few resources and limited
access to the spare parts required. Support from private sector companies is usually
limited to certain brands of equipment, which they also sell. It is unlikely that
private enterprises will be either able or willing to expand their services to cater for
all brands of equipment. In any case, health service providers would not want to be
tied to such a monopoly situation. For a fuller discussion on contract management,
see Guide 5.

It is also rare for private sector companies and individuals to be based at your health
facility site, so the quality of their support may be affected by factors such as the
distance to travel, response time, and their workload.

4.1.1 Possible sources

63

Service Co. Ltd.

technical support

workshop

Besides maintenance, repair, installation, commissioning, and training, it is unusual
to hand over control of any other HTM activities to private sector companies that
you have contracted, such as:

◆ making work schedules

◆ advising on selection and procurement

◆ planning and costing work

◆ monitoring and ordering stores

◆ managing the database

◆ financial management

◆ writing reports and keeping statistics

◆ managing and supervising technical staff.

Thus you will always need in-house technical staff to undertake these tasks, manage
the contracts with the private sector, and monitor the work of private sector
personnel. It is a good idea to develop a register of these artisans and firms, which
can be updated regularly to include new sources of support or exclude others who
have not performed to the required standards. For more details on how to do this, see
Guide 5 on maintenance management.

4.1.2 Strategies to Consider

HTM activities come under the ‘service provision’ function of health services
(Section 2.1). This means that, as with health services, they could be controlled and
run either by:

◆ government agencies, such as Ministries of Health, Works, or Defence

◆ non-government organizations, such as churches or charities

◆ private sector companies, such as mines, plantations, or health insurance companies

◆ a mixture of these organizations.

In reality, it is usually simplest for your HTM Service to be controlled and run along
the same lines as your health service provision system. For example:

◆ if health service provision is totally dependent on the government, it is advisable

to include the HTM Service in government services

◆ if health service provision is run privately or by a mixture of the private and public

sector, it might be more effective for your HTM Service to be run privately.

In either case, you would need to establish a regulating system in order to ensure
quality, standards, and safety of the services provided (Section 2).

4.1.1 Possible sources

64

4.1.2 Strategies to consider

65

An HTM Service provides your health service provider with an internal technical and
managerial capability for HTM activities. This is essential if you are to obtain overall
management control of all your equipment.

For this to happen smoothly, we suggest the first requirement for your HTM
Service is to have your own HTM Team (Section 1.1) at each health facility and
administrative level, whether a workshop exists or not, to undertake technical
activities. The second requirement is for these in-house teams to be linked in a
referral network, which will provide access to an increased range of skills and
support. In Sections 5 and 6, we discuss ways in which you can achieve these
requirements with limited staff. We also provide a description of the responsibilities
of the HTM Teams at different levels of the health service.

Although your HTM Service will oversee HTM activities it does not have to carry
them all out itself. In reality, it would not be able to do so. Therefore, the third
requirement for your HTM Service is to ensure all HTM activities you require (as
identified in Section 3) take place, by using a range of the different providers
(Section 4.1.1). It is common for a mix of providers to be used to deliver the full
range of technical activities, for example:

◆ the government health service may have a technical referral network, services

provided by other sectors (such as Ministry of Works), and make use of the
private sector

◆ church health service providers may use collaborative arrangements, and contract

help from another health service provider

◆ private health service providers may have in-house skills and make use of private

sector support.

Of course, the model you use to deliver all your technical requirements will depend
on the size of your health service provider, the area it covers, and the available
providers of HTM activities. However, innovative solutions arise when health service
providers consider new collaborations, and make use of other sectors to cover the
HTM activities they cannot currently cope with themselves. Your HTM Teams
should therefore:

◆ offer to provide their services to other health service providers, where possible

◆ oversee the work of other providers of HTM activities who you contract in to help.

4.1.2 Strategies to consider

66

4.2 INCORPORATING HTM INTO HEALTH

MANAGEMENT

Very often healthcare technology management is seen as an independent task with
very limited links with the other parts of the health service. This has meant that, in
the past, technical staff were rarely involved in such crucial tasks as investment
planning, evaluation of the quality of health services, or organizational issues.
Fortunately, these attitudes are slowly changing.

Therefore, we suggest that the fourth requirement for your HTM Service is to
have the head of each HTM Team – the HTM Manager – as a member of the
relevant health management team (at facility, district, regional, or central level). The
HTM Manager will represent the HTM Team in management committees at all
levels, ensuring that:

◆ a technical viewpoint is present in health planning decisions

◆ healthcare technology management is seen as a collective responsibility for all

health staff.

In addition, we need to ensure HTM finds its proper place in the health system
(Section 1.1), and becomes part of normal health management activities undertaken
by health staff at all levels of the health service. Equipment should not be managed
in isolation, but must be linked to all the other components which are necessary for
healthcare delivery, including the aims, procedures, finances, staffing levels,
supplies, and support systems at each level of the health service.

Experience in Tanzania

In Tanzania, over recent years, eight separate HTM Services have been created in

different parts of the country. These ‘zonal health care technical services’ are

associations of various hospitals and health facilities. The health facilities are run by the

government, the private sector, or churches and NGOs.

Each of the zonal health care technical services covers 10 to 15 hospitals in one or more

regions of the country and also assists the health centres in that area. The member

hospitals usually have to pay a yearly membership fee, which assures them of

preferential treatment by the zonal health care technical service and preferential fees for

HTM activities, including a limited number of free maintenance services. Non-members

also receive support, but have to pay much higher service fees.

The zonal health care technical services are supported by a country-wide health care

technical service, which is assisting the zonal services by supervising them and

providing networking activities. The country-wide health care technical service is

provided by the Christian Social Services Commission, which is a national organization

representing the public sector and the major churches active in Tanzania.

To achieve this, we suggest that the fifth requirement for the HTM Service is to
establish an HTM Working Group at each level (facility, district, region, centre).
This multi-disciplinary group should report to the health management team, and be
responsible for reviewing the equipment situation and planning equipment needs at
that level. It should comprise all types of stakeholders that have an important role to
play in HTM, such as administrative, medical, finance, supplies, and technical
personnel, as detailed in Section 1.1. Some members of the HTM Team are
therefore also part of the HTM Working Group.

Teamwork is very important and collective decisions should be taken on all
equipment management matters. Working Group members should communicate
regularly and help one another solve daily operational problems. The healthcare
technology management considerations of this HTM Working Group could include:

◆ identification of health needs (see Guide 2 on planning and budgeting)

◆ equipment purchase plans (see Guide 2)

◆ budgeting for equipment purchases and maintenance (see Guide 2)

◆ establishment and updating of inventories (see Guide 2)

◆ specification of equipment needs (see Guide 3 on procurement and commissioning)

◆ supervision of procurement processes (see Guide 3)

◆ logistics support (see Guide 3)

◆ training of users and technical staff (see Guide 4 on operation and safety, and

Guide 5 on maintenance management)

◆ organization of the supply and storage of accessories, consumables, and spare parts

(see Guides 4 and 5)

◆ ensuring maintenance and repair activities take place (see Guide 5)

◆ ensuring the efficiency of the HTM Teams (see Guide 6 on financial management).

4.2 Incorporating HTM into health management

67

4.2 Incorporating HTM into health management

68

In this way, the full range of HTM activities (Section 3) become part of the normal
working considerations of the health management team.

However, the HTM Working Group should only undertake the tasks for which they
have the appropriate management skills.

Tip

•

It is important not to decentralize responsibility too quickly before the necessary
management skills are in place. For example, some countries have tried to
decentralize the funding for equipment maintenance, but when funds were short
the local authorities, without an appreciation of its importance, simply cut planned
preventive maintenance activities.

•

The range of HTM activities undertaken at each level of health management should
depend upon the development of management skills at that level.

In a number of developing countries, moves have been made at central or national
level to try to incorporate HTM into the general health management system.
However, it is commonly recognized now that it is essential for equipment
management activities to form part of district planning processes. Thus HTM
should be interlinked with all the conventional elements of the (district)
management cycle, such as:

◆ planning and coordination of budgets, staff, supplies and transport

◆ the Health Management Information System (Section 7.3), including inventories

◆ communication, supervision and support, monitoring and evaluation

◆ human resource development and training

◆ operations research.

The HTM Service does not require a separate management system for daily operations
but should be part of the district management system. Setting up special management
schemes for specific work areas in healthcare (‘vertical programmes’) is widely seen
as inefficient due to duplication of effort, and may also be unsustainable. However,
internal workshop and technical work organization should be managed with professional
technical support from within the HTM Service

If HTM Teams are to support other facilities by outreach, the hospitals where they
are based must appreciate the HTM Team’s dual role – to undertake HTM activities
both for the hospital, and also for other health facilities, as part of a broader
organization-wide network.

Section 4 summary

69

Box 22 outlines the issues to consider if you wish to determine the model to use for
your HTM Service.

BOX 22: A Checklist for Determining the Model for Your HTM Service

Check which delivery models and strategies already exist in your country:

◆ Can you describe the different types of HTM providers available in your country?

◆ Which HTM providers does your health service provider make use of?

◆ Are there other collaborations you could make that would usefully cover some of your unmet HTM needs?

◆ Is your HTM organization a network covering many facilities at the same time?

◆ Do you have HTM Teams at each facility and decentralized authority level for technical tasks?

◆ Do your technical staff get involved in health planning issues, by being present on health management

committees?

◆ Is HTM seen as a normal part of health management?

◆ Do you have HTM Working Groups at each facility and decentralized authority level to advise on

equipment issues?

Box 23 contains a summary of the issues covered in this Section.

BOX 23: Summary of Issues in Section 4 on Choosing the Model for Your HTM Service

Health Service
Providers and
Health
Management
Teams

Health Service
Providers and
Health Management
Teams

Incorporate HTM HTM Providers

◆ investigate what types of HTM providers are available

◆ consider new collaborations so that all HTM needs are covered

◆ develop HTM Teams at facility and decentralized administration levels

◆ link these HTM Teams in a referral network

◆ incorporate HTM into health management at all levels of the health service

◆ ensure HTM is linked to its complementary components for delivering

healthcare

◆ ensure HTM Managers participate in health management committees

◆ create multi-disciplinary HTM Working Groups to advise health management

teams

70

5. How to develop an organizational structure for the HTM service

71

5. HOW TO DEVELOP AN ORGANIZATIONAL

STRUCTURE FOR THE HTM SERVICE

Why is This Important?

A Healthcare Technology Management Service (HTMS) has specific tasks at
different levels of the health system. It is important to understand the variety of
tasks that should be undertaken by the HTM Teams and HTM Working Groups
at the various levels. A clearer understanding of how the various different levels
of the HTMS relate to one another will help you to clarify staffing roles and
ensure an adequate division of labour across the health service.

You need to design an organizational structure for your HTMS that is suited to
your health service provider organization, and can be incorporated into any
countrywide system.

Having chosen your model for providing an HTM Service (Section 4), you need
to establish the organizational structure required to implement it. In this Section,
we discuss:

◆ the relationship between the health delivery system and the HTM Service

(Section 5.1)

◆ the placement of staff at different levels of the HTM Service (Section 5.2)

◆ responsibilities at each level of the HTMS (Section 5.3).

The way in which your HTM Service is organized will depend upon your country and
health service provider organization. It will depend upon factors, such as:

◆ the geography of the area

◆ population distribution

◆ financial and human resources

◆ the form of health service provision.

However, it is important for the HTM Service structure to spread throughout your
health service provider organization, and for there to be an HTM organizational
structure throughout the country.

In this Section, we present a complete example of an organizational structure for the
HTM Service. This is based on a concept already being implemented in many
developing countries. However, you may need to adapt this model to suit your own
country’s situation. If your health service provider is a small organization, or if you are
just starting out, your organizational structure may form only a small portion of the
structure presented here.

5.1 Relationship between the health delivery system and the HTM service

72

5.1 RELATIONSHIP BETWEEN THE HEALTH

DELIVERY SYSTEM AND THE HTM SERVICE

The level and complexity of services offered determines the structure of health
delivery systems. At the lower end of the network are health service units, such as
health posts and health centres (see the Glossary in Annex 1), which perform only
limited tasks. At the top of the network are more complex facilities, such as a central
hospital covering all the specialities present in the country.

Such a network is known as a referral system, because the many health facilities at
the lower level refer patients for more complex treatment to the fewer facilities at
higher levels, where specialists are concentrated and can provide the sophisticated
services required. An outline of a typical national referral system in the government
sector is shown in Figure 7.

Figure 7: Pyramid Referral System of Government Health Services

As the example in Figure 7 is from the government sector, the decentralized levels
are based on political administrative divisions in the country, such as regions and
districts. The referral system for other health service providers will look slightly
different. Their administrative levels will cover facilities in different geographical
zones based on features of the organization, for example:

◆ Church organizations may administer their health facilities by diocese, and refer

patients to a diocesan hospital.

◆ The private sector may have facilities spread over a large area and administer

them by province, and refer patients to a provincial hospital.

National level

Regional level

District level

Regional

hospital

District

hospital

Health centres, health posts, etc.

Central

hospital

District

hospital

Regional

hospital

District

hospital

Tertiary care

Secondary care

Primary care

5.1 Relationship between the health delivery system and the HTM service

73

The type of zones, their labels, and the number of zonal levels will vary with the
health service provider.

Our first consideration for the HTM Service is that it should cover the needs of the
different types of health facility of your health service provider. In Section 3.2.1
(Box 15), we distinguished four skill levels required for the maintenance of our
equipment stock, and for HTM activities in general:

skill level one – basic-level tasks

skill level two – medium-level tasks

skill level three – high-level tasks

skill level four – sophisticated-level tasks.

We discovered that:

◆ The major workload at primary care facilities (health posts, health centres, and

the first-referral hospital, such as a district hospital) is at skill levels one and two.
It should be possible to tackle this workload with the staff present in the district,
with some additional training.

◆ Anything more complex (requiring skill level three) could be referred up to a

location with more specialist technical staff. These specialists would be fewer in
number and grouped at locations where they could offer technical support by
outreach to a range of health facilities.

◆ Finally, there would be central level supervision and support (at skill level four)

from technical managers overseeing the HTM Service as a whole, and
sophisticated maintenance input from the private sector.

Our technical requirements for HTM will therefore naturally fall into a referral
system that mirrors the health delivery system.

In Section 4 we determined that healthcare technology management should be a
part of health management at each level of the health service. Therefore, the second
consideration for the structure of the HTM Service is that it should fit the
decentralized health authority levels of your health service provider organization.

We defined five requirements for the HTM Service:

◆ an HTM Team at every facility and level, whether a workshop exists or not

◆ the teams to be linked in a referral network

◆ all HTM activities to be covered by making use of other HTM providers for

unmet needs

◆ the head of each team, the HTM Manager, to sit on the health management team

◆ a multi-disciplinary HTM Working Group at every facility and level to advise the

health management team on equipment issues.

If we combine these needs we can start to see the sort of organizational structure
required for an HTM Service that reflects the referral nature of healthcare delivery.
This is laid out in Section 5.2.

5.1 Relationship between the health delivery system and the HTM service

74

This hierarchical referral structure for the HTM Service helps us to determine the
sort of partners that HTM staff will work with at each level. An example is shown in
Figure 8 for the government sector. Again, for other health service providers the
names of the partners may vary (such as a diocesan health management team, a
provincial HTM Team), although the principle remains the same.

Figure 8: Partners Working with HTM Staff at Each Level of the HTM Service

Level HTM Actors Partners

National Level

Regional Level

District Level

National HTM Team and
HTM Working Group

Regional HTM Team and
HTM Working Group

District HTM Team and
HTM Working Group

Ministry of Health
Regional HTM Teams
Regional HTM Working Groups
External support agencies
Training facilities
Private sector companies
Hospital health management teams
Central hospital
Regional hospitals
Equipment users in hospitals
Other HTM providers
HTM Services of other health service providers

Regional health management team
District health management teams
District HTM Teams and Working Groups
Hospital health management teams
Regional hospital
District hospitals
Equipment users in hospitals
Private sector companies and individuals
Other HTM providers

District health management team
Facility HTM Teams and Working Groups
Facility health management teams
District hospital
Health centres
Health posts
Equipment users
Private sector companies and individuals
Other HTM providers

Facility Level

Facility HTM Team and
HTM Working Group

Facility health management team
Smaller health facilities
Equipment users
Private sector companies and individuals
Other HTM providers

5.2 PLACING STAFF AT THE DIFFERENT LEVELS OF

THE HTM SERVICE

The HTM Service should be structured in order to provide a clear division of labour
between the different levels of the HTM system. We recognize that the overall
number of HTM Teams and levels will depend on the size of your country, size of
your health service provider organization, number of health facilities, and how far you
have gone in developing your HTM Service. However, using the recommendations
from Section 5.1, the following levels are suggested.

Facility Level

Facilities Without Workshops

Equipment maintenance and general management need to take place even where
there are no workshops. Thus, general health facility staff should be included in the
HTM Service. A number of countries have developed the first level of their HTM
network as ‘maintenance teams’ or ‘equipment management teams’ based at small
facility level where there are no workshops. Such HTM Teams are made up of a
couple of suitable and interested staff from any discipline (such as a nurse, an
administrator, a storesperson), who are given additional training. They:

◆ oversee the daily running of technology within the facility

◆ are the contact point for all equipment and maintenance matters

◆ are responsible for finding the correct solutions to problems

◆ possibly undertake the maintenance themselves (depending on the size of the

facility, the skills available, and the training provided).

These Facility HTM Teams ensure that basic-level tasks (skill level 1) are
undertaken by themselves, equipment users, or locally available artisans (Section 3),
with support from a higher referral level (see below). All the tasks at other skill levels
are undertaken by technical staff from higher up the HTM Service (see below) or by
other HTM providers (Section 4).

5.2 Placing staff at different levels of the HTM service

75

To complete the HTM Service at this level, there is a Facility HTM Working Group
that advises the health management team on equipment issues. The multi­disciplinary Facility HTM Working Group should include the head of the HTM Team
(the HTM Manager). For small health facilities (such as a health centre with only a
few beds, and few staff) the health management team will be small, but members can
still be nominated to be responsible for HTM issues. For very small facilities (such as
a health post with no beds and only a couple of staff), there may be no health
management team but a community committee instead. This committee could
consider how it can respond to minor HTM issues (mainly to do with the fabric of the
building), and more major issues could be referred to the district health authority.

5.2 Placing staff at different levels of the HTM service

76

Small health
facility

technical

support

from a

higher level

technical

assistance

HTM

Team

HTM
Working
Group

health
manage­ment
team

Experience in Madagascar

In Madagascar, a maintenance system is being developed in Majunga Province that uses

existing health workers at sub-district level without workshop facilities. The health workers

are called ‘Agents de Maintenance’. They look out for technical problems and coordinate

maintenance interventions with their provincial workshop. They are being trained by

workshop staff and equipped with a set of tools to undertake some of the work themselves.

To date, the ‘Madagascar Model’ has worked more effectively than expected. The main

reason for its success is that the individuals involved have experienced an increase in

prestige, and have started to utilize their newly acquired maintenance knowledge

outside their work, enabling them to supplement poor salaries. The personnel made

responsible for maintenance are being supported and supervised by the technicians of

the provincial workshop and, hopefully in future, by the provincial supervision team.

Facilities With Workshops

Larger health facilities will have Facility HTM Teams containing different types of
technical personnel (such as artisan, technician, technologist), and will require a
workshop. Which type of hospital has technical staff based within it, and which type
has a workshop of its own, depends on your country, your health service provider, the
facility size, and how recently you began to establish an HTM Service.

5.2 Placing staff at different levels of the HTM service

77

For example, a district hospital could have a workshop and three to four technical
staff (artisans and technicians), who would carry out the appropriate HTM tasks at
skill levels 1 and 2 (basic- and medium-level tasks) as described in Section 3.
Depending on your organization, these tasks could be undertaken by the existing
technical staff in your hospitals, after receiving appropriate retraining.

Bigger hospitals would have larger HTM Teams and would require skills for
medium- and high-level tasks (levels 2 and 3). Their HTM Team would therefore
include technologists and possibly an engineer, depending on your country (see
zonal level below).

For facilities with workshops, the head of the HTM Team, the HTM Manager, will
have technical skills. The HTM Manager should sit on the health management
team, a large committee, to provide technical advice. The HTM Manager should
also be a member of the multi-disciplinary Facility HTM Working Group, which will
advise the health management team on equipment issues.

Since hospitals with workshops have larger HTM Teams with a greater variety of
skills, these HTM Teams can act as referral centres for lower-level health facilities
(such as health posts and health centres) in the surrounding area. Back-up support
would be provided by technical staff higher up the HTM Service.

The technical team based in a hospital will therefore require sufficient staff, skills,
and resources to enable them to provide technical support to smaller facilities. In
particular, such teams need access to support staff, such as a cleaner, clerk, secretary,
storesperson, and driver. Which type of hospital offers technical support by outreach
will depend on your health service provider and country. The workshop at a hospital
offering technical outreach support may be designated as a district workshop or a
regional workshop in the HTM Service (see zonal level below).

Large facility

Small facility

technical

support

from a

higher level

technical

support

technical

assistance

HTM

Team

HTM
Working
Group

Workshop

health
manage­ment
team

technical

assistance

HTM

Team

HTM
Working
Group

health
manage­ment
team

5.2 Placing staff at different levels of the HTM service

78

Zonal Level

The facility level needs to be supervised and supported by a workshop at a higher
level. Such a workshop can be based at the administrative division of a particular
country – a district, or a region. Alternatively, it can be based on a ‘zone’ – a specially
formed geographically coherent area. For the HTM Service, such areas could be
determined on the basis of the following criteria:

◆ Coverage of an area with unsatisfied demand.

◆ Availability of a strong and competent HTM implementing agency.

◆ Sufficiently large numbers of health facilities to ensure economies of scale and

financial viability for HTM activities.

◆ Existence of a commercial centre for provision of equipment, spare parts, and

sub-contractors.

The number of administrative levels in the HTM Service will depend on the
number of zonal levels you use. This will depend on your organization, and how far
you have developed your HTM Service. For example, many countries place a
workshop in a large zone such as a region or province, each of which covers a number
of districts. Ideally, at some point you will develop your HTM Service to also have
workshops at a smaller zonal level, such as the district or diocesan level. This is
important since equipment management activities should form part of district
planning processes.

District or Diocesan Level

The HTM Service should be represented at district level and be responsible for all
health facilities in the district. The district workshop acts as a referral centre for
HTM needs from the periphery, and undertakes HTM activities by outreach for
facilities within the district. There is no set rule for locating the district workshop.
Some health service providers expand the responsibilities of the district hospital
workshop to cover the needs of the whole district. Others establish a workshop at a
separate site to cover the needs of health posts and health centres, and leave the
district hospital workshop to care for the hospital’s needs.

The District HTM Team is usually in charge of basic- and medium-level technology
tasks (skill levels 1 and 2). It looks after the maintenance needs of the health centres
and health posts, which rarely have their own technical staff. Thus all HTM activities
within the district can normally be carried out using the skills already available, such as:

◆ equipment users, with additional training

◆ retrained technical staff that already exist, based at your hospital or district workshop

◆ private sector artisans.

79

5.2 Placing staff at different levels of the HTM service

However, in order to carry out these activities, they would require back-up support
from technical staff higher up the HTM Service, such as a Regional or Provincial
HTM Team (see below).

The activities of the District HTM Team are headed by the District HTM Manager.
To ensure all HTM activities are considered at district level, the District HTM
Manager sits on the multi-disciplinary District HTM Working Group, which advises
the district health authority on equipment issues.

Depending on the organizational arrangement, the District HTM Team reports to
the district (or diocesan) health authority for daily operational issues. For technical
and professional issues, the District HTM Team reports to a higher level HTM
Team, that offers supervision and support (see below).

Zonal level

Facility level

– large

– small

technical

support

technical

support

from a

higher level

technical

assistance

HTM

Team

HTM
Working
Group

Workshop

health
manage­ment
team

technical

support

technical

assistance

HTM

Team

HTM
Working
Group

Workshop

health
manage­ment
team

technical

assistance

HTM

Team

HTM
Working
Group

health
manage­ment
team

5.2 Placing staff at different levels of the HTM service

80

Regional or Provincial Level

The HTM Service is also represented at regional level, in order to supervise and
assist both the district and the facility levels contained within the region. The
regional workshop acts as a referral centre for HTM needs that cannot be
undertaken in the districts, and undertakes HTM activities by outreach for facilities
within the region. Again, there is no set rule for locating the regional workshop – it
could be an expansion of the role of the regional hospital workshop, or it could be at
a separate site.

The Regional HTM Team is usually in charge of high technology tasks (skill level 3)
for the region. It also supervises and supports the work undertaken by the District
and Facility HTM Teams and the private sector artisans and firms. Thus the
Regional HTM Team should have technologists, and even engineers, to offer this
higher level of referral support.

To begin with, the maintenance specialists at regional level will need to devote a
large part of their time retraining artisans and technicians at lower levels of the
service. In time, the artisans and technicians in the districts will be able to carry out
many of the necessary jobs by themselves, turning to the specialists only in difficult
cases and for certain equipment. The Regional HTM Teams will then be able to
concentrate on more complex jobs, sophisticated equipment, and their supervisory
role, with help from the Central or National HTM Team.

The Regional HTM Team is headed by a Regional HTM Manager. To ensure all
HTM activities are considered at regional level, the Regional HTM Manager sits on
the multi-disciplinary Regional HTM Working Group which advises the regional
health authority on equipment issues.

Depending on the organizational arrangement, the Regional HTM Team reports to a
Regional (or Provincial) health authority for daily operational issues. For technical
and professional issues, the Regional HTM Team reports to a higher level HTM
Team that offers supervision and support (see below).

Central or National Level

At the head of the HTM Service, an HTM Team acts as a coordinating and
supervising unit for the entire system. Depending on your organization, this will be
your Central HTM Team or the National one. Such a Central HTM Team supports
and supervises the Zonal and Facility HTM Teams and Working Groups.

5.2 Placing staff at different levels of the HTM service

81

The Central HTM Team may have its own central workshop. This may be based at
the largest type of hospital in your organization (for example, a national referral
hospital in the government sector) or at a separate site. This is where the highly
qualified HTM staff, such as engineers and engineering managers, are based to
supervise the work of all other HTM Teams.

The skills of the staff at central level are such that they could undertake, and will
monitor, most of the jobs required at lower levels of the system. However, the major
workload at this level should be advisory and supervisory tasks. The central level
manages the contracts with the private sector for specialized maintenance tasks
(skill level 4). The Central HTM Team undertakes all other HTM activities at skill
level 4, in collaboration with the multi-disciplinary Central HTM Working Group
that advises the central body of the health service provider organization.

Figure 9 (overleaf) completes the organizational structure of the HTM Service. It
provides a sample organizational chart showing the relationship between the
different levels of the HTM Service, and shows that it follows a typical health service
referral structure.

The organizational chart in Figure 9 is only an example. The number of
administrative levels in your HTM Service will depend on the number of zonal levels
you use. This depends on your health service provider organization, the geographical
area to be covered, and the number of health facilities. Also the shape of your
organizational chart will vary, depending on when you started to develop your HTM
Service and whether you started developing an HTM Service at district level, or
from the top down. Some service providers and countries have:

◆ no HTM Service

◆ a central level and nothing else

◆ an organizational structure at facility, district, and regional level, but no central level

◆ a narrow organizational chart, as they only have a few zones

◆ a large structure with many zones, and workshops at both district and facility level.

Tip

•

Start with the skills and resources you currently have, and expand later.
Decentralization should only take place when you have the technical staff and skills
in place, backed up with the appropriate knowledge in the health management
system, and the necessary physical and financial resources.

5.2 Placing staff at different levels of the HTM service

82

Figure 9: Sample Organizational Chart for the HTM Service

technical

support

technical

assistance

HTM

Team

HTM

Working

Group

Workshop

health

manage-

ment

team

Central level

Zonal level

Facility level

– large

– small

technical

support

technical

assistance

HTM

Team

HTM

Working

Group

Workshop

health

manage-

ment

team

technical

support

technical

assistance

HTM

Team

HTM

Working

Group

Workshop

health

manage-

ment

team

technical

assistance

HTM

Team

HTM

Working

Group

health

manage-

ment

team

Box 24 outlines the issues to consider when assessing the organizational structure of
your HTM Service, and how staff are placed within it. Section 6 discusses possible
numbers of staff required in such a network.

BOX 24: A Checklist for the Organizational Structure and Staff Placement for Your

HTM Service

Check which of these structures are available in your country:

Facility level

◆ Are there HTM Services based at this level in your health service provider organization or in your country?

◆ Which facilities are not covered by such services?

◆ What types of staff exist in the HTM Services at this level at the moment?

◆ Is use made of general health staff in the HTM Service at this level?

◆ What skill level (Section 3) can the HTM staff offer at this level?

District/diocesan level

◆ Are there HTM Services based at this level in your health service provider organization or in your country?

◆ Which areas are not covered by such services?

◆ What types of staff exist in the HTM Services at this level at the moment?

◆ What skill level (Section 3) can the HTM staff offer at this level?

Regional/provincial level

◆ Are there HTM Services based at this level in your health service provider organization or in your country?

◆ Which areas are not covered by such services?

◆ What types of staff exist in the HTM Services at this level at the moment?

◆ What skill level (Section 3) can the HTM staff offer at this level?

Central/national level

◆ Does your health service provider organization have a Central HTM Team to coordinate the Service?

◆ Is there also a National HTM Team for the country as a whole?

◆ What types of staff exist in the HTM Services at these levels at the moment?

◆ What skill level (Section 3) can the HTM staff offer at these levels?

5.3 RESPONSIBILITIES AT EACH LEVEL OF THE

HTM SERVICE

In Section 5.2, we outlined a proposed structuring of staff at the various levels of
the HTM Service. This was based on the skills that would be required to enable
HTM activities (Section 3) to take place, as well as planning, supervision and
monitoring activities.

5.2 Placing staff at different levels of the HTM service

83

Of course, what can be achieved at each level will depend on the skills of the staff
you have available at each level. The example that is presented below assumes that
all the skill requirements for HTM activities (described in Sections 3 and 4) are
available. Additional information on reporting structures is given in Section 6.2.

Facility Level

The responsibility of the Facility HTM Team and Working Group depends on
whether the facility has a workshop with technical staff based in it.

Facilities Without Workshops:

Together, the HTM Team and Working Group:

◆ advise the health management team on healthcare technology issues

◆ are the contact point for equipment and maintenance problems which they try

to solve

◆ supervise private sector artisans

◆ support and supervise equipment users

◆ undertake maintenance and other HTM activities (Section 3) at skill level 1, if

they have received the training

◆ liaise with a higher zonal level of the HTM Service (for example, district or region).

Hospitals With Workshops

In addition to the responsibilities listed above, the HTM Team and Working Group
at these types of facility also:

◆ undertake maintenance and other HTM activities (Section 3) at skill levels 1 and 2

in the hospital itself (and possibly level 3 if a large hospital), and sometimes for
health centres and health posts in their area by outreach

◆ keep stocks of spare parts according to first-line maintenance levels

◆ monitor and supervise the work conducted by private companies

◆ undertake quality assurance and cost control at facility level

◆ provide adequate representation of HTM in the planning and budgeting of the

facility health management team.

The Facility HTM Team and Working Group should report to the health facility
board, or equivalent. In principle, the facility technical staff should be employed by
the health facility or the district health authority, and be supervised and assisted by
the Zonal HTM Team.

5.3 Responsibilities at each level of the HTM service

84

5.3 Responsibilities at each level of the HTM service

85

Zonal Level

District or Diocesan Level

Ideally each small administrative zone (such as a district or a diocese) should
establish its own HTM Team and Working Group under the district/diocese health
board or authority. At this level, the HTM Service undertakes the following tasks:

◆ advises the district health management on healthcare technology issues

◆ undertakes maintenance and other HTM activities (Section 3) which require

basic- and medium-level skills (skill levels 1 and 2) in the district hospital, as well
as the health centres and health posts in their area

◆ keeps stocks of spare parts according to their maintenance level

◆ monitors and supervises work conducted by private sector companies and artisans

◆ supervises and supports the work of Facility HTM Teams and Working Groups in

their area

◆ undertakes quality assurance and cost control at district level

◆ provides adequate representation of HTM in the planning and budgeting of the

district health management team

◆ liaises with a higher level of the HTM Service (such as a region or the centre).

It may be that the District HTM Service cannot initially carry out all of these tasks.
In many countries, experience has shown that decentralization should be undertaken
gradually. If too many responsibilities are given to a District HTM Team and
Working Group at the start, it can prove overwhelming.

Tip

•

It is helpful to keep responsibilities in certain crucial areas, (such as advice on
planning and budgeting), at the regional level and only decentralize these activities
at a later stage.

•

When decentralizing, it is helpful to keep finances for basic maintenance in a budget
line of its own. This will ensure that the maintenance activities take place and the
monies set aside for them cannot be diverted for other activities.

In principle, the district technical staff should be employed by the hospital at which
they are based, or by the district health authority. They should be supervised and
assisted by a larger Zonal HTM Team or the Central HTM Team.

Regional or Provincial Level

Each large administrative zone (such as a region or province) should also establish its
own Regional HTM Team and Working Group, which is responsible for running the
HTM Service in their area. At this level, the HTM Service will:

◆ provide consultancy support as well as management and technical advice to

regional and district health management teams on healthcare technology issues

◆ undertake maintenance and other HTM activities (Section 3) at skill level 3 in

the regional hospital, as well as the hospitals, health centres, and health posts in
their area

◆ supervise and monitor the work undertaken by private sector firms and artisans

◆ advise on the procurement and stock control of equipment accessories,

consumables, spare parts, and working materials for standardized equipment

◆ in selected cases, undertake centralized bulk purchasing of equipment

accessories, consumables, spare parts, and working materials on behalf of health
facilities in their area

◆ organize training courses, contact training facilities, and train equipment users

and facility and district HTM Teams

◆ supervise and support the work of HTM Teams and Working Groups at lower

levels of the HTM Service

◆ implement all aspects of the HTM policy

◆ undertake quality assurance and cost control of HTM activities at the regional level

◆ provide adequate representation of HTM in decision-making bodies concerned

with planning and budgeting at regional and district levels

◆ liaise with the highest level of the HTM Service (the central or national level).

The Regional HTM Service should form a link between all the health facilities they
cover in their area, and act as a means for exchanging information. The Regional
HTM Working Group will also help to integrate technical services into the existing
healthcare system.

Activities carried out by the Regional HTM Team will include:

◆ determining the range of equipment to be serviced

◆ visiting the health facilities in their region at regular intervals to carry out

maintenance, commissioning, training

◆ dealing with emergency cases; and

◆ supervising local activities.

In principle, the regional technical staff should be employed by the hospital at which
they are based or by the regional health authority. They should also be supervised
and assisted by the Central HTM Team.

5.3 Responsibilities at each level of the HTM service

86

Central and National Level

In order to make efficient use of the proposed HTM system, the work of all the
HTM Teams and Working Groups needs to be properly coordinated and monitored.
This task is carried out at the central level of the HTM Service. The HTM Service
of your health service provider organization will have its own central level and, in
addition, the government HTM Service will have a National HTM Team and
Working Group with extra responsibilities.

Your Central Level

The central level assists and supervises the zonal HTM activities, but cannot
organize and run zonal HTM activities itself. Thus the responsibilities of the Central
HTM Team and Working Group are to:

◆ provide consultancy support as well as management and technical advice to the

central health management team on healthcare technology issues

◆ undertake maintenance requiring high level skills (level 3) for any health facility

in the health service provider organization, as required

◆ undertake other HTM activities (Section 3) at skill level 4 for the facilities of the

health service provider organization

◆ support and supervise the zonal and facility HTM Teams and Working Groups

◆ set budgets and supervise costs and service conditions for provision of

HTM activities

◆ organize regular information exchanges between all parts of the HTM Service,

and with the government HTM Service

◆ establish contacts with external training facilities, and organize and supervise

regular training activities

◆ assist in recruitment of skilled staff for the HTM Service

◆ introduce nationally developed healthcare technology standards into health facilities

◆ introduce standardization into the health service provider’s acquisition policy,

preferably in line with national standardization efforts

◆ collect, document, and disseminate all relevant technical and economic

information regarding the performance of the HTM Service

◆ liaise with other health service providers, donor agencies, and other relevant

institutions regarding HTM issues

◆ establish contacts with key suppliers to ensure the provision of adequate

maintenance and repair services, draw up contracts with them, and monitor and
supervise their work.

5.3 Responsibilities at each level of the HTM service

87