Healthcare Technology Management (HTM) guide 2 How to Plan and Budget GLIDESCOPE SYSTEM RANGER SINGLE USE Operations & Maintenance Manual

‘HOW TO MANAGE’ SERIES

FOR HEALTHCARE TECHNOLOGY

Guide 2
How to Plan and Budget for

Your Healthcare Technology

Management Procedures for
Health Facilities and District Authorities

TALCTALC

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Copyright © 2005 Ziken International

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‘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,
planning, budgeting, financial management, 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: 0-9549467-1-5

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 2

How to Plan and Budget for your

Healthcare Technology

by:

Caroline Temple-Bird

Healthcare Technology Management Consultant,

Ziken International Consultants Ltd, Lewes, UK

Willi Kawohl

Financial Management Consultant, FAKT, Stuttgart, Germany

Andreas Lenel

Health Economist 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 vii

1. Introduction 1

1.1 Introduction to the Series of Guides 1

1.2 Introduction to this Specific Guide 9

2. Framework Requirements 23

2.1 Framework Requirements for Quality Health Services 24

2.2 Background Conditions Specific to this Guide 33

3. How to Discover your Starting Point – Planning Tools I 41

3.1 The Equipment Inventory 42

3.1.1 Understanding Inventories 42

3.1.2 Establishing the Equipment Inventory 46

3.1.3 Establishing Inventory Code Numbers 50

3.2 Stock Value Estimates 53

3.3 Budget Lines for Equipment Expenditures 57

3.4 Usage Rates for Equipment-related Consumable Items 61

4. How to Find Out Where You are Headed – Planning Tools II 65

4.1 Reference Materials 66

4.2 Developing the Vision of Service Delivery for Each Facility Type 68

4.3 Model Equipment Lists 73

4.4 Purchasing, Donations, Replacement, and Disposal Policies 79

4.4.1 General Issues 79

4.4.2 Purchasing and Donations Policies 80

4.4.3 Replacement and Disposal Policies 85

4.5 Generic Equipment Specifications and Technical Data 87

5. How to Make Capital Budget Calculations
– Budgeting Tools I 99

5.1 Replacing Equipment 101

Contents

5.2 Purchasing New Equipment 106

5.3 Pre-Installation Costs 111

5.4 Support Activities to Enable You to Use Your
Purchases and Donations 116

5.4.1 Installation and Commissioning Costs 118

5.4.2 Initial Training Costs 122

5.5 Large-scale Major Rehabilitation Projects 127

6. How to Make Recurrent Budget Calculations
– Budgeting Tools II 133

6.1 Maintenance Costs 134

6.2 Consumable Operating Costs 144

6.3 Administrative Costs 153

6.4 Ongoing Training Costs 156

7. How to Use the Tools to Make Long-term Equipment Plans
and Budgets 161

7.1 Equipment Development Plan 162

7.2 Equipment Training Plan 172

7.3 Equipment Budget – Financial Plans 180

7.3.1 Core Equipment Expenditure Plan 180

7.3.2 Core Equipment Financing Plan 185

8. How to Undertake Annual Planning, Budgeting,
and Monitoring 191

8.1 Annual Equipment Planning and Budgeting (Setting Goals) 192

8.2 Monitoring Progress 206

8.2.1 How to Monitor Progress Against Annual Equipment Plans

and Budgets 209

8.2.2 How to Monitor Progress in General 215

Annexes 219

1. Glossary 219

2. Reference Materials and Contacts 224

3. Typical Equipment Lifetimes 255

4. Sample Long Generic Equipment Specification 270

5. Sample Technical and Environmental Data Sheet 277

6. Shortcut Planning and Budgeting When Starting Out 279

7. Source Material/Bibliography 281

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:

Pieter de Ruijter, Consultant, HEART Consultancy, Holland

◆ 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, Ghana

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

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

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

Trond Fagerli, Senior Advisor, Haraldsplass Deaconal Hospital, Bergen, Norway
(former Chief Bio-Medical Engineer, Ministry of Health, Botswana)

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

Acknowledgements

iii

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

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

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

Dyness Kasungami, District Director of Health – Kafue DHMT/Reproductive
Health Advisor – USAID, Lusaka, Zambia

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

Alex Manu, National Director of Finance, Aga Khan Foundation Private Hospital,
Nairobi, Kenya

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

Khout Thavary, Chief of Financial Planning Office, Ministry of Health,
Phnom Penh, Cambodia

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

Dr K. Upadhyaya, Medical Superintendent, Western Regional Hospital,
Pokhara, Nepal

◆ using source material:

as described in Annex 7: 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

ACA annual corrective activities

AEB annual equipment budget

AHA American Hospital Association

APA annual purchase activities

ARA annual rehabilitation activities

ATA annual training activities

BP blood pressure

CD-Rom compact disc – read only memory

CEEP core equipment expenditure plan

CEFP core equipment financing plan

CSSD central sterile supplies department

CT computed tomography (scanner)

DVD digital versatile disc

ECG electrocardiograph

EDP equipment development plan

ENT ear, nose and throat

ETP equipment training plan

FOB free-on-board

GTZ Deutsche Gesellschaft für Technische Zusammenarbeit

(German Government Technical Aid Agency)

HTM healthcare technology management

HTMS healthcare technology management service

HTMWG healthcare technology management working group

ICU intensive care unit

IEC International Electrotechnical Commission

INCO Terms international commercial terms (for transportation of trade)

ISO International Organization for Standardization

MOH Ministry of Health

MTBF mean-time between failures

NGO non-governmental organization

OPD out-patients department

p.a. per annum

Abbreviations

v

Abbreviations

vi

PPM planned preventive maintenance

UMDNS united medical devices nomenclature system

UPS uninterruptible power supply

US $ United States dollars

VEN/VED vital, essential, not so essential/desirable (prioritizing categories)

WHO World Health Organization

List of boxes and figures

vii

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 planning and budgeting process described in this Guide 18

Box 4: Summary of issues in Section 2 on framework requirements 38

Box 5: Sample record sheet for taking the equipment inventory 44

Box 6: Other types of equipment information to keep 45

Box 7: Taking the equipment inventory 48

Box 8: Types of inventory code-numbering systems 51

Box 9: Example of equipment stock values for a 120-bed district

hospital (in 2003) 56

Box 10: Strategies for developing budget lines for

equipment expenditure 61

Box 11: Summary of procedures in Section 3 on discovering your

starting point 64

Box 12: Strategies for sourcing useful literature and expanding your library 67

Box 13: Equipment considerations for the vision at central level 71

Box 14: Equipment considerations for the vision at regional/district level 72

Box 15: Equipment considerations for the vision at facility level 73

Box 16: Exercise to develop your model equipment lists 78

Box 17: Example of valid reasons and order of priority for purchasing

and donations of equipment 81

Box 18: Example of good selection criteria for purchasing and

donations of equipment 82

Box 19: Example of valid reasons for condemning and replacing equipment 86

Box 20: Contents of a typical equipment specification 92

Box 21: Summary of procedures in Section 4 on discovering where

you are headed 97

Box 22: Principles behind replacement cost calculations 103

Box 23: How to make rough estimations of equipment purchase costs

for forward planning and bulk purchasing 108

Box 24: How to make exact estimates for specific equipment purchases 109

Box 25: Total purchase cost estimates depending on equipment type 109

Box 26: Suggestions for rough estimations of pre-installation costs for

forward planning 113

List of boxes and figures

viii

Box 27: Suggestions for rough estimations of large-scale major

rehabilitation costs for forward planning 129

Box 28: Summary of procedures in Section 5 on capital budget calculations 131

Box 29: Elements of annual maintenance budgets 141

Box 30: Suggestions for rough estimations of consumable operating costs

for forward planning 148

Box 31: Examples of calculations for consumable operating costs 151

Box 32: Suggestions for rough estimations of equipment-related

administrative costs for forward planning 155

Box 33: Resources required when training staff 157

Box 34: Suggestions for rough estimations of equipment-related

ongoing training costs for forward planning 159

Box 35: Summary of procedures in Section 6 on recurrent

budget calculations 160

Box 36: Analysis required for the equipment development

planning process (in Figure 23) 166

Box 37: Example of the layout for an equipment development plan

record sheet 169

Box 38: Example of a summary Equipment Development Plan 170

Box 39: Ways of categorizing equipment for a bulk EDP 171

Box 40: Strategies for developing equipment skills 175

Box 41: Example of an Equipment Training Plan 179

Box 42: Example of a Core Equipment Development Plan 184

Box 43: Example of a Core Equipment Financing Plan 188

Box 44: Summary of procedures in Section 7 on making plans and budgets 189

Box 45: The VEN (or VED) system for prioritizing actions 201

Box 46: Sample Annual Action Plan for Equipment 205

Box 47: Sample Annual Equipment Budget 206

Box 48: Examples of how to measure goals 207

Box 49: Procedures for emergency equipment purchase requirements 212

Box 50: Procedures for maintenance contingencies 212

Box 51: Procedures for consumable contingencies 213

Box 52: Procedures for monitoring expenditure against allocations 214

Box 53: Monitoring the establishment of ‘tools’ 215

List of boxes and figures

ix

Box 54: Summary of procedures in Section 8 on setting annual goals and

monitoring progress 217

Box 55: WHO’s definition of the technology management hierarchy

(Annex 1) 223

Box 56: Sample technical and environmental data sheet (Annex 5) 278

Box 57: Bare minimum planning and budgeting requirements (Annex 6) 279

Figure 1: The place of HTM in the health system 2

Figure 2: The relationship between the Guides in this Series 6

Figure 3: Healthcare technology performance related to your

management style 12

Figure 4: Cycle of planning and budgeting topics followed in this Guide 14

Figure 5: The structure of Guide 2 15

Figure 6: The healthcare technology management cycle 26

Figure 7: Sample organizational chart for the HTM Service 31

Figure 8: How to estimate total equipment stock values 55

Figure 9: The iceberg syndrome of life-cycle costs for healthcare technology 58

Figure 10: Exercise to establish your usage rates and requirements for

equipment-related consumable items 63

Figure 11: Steps for writing specifications 95

Figure 12: Steps for writing technical and environmental data sheets 97

Figure 13: The danger of a cyclical approach to funding equipment 101

Figure 14: How to make rough estimations of replacement costs for

forward planning 105

Figure 15: How to make specific estimates of equipment pre-installation costs 115

Figure 16: How to make specific estimates of installation and

commissioning costs 121

Figure 17: How to make specific estimates of costs for initial training linked

to purchases 126

Figure 18: How to make specific estimates of large-scale major rehabilitation

project costs 130

Figure 19: Traditional ‘bath-tub’ curve of maintenance costs over the lifetime

of equipment 137

Figure 20: How to make rough estimations of maintenance costs for

forward planning 139

Figure 21: How to make specific or annual estimates of maintenance costs 142

Figure 22: How to make specific or annual estimates of consumable

operating costs 151

List of boxes and figures

x

Figure 23: How to make specific estimates of assorted equipment-related

administrative costs annually 155

Figure 24: How to make specific estimates of annual equipment-related

ongoing training costs 159

Figure 25: The basic equipment development planning process 165

Figure 26: Example of prompts showing that training is required 174

Figure 27: Making an Equipment Training Plan 178

Figure 28: Making a Core Equipment Expenditure Plan 182

Figure 29: Making a Core Equipment Financing Plan 187

Figure 30: The planning and review cycle 191

Figure 31: Annual calendar for the planning and budgeting process 195

Figure 32: Updating the equipment inventory as part of the annual

planning process 196

Figure 33: Reviewing the EDP to determine your annual needs 197

Figure 34: Reviewing the ETP to determine your annual needs 198

Figure 35: Costing your annual needs 199

Figure 36: Reviewing the CEEP and CEFP, prioritizing the allocation of

funds, and preparing proposed annual plans and budgets 202

Figure 37: Updating all long-term plans and budgets with the final agreed

and financed annual actions 203

Figure 38: Shortened version of planning and budgeting (Annex 6) 280

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
planning and budgeting is introduced 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; and 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 technology 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. 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

Why Is There a Need for Equipment Planning and Budgeting?

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.

The expansion in healthcare technologies has brought with it many new challenges.
For example:

◆ Health service providers and the general public believe that this technology offers

great promise for improving conditions for the sick.

◆ The public expects their health services to be continually improving.

◆ Manufacturers, professional staff, and the private health sector exert pressure to

introduce the latest technological advances.

◆ People commonly believe that quality of care is directly linked to the presence of

sophisticated technologies.

1.2 Introduction to this specific guide

9

Did you know?

◆ 80 per cent of the world’s population is not able to afford US$100 per head per year on health.

◆ Many sub-Saharan African countries cannot even spend US$15 per head per year on health.

◆ The majority of equipment is designed in countries that spend between US$1,500 and 2,500

per head per year on health.

◆ For 80 per cent of the world’s population, the standards and technology set by the equipment-

manufacturing nations are not sustainable.

Planning and Budgeting Equipment – Why Does It Matter?

1. Planning and budgeting helps you to control the direction of
technology development in your country.

Investing in expensive technologies can lead to many potential difficulties. For example:

◆ The capabilities of the technology may increase at a faster rate than the country’s

infrastructure and support systems can cope with.

◆ Large amounts of money may be spent on expensive and complex new

technologies which do not always lead to the improvements hoped for, in terms of
better access to healthcare and a better quality service.

◆ When investing in technology, planners may fail to take account of the potential

impact on other spending needs (for example, maintenance costs, extra staff
requirements, operational costs, replacement funding).

◆ Planners may fail to take into account the recurrent cost burden of such technologies.

This could have a negative impact on long-term health service budgets, creating a
serious imbalance in health service provision and existing services.

In order to maintain a quality health service, careful planning of your existing and
future healthcare technology needs is essential. Before investing in expensive and
complex technologies, ask yourself whether there are other, more effective means by
which you could improve the quality and level of health services which you deliver to
the public.

Did you know?

◆ In many poor countries, 50 per cent of health finances goes to the highest referral level, while

all the other services have to share the remaining 50 per cent.

◆ Thus, the equity statement that many countries have in their health plan/policy is not really served.

◆ It is possible to consider the cost-effectiveness of using different types of equipment.

◆ Although controversial, it could be argued that providing basic facilities for sterilizing

instruments is of a higher level of priority than an X-ray service, for example.

1.2 Introduction to this specific guide

10

2. Planning your equipment requirements helps to obtain the right
balance within your budget between various needs.

It is common in many developing countries to find:

◆ considerable cuts are made in recurrent expenditures

◆ funds for salaries are often protected

◆ money for other costs is frequently limited. For example, fuel is often not available

or reagents are insufficient for existing services

◆ there is no guarantee that the recurrent costs required for new services will be

provided sufficiently to run the equipment properly.

Did you know?

◆ European Community countries spend more than US$53 per person on medical equipment

per year, Japan more then $92, and the United States more than $118.

◆ But sub-saharan African countries spend on average less than $1 per person on medical

equipment per year, and the less developed countries in Asia spend only around $12

◆ In most countries, capital expenditure on buildings and equipment is typically not more than

five per cent of the total annual healthcare expenditure.

◆ In some developing countries, however, this can rise to as much as 40 per cent over short

periods (1–2 years), due to the injection of donor funds for the occasional construction or
rehabilitation project.

◆ In many developing countries, 66 per cent or more of the recurrent health budget is spent on

staff salaries.

◆ This leaves only a small fraction of the total budget for all the remaining requirements –

maintenance of buildings and equipment, skill development, and consumables.

◆ As a result, many staff do not have the tools required to do their jobs.

Health service providers may concentrate on obtaining the right staff for the delivery
of healthcare. But there is little use in allocating a large proportion of the health
budget on salaries, if the staff do not have the necessary tools to work with. Without
functioning facilities, equipment, and medicines, it does not matter if the knowledge,
skills and staff levels are high. The delivery of services will be poor.

Poor investment in technology will also have a negative impact on staff motivation,
leading to poor performance. Therefore, when planning and allocating your budgets,
it is important to maintain the right balance between staffing and technology costs.

1.2 Introduction to this specific guide

11

3. Planning is essential, in order to make the most of your assets.

Developing countries have limited funds, so it is important to ensure that any
investment in healthcare technology has been properly thought through.

Good management practices will
create sustainable circumstances for
your healthcare technology. To achieve
this, you will need to plan and budget
for the regular replacement of
equipment, effective maintenance,
and training needs. Figure 3 illustrates
how effective management can
improve the performance of your
healthcare technology.

Figure 3: Healthcare Technology Performance Related to Your Management Style

Curve A: Crisis Management:

◆ major periodic injections of new equipment

◆ poor preservation of existing stock

Curve B: Stable Healthcare Technology Management:

◆ preservation (maintenance) of equipment

◆ regular planned replacement

Curve C: Good Healthcare Technology Management:

◆ preservation of equipment

◆ regular planned replacement

◆ improved performance through internal learning processes

Source: Remmelzwaal, B, 1994, ‘Foreign aid and indigenous learning’, Science Policy Research Unit,

University of Sussex, UK

1.2 Introduction to this specific guide

12

Did you know?

◆ In one South American country, it is

estimated that the replacement value of
medical equipment is US$5 billion.

◆ But 40 per cent of this equipment is

not functioning.

◆ This represents a loss of assets of

US$2 billion.

Sustainable

C

B

A

(% of total)

Not sustainable

Equipment availability

Time

13

1.2 Introduction to this specific guide

Who is this Guide Aimed at?

This Guide is particularly suitable for the following:

◆ Managers, and planning and finance officers within your organization

◆ Technical (maintenance) and administrative staff in your Healthcare Technology

Management Service

◆ Other types of staff who have various responsibilities relating to planning and

budgeting, such as:

- administrators, heads of department

- purchasing, human resources, supplies and stores personnel

◆ Policy makers.

All these staff should have a good understanding of equipment planning and
budgeting issues, in their common effort to provide an effective and sustainable
health service.

The recommendations and procedures outlined in this Guide are aimed at personnel
at various levels of your organization (facility, district/region, central). The Guide
explains what the responsibilities are at all levels of the system, to enable you to see
the bigger picture.

Tip

•

The principles of planning and budgeting are the same wherever the money comes
from – whether received from patients, government funds, private support or any
other source.

What Topics are Covered?

Managing the planning and budgeting of equipment involves understanding and
developing a series of ‘tools’. These tools enable you to make your equipment plans
and calculate your budgets, which will ensure that you have sufficient stocks of
functioning equipment to be able to deliver your health services.

This Guide answers the following questions for your healthcare technology sector:

◆ What is my current equipment situation – where am I starting from?

◆ What are my future plans for my equipment?

◆ How do I make budget calculations for capital expenditure?

◆ How do I make budget calculations for recurrent expenditure?

◆ How do I develop the plans and budgets for my equipment in the long-term and

short-term?

◆ How do I review my plans and budgets annually, and monitor progress?

1.2 Introduction to this specific guide

14

Figure 4 shows how the topics covered in this Guide fit together to create a
planning and budgeting cycle. In Section 8, we go on to discuss the way in which
this planning and budgeting cycle relates to your annual calendar.

Figure 4: Cycle of Planning and Budgeting Topics Followed in This Guide

Tip

•

Putting into place the procedures outlined in this Guide may appear to be a
daunting task, on first sight. However, by taking a step-by-step approach, you can
minimize the effort involved. The discussion of tools (Sections 3–6) covers one-off
exercises which you can undertake to set up the tools initially. Section 7 goes on to
explain how to set up the long-term plans and budgets. Finally, Section 8 goes on to
explain how to regularly review and update the existing tools, plans, and budgets
during the annual planning process.

•

If this Guide is still too daunting, Annex 6 offers advice on a shortened version of
planning and budgeting for those just starting out.

The system introduced in this Guide provides a solid approach to managing
equipment planning and budgeting. However, we recognize that there are other
ways of organizing these issues which may be more appropriate for your
administrative system. The most important thing is to implement a well­functioning 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.

a. Developing
planning tools

Cycle of

e. Monitoring
progress

Topics

d. Making
annual plans

b. Understanding
budget calculations

c. Making
long-term plans

How is This Guide Structured?

The structure of Guide 2 highlights the different steps you must take in order to
plan and budget for your healthcare technology, as shown in Figure 5.

Figure 5: The Structure of Guide 2

Who Does What in Planning and Budgeting?

Depending on how many staff you have with management skills, planning and
budgeting tasks may take place at any level. This will depend on:

◆ your country

◆ your health service provider

◆ which level of the health service you work at

◆ the degree of autonomy of your health facility.

1.2 Introduction to this specific guide

15

Introducing the Series, and this particular GuideSection 1

Understanding the central framework for HTM, and
background conditions specific to this Guide

Section 2

Developing planning tools that tell you your starting
point for making plans

Section 3

Developing planning tools that tell you the direction
in which you are headed

Section 4

Understanding budgeting tools for capital budget
calculations

Section 5

Understanding budgeting tools for recurrent budget
calculations

Section 6

Using these tools to make long-term equipment
plans and budgets

Section 7

Reviewing and updating the plans and budgets
annually, and monitoring progress and expenditure

Section 8

However if you have limited management skills at your level, and planning and
budgeting presents a heavy workload, much of this work should be undertaken at a
higher level in your organization.

We suggest that the HTM Working Group (Section 1.1) has a large role to play in
advising the Health Management Team on all equipment matters. Depending on
the size of your facility or what level of the health service you are operating at, your
HTM Working Group may prefer to set up a number of smaller sub-groups.

The suggestions given in this Guide are only intended as examples of the type of
background required for the members of the sub-groups. It is likely that many staff
will sit on more than one sub-group. If you are short of staff, you could use fewer
members, as relevant to the operational level of the sub-group.

In this Guide, the following groups and sub-groups are suggested:

A planning sub-group, which is responsible for equipment development planning
could have the following types of members:

◆ Head of the Health Facility or Head of Medical Services (as team leader)

◆ HTM Manager

◆ Finance Officer

◆ maintenance staff from various disciplines

◆ Nursing Services Manager

◆ Support Services Manager

◆ co-opted members (it is important to involve relevant users as each department

is considered).

A stock sub-group, which evaluates the usage rates and recurrent stock
requirements for equipment-related consumable items could have the following
types of members:

◆ Purchasing and Supplies Officer

◆ HTM Manager

◆ Stores Controller

◆ representatives from equipment user departments (as appropriate to the

equipment being considered).

1.2 Introduction to this specific guide

16

A training sub-group, which considers equipment-related training issues, could
include the following types of staff:

◆ Human Resource Manager

◆ Head of Medical Services

◆ Head of Support Services

◆ HTM Manager

◆ In-service Training Coordinator

◆ Infection Control Officer, senior users, and maintenance staff (as appropriate to

the equipment being considered).

A pricing sub-group, which is responsible for developing equipment price lists and
stock values, and which could include the following types of staff:

◆ Purchasing and Supplies Officer

◆ HTM Manager

◆ Medical Equipment Maintenance Technician.

A Specification Writing Group which is responsible for developing a library of
generic equipment specifications, and the technical and environmental data sheet.
This could include the following types of staff:

◆ HTM Manager

◆ maintenance staff from various disciplines

◆ Purchasing and Supplies Officer

◆ Stores Controller

◆ managers and representatives from equipment user departments

– clinical, paramedical, and support services (as appropriate to the equipment
being considered).

A Commissioning Team, which is responsible for overseeing or undertaking the
installation and commissioning of new equipment. This could include the following
types of staff:

◆ HTM Manager

◆ maintenance staff from various disciplines

◆ Purchasing and Supplies Officer

◆ Stores Controller

◆ Support Services Manager

◆ representatives from equipment user departments (as appropriate to the

equipment being considered)

◆ where necessary, stores and grounds staff to help move and open crates.

1.2 Introduction to this specific guide

17

A Tender Committee, which will decide which quotes to accept for the equipment
and services you plan and budget for. A full description of this team is described in
Guide 3.

Tip

•

There may seem to be a large number of sub-groups but the aim is to spread the work
around different members of staff so that the HTM Working Group (Section 1.1)
does not have to do everything.

•

If you have a small health facility with few staff, the groups created to undertake
planning and budgeting could be much smaller. Try to use relevant staff with
experience and involve those who show an interest in the task.

A wide range of people will be involved in planning and budgeting, as can be seen
from the membership of these sub-groups. It is important for everybody involved to
understand the planning and budgeting process that will be followed in this Guide.
This process is described in Box 3.

Section 1 summary

18

Steps in the Process

Plan and budget within
the framework of
guidance and direction
from the central level of
your health service
provider

People Responsible

Health service managers
at central level in
consultation with
managers at other levels

Actions Described in this Guide

Framework Requirements (Section 2)

◆ follow regulations and standards set by government

◆ develop a Healthcare Technology Policy including

decisions on standardization, maintenance
provision, finances for HTM activities, and the
organizational structure for an HTM Service

◆ define the overall ‘Vision’ for healthcare delivery

at each level of the health service

◆ develop ‘Model Equipment Lists’ which define

the essential equipment stock for the healthcare
to be delivered at each level

◆ use ‘Generic Equipment Specifications’ for

acquisition of equipment

◆ develop good policies for purchasing, donations,

replacement, and disposal of equipment.

Continued opposite

BOX 3: The Planning and Budgeting Process Described in this Guide

Knowing where you are starting from (Section 3)

◆ establish an Equipment Inventory to keep up-to-

date records of the current equipment stock.

◆ estimate the equipment stock values

◆ define the usage rates of equipment-related

consumable items so that realistic estimates can
be made of the finances required for equipment
accessories, consumables, and spare parts.

◆ set up budget lines to record and monitor

expenditure on all the different equipment
activities.

Knowing where you are headed (Section 4)

◆ develop a library of literature and sources of

advice which will help with equipment planning
and budgeting

◆ adapt the Vision for healthcare delivery at their

service level

◆ adopt good policies for purchasing, donations,

replacement, and disposal of equipment.

◆ adapt the Model Equipment List for their

service level.

◆ develop Generic Equipment Specifications and

technical and environmental data.

Capital budget calculations (Section 5)

◆ calculate expenditure requirements for

replacement items

◆ calculate expenditure requirements for new

purchases

◆ calculate expenditure requirements for support

activities linked to purchases and donations.

◆ calculate expenditure requirements for pre-

installation work

◆ calculate expenditure requirements for major

rehabilitation work.

Section 1 summary

19

BOX 3: The Planning and Budgeting Process Described in this Guide (continued)

Increase the availability
of planning skills for
equipment at all service
levels, by developing
planning ‘tools’ through
one-off exercises

Ensure realistic
estimates are made for
all equipment-related
allocations at all service
levels, by using
budgeting ‘tools’ which
teach you how to
calculate the
expenditures required

HTM Managers

HTM Working Groups
and sub-groups

Finance Officers

Health Management
Teams

HTM Working Groups

HTM Working Groups
and sub-groups

HTM Working Groups
and sub-groups

HTM Managers and
their Teams

Continued overleaf

Section 1 summary

20

Recurrent budget calculations (Section 6)

◆ calculate recurrent expenditure requirements for

maintenance.

◆ calculate recurrent expenditure requirements for

consumable operating costs.

◆ calculate recurrent expenditure requirements for

administrative expenses

◆ calculate recurrent expenditure requirements for

ongoing training.

Long-term planning (Section 7)

◆ establish an Equipment Development Plan

covering the priorities for equipment needs across
their service level over time

◆ establish an Equipment Training Plan to cover

the ongoing rolling programme of training required
in relation to equipment activities

◆ establish a Core Equipment Expenditure Plan

which prioritizes equipment spending across the
facility over the long-term

◆ establish a Core Equipment Financing Plan which

identifies sources of funds for the long-term plans.

Annual planning (Section 8)

◆ update the Equipment Inventory.

◆ update the Equipment Development Plan

◆ update the Equipment Training Plan

◆ cost the capital and recurrent requirements for

the current year, and update the Core Equipment
Expenditure Plan and Core Equipment
Financing Plan

◆ prioritize across their service level to obtain the

Annual Purchase Activities, Annual Rehabilitation
Activities, Annual Corrective Activities, Annual
Training Activities, and therefore obtain their
Annual Equipment Budget.

BOX 3: The Planning and Budgeting Process Described in this Guide (continued)

Ensure realistic
estimates are made for
all equipment-related
allocations at all service
levels, by using
budgeting ‘tools’ which
teach you how to
calculate the
expenditures required

Use the tools to make
long-term plans and
budgets

Review the plans and
budgets annually, and
monitor progress in
order to improve
planning and budgeting

HTM Managers and
their Teams

Heads of Section

HTM Working Groups
and sub-groups

HTM Working Groups
and sub-groups

HTM Teams

HTM Working Groups
and sub-groups

Continued opposite

Section 1 summary

21

Monitoring progress (Section 8)

◆ ensure annual plans are implemented

◆ study the implications arising from planning and

budgeting.

◆ request help for any deviations from plans such as

emergency purchases, maintenance and
consumable contingencies

◆ monitor actual expenditure against allocations.

◆ seek the funding identified

◆ consider linking allocation of budgets to whether

departments achieve their performance targets

◆ monitor progress with establishing all planning

and budgeting ‘tools’

◆ ensure that the information generated by the

‘tools’ is used to improve stock control, training,
procurement, etc.

BOX 3: The Planning and Budgeting Process Described in this Guide (continued)

Review the plans and
budgets annually, and
monitor progress in
order to improve
planning and budgeting

HTM Working Groups

Heads of Department
and HTM Managers

Health Management
Teams

Tip

•

Remember – if you do not think you can undertake all this work initially, Annex 6
contains a shortened version of planning and budgeting for equipment based on parts
of this Guide.

22

23

2 Framework requirements

2. FRAMEWORK REQUIREMENTS

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.

Guide 1 provides a fuller analysis of how to develop these instruments, and shows that
effective healthcare technology management (HTM) is essential in order to deliver
quality health services. Section 2.1 summarizes these points and offers advice on:

◆ the regulatory role of government

◆ establishing standards for your health system

◆ policy issues for HTM

◆ the importance of introducing an HTM Service

◆ managing change.

Section 2.2 goes on to discuss the background conditions specific to this Guide, and
provides advice on:

◆ authorities responsible for guidance on equipment planning and budgeting

◆ central plans and policies, management skill requirements, and economies of scale

for planning and budgeting.

2.1 Framework requirements for quality health services

24

2.1 FRAMEWORK REQUIREMENTS FOR QUALITY
HEALTH SERVICES

Regulatory Role of 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).

Health service provision and financing, as well as resource creation may be taken on by
both the government and private sector. Thus, there are various options for organizing
health systems:

◆ 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.

However in all these systems, the government is solely responsible for the regulation
of health services. 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 is vital. However, in many countries this regulatory function is
underdeveloped, with weak legal and regulatory frameworks.

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

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

regulations have legal sanctions they can use if standards are infringed

◆ establish wide-ranging policies covering all aspects of the utilization,

effectiveness, and safety of healthcare technology, drugs, and supplies

◆ establish systems to ensure these policies can be implemented.

2.1 Framework requirements for quality health services

25

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.

Establishing Standards for your Health System

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

◆ procedures and training

◆ construction of facilities

◆ healthcare technology, drugs, and supplies

◆ safety

◆ the environment

◆ quality management.

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.

The adoption of suitable international or national standards for healthcare technology
is of particular relevance to this Guide. Such standards would cover areas such as:

◆ manufacturing practices

◆ performance and safety

◆ operation and maintenance procedures

◆ environmental issues (such as disposal).

These are important since countries can suffer if they acquire sub-standard and
unsafe equipment. Again, in the majority of cases ministries of health would save
money and time by adopting internationally recognized standards. For more
information on introducing internationally recognized standards into your
procurement procedures, refer to Guide 3 on procurement and commissioning.

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.

Much healthcare technology in developing countries is received through foreign aid
and donations, but such products don’t 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).

Standard

a required or agreed level

of quality or attainment

set by a recognized authority,

used as a measure,

norm, or model.

2.1 Framework requirements for quality health services

26

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.

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. 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 to ensure they are implemented.

One key framework requirement for this Series of Guides is that your health service
provider should have started work on a Healthcare Technology Policy (for guidance
on this process, see Annex 2). Such a policy usually addresses all the healthcare
technology management (HTM) activities involved in the life-cycle of equipment,
as shown in Figure 6.

Figure 6: The Healthcare Technology Management Cycle

Planning and
Assessment

Decommissioning
and Disposal

Maintenance
and Repair

Operation
and Safety

• Create
awareness

• Monitor
and
evaluate

Budgeting and
Financing

Technology Assessment
and Selection

Procurement
and Logistics

Training and Skill
Development

Installation and
Commissioning

2.1 Framework requirements for quality health services

27

Here we will consider just four issues that provide key background conditions:

◆ A Vision for health services.

◆ Standardization.

◆ The provision of maintenance.

◆ Finances.

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.

If there is no health service plan, there is no framework on which to base decisions.
Section 4.2 provides further information on developing a Vision and planning your
healthcare technology stock.

Standardization of Healthcare Technology

Introducing an element of standardization for healthcare
technology will help you to limit the wide variety of makes and
models of equipment found in your stock. By concentrating on a
smaller range for each equipment type, your technical,
procedural, and training skills will increase and your costs and
logistical requirements will decrease (see Guide 1).

It is easier to achieve standardization if equipment is planned and
ordered on a country-wide, district-wide or health service

provider basis. It is therefore important to combine forces with
other facilities or health service providers, and it may be wise to follow standardization
strategies of the Ministry of Health. It is important that these standardization efforts
do not just apply to products purchased by health facilities, but also to donations.

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).

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 named

makes and models.

2.1 Framework requirements for quality health services

28

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.

Provision of Maintenance

Proper maintenance is essential to ensure that the equipment you have purchased
continues to meet the standards required throughout its entire working life.

Undertaking maintenance belongs to the service provision function of health
systems, and could therefore, in principle, be carried out by the government, the
private sector, or by a mixture of the two.

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 sector 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 guarantee that healthcare technology performs effectively,
accurately, and safely. The rules established are valid for all health service providers,
irrespective of their type of organization.

Specific maintenance requirements would not need to be prescribed by the regulatory
body. Instead, it is up to individual health service providers to decide how these will
be provided. However, the nature and the complexity of some maintenance services
often calls 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. For more details, refer to Guide 1.

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. For more details on how to organize an HTMS, refer to Guide 1.

2.1 Framework requirements for quality health services

29

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 capital and
recurrent budgets. See Sections 5 and 6 for more advice on this.

In a government-organized system these funds have to be provided by government
budgets, while private systems or mixed systems must generate the required funds
from their customers, or from benefactors and donors.

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 or central finance office). Guide 6 provides
advice on this.

The Importance of Introducing an HTM Service

We have established the importance of:

◆ adopting standards for healthcare technology

◆ developing healthcare technology policies

◆ establishing systems to ensure the policy is implemented.

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. Guide 1
attempts to express this in terms of the sorts of savings that can be made if HTM is
effectively carried out. Taking maintenance as an example, we can see that it has not
only a positive impact on the safety and effectiveness of healthcare technology, but
that it also has two important economic benefits:

◆ it increases the life-span of the equipment

◆ 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.

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. 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 that 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.

The government body responsible for providing regulations could be the central
level of the 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. In order to establish an effective HTM
Service, you will need to provide sufficient inputs, such as finance, staff, workshops,
equipment, and materials. Only in this way will you get the outputs and benefits that
you require. For details of how to develop such an HTM Service, see Guide 1.

The organizational chart for the HTM Service will vary depending on the size of your
country and your health service provider organization, and whether you are just
starting out. However, Figure 7 provides an example of the relationship between
HTM Teams and HTM Working Groups (Section 1.1) that we envisage.

2.1 Framework requirements for quality health services

30

2.1 Framework requirements for quality health services

31

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

Figure 7: Sample Organizational Chart for the HTM Service

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.

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
(Section 8). 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 of 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.

2.1 Framework requirements for quality health services

32

33

2.1 Framework requirements for quality health services

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.

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.

2.2 BACKGROUND CONDITIONS SPECIFIC TO
THIS GUIDE

Your country and health service provider may have existing regulating principles
and conditions which will affect, or can inform, aspects of your planning and
budgeting work.

You will need to find out whether the regulations and policies discussed in this
Section exist in your country and organization. If they do, it makes sense to follow
them. If such regulations do not exist, you will need to highlight these issues at the
central level of your organization, and continue to follow the advice provided in this
Guide at your level.

2.2 Background conditions specific to this guide

34

Responsible Management Authorities

If you work for a health service provider organization, you must conform to:

◆ any existing regulations and guidelines concerning equipment planning and

budgeting, which are produced by the central management body.

In addition, there may be professional bodies which provide guidance for their area
of expertise. For example:

◆ the National Board of Survey, which has regulations and procedures on

decommissioning and disposal of equipment. These cover the condemning,
boarding, and auctioning of equipment at the end of its life.

Responsible Finance Authorities

If you work for a health service provider organization, you must work within the
financial resources allocated to you. Thus you must conform to:

◆ the regulations and guidelines produced by the central Finance Office (for

example, the treasury in the government system), such as:

- any accounting policies and procedures covering budgetary processes

- any budgetary limitations and criteria set by the central level of your health
service provider (such as guidelines on maintenance expenditure as a
percentage of health facility operational budgets)

- any financial policies and procedures which govern stock management and
expenditure accounting

- any local regulations regarding co-financing schemes.

Central Plans for the Health Service

When making plans which will introduce changes to your work, your health facility,
or your district/region, you must conform to:

◆ the overall central plans and aims of your health service provider.

Individual health facilities and district authorities should not work independently of
the plan for the health service as a whole. In equipment terms, there are several key
areas where this especially applies:

The ‘Vision’ for the Health Service

As explained in Section 2.1, every health service provider needs a realistic Vision of
the services it can offer, so that it can decide what equipment it should own, and
prioritize the actions to take to develop its stock of equipment. Section 4.2
describes how to develop a Vision.

2.2 Background conditions specific to this guide

35

Your country and health service provider may already have developed central level
guidance such as Essential Service Packages. But many countries and organizations
may not have defined the functions for each level of healthcare delivery, or written
them down in a policy document. This makes it very difficult to plan, since there is
no framework on which to base decisions. Thus, you should conform to:

◆ any guidance from your health service provider on the direction of healthcare

delivery for your level of facility.

When developing Essential Service Packages, be careful to ensure that you can
afford the technology implications. For example, you may wish to improve equity of
access and think it ideal to move a service, such as CT scanning, from central level to
regional (provincial) level. But if there are five regions, you will require not only five
times the pieces of equipment, but also five times the qualified staff, consumable
items, support services and energy supplies. You may find instead that it is more
cost-effective to transport patients to the central unit. Thus the money might be
better spent on improving the central unit and the patient referral transport system.

There are many issues affecting service delivery in the future which are still being
aired in international discussion documents. For example, the changing disease profile
is likely to affect both care and equipment requirements. Also, controversies are being
examined for lessons learnt, such as the need in some countries to re-centralize in
order to be able to afford and manage services (see Annex 2).

Model Equipment Lists

Once you have drawn up a Vision for health service delivery, you can determine what
types of healthcare interventions to offer at each service level. Next, you must
define what equipment is required.

This is done by drawing up Model Equipment Lists, which describe what
equipment is essential for providing each healthcare intervention. (The process of
developing such lists is described in Section 4.3). When drawing up Model
Equipment Lists, you should conform to:

◆ any guidance from your health service provider on equipping levels for your facility.

Since Model Equipment Lists are linked to the healthcare interventions you carry
out, they will not necessarily be tied to specific rooms. However, when drawing up
Model Equipment Lists, it is also important to consult with architects, to determine
factors such as room size, accessibility and flow patterns, based on the function of
the room. Such minimum room standards ensure that the furniture and equipment
can fit into the space in an orderly and effective way. Your plans should include the
number of square metres, the requirements for water, electricity, light levels and any
other factors which could have an impact on equipment use and accessibility (see
Annex 2). These building aspects are often forgotten. Thus, you should conform to:

◆ any guidance from your health architects on the space requirements for your

Model Equipment Lists.

36

2.2 Background conditions specific to this guide

When planning equipment, it is also important to remember the other capital
investments (outside the Model Equipment List), such as training requirements,
and buildings and utilities (power, water, waste management). These investments
are significant and often are a pre-condition, before you can start to make wise
equipment investments. Thus, you should conform to:

◆ any guidance from your health service provider on the other capital investments

arising from your equipment plans.

Purchasing, Donations, Replacement, and Disposal Policies

To avoid wastage, you need to ensure that equipment is acquired in a rational and
planned way. Equipment should be obtained according to good policies and
procedures, covering both the disposal and replacement of existing equipment, and
the purchase and donation of additional items. (The development of such policies is
described in Section 4.4). Thus, you should conform to:

◆ any policies of your health service provider which guide you on valid reasons for

replacing equipment and obtaining new items.

Where possible, you should introduce an element of standardization when acquiring
equipment in order to gain technical, financial, logistic, procedural, and training
benefits (Section 2.1). However, government or institutional procurement
guidelines often do not allow direct procurement, but stipulate procurement
through tenders based on generic specifications (see Guide 3). In such cases, the
only way to introduce a level of standardization is to procure for many health
facilities at one time. For example, the whole country, region, or organization might
replace all their suction pumps at the same time and a standard can evolve. Thus,
you should conform to:

◆ any standardization policies of your health service provider.

Procurement on an individual facility basis will almost certainly produce many one­off examples of different types of equipment which are not economical to maintain.
To avoid such issues, it is very important to combine forces with other facilities
when planning and purchasing new equipment. In order to make the planning of
such procurement possible, it is almost mandatory to have a computerized inventory
and procurement system. Thus, you should conform to:

◆ any strategies introduced by your health service provider for collaboration

between bodies during planning and procurement.

2.2 Background conditions specific to this guide

37

Generic Equipment Specifications

Once you have developed Model Equipment Lists, it will be necessary to describe
the equipment required in detail. This is necessary to ensure that you acquire the
types of equipment you want (this applies equally whether your equipment is
received through procurement or via donations). Section 4.5 gives further advice on
how to write such Generic Equipment Specifications. Thus you should conform to:

◆ any equipment specifications developed by your health service provider.

Generic Equipment Specifications will also enable you to conform to the standards
set by government, and to continue to meet the standardization policy of your health
service provider.

Availability of Management Skills

This Guide presents a detailed and complete description of the planning and
budgeting process. To carry out the procedures outlined here, you will require a
reasonable number of well trained staff. In many countries, this level of management
skills may be available at national level or in large hospitals, but will be a problem at
district level.

The current decentralization efforts in the health sector will bring about significant
changes in the management and procurement of healthcare technology. District
managers may be asked to quantify and specify all future procurement activities.
This task is large and complex and the present skills of district managers in some
countries will be inadequate.

For these reasons, it may be necessary to:

◆ encourage planning, budgeting, and procurement tasks to be carried out at central

level for those facilities and service levels which cannot undertake the whole
management process themselves

◆ encourage district managers to understand the process and be aware of what they

are able to manage, and where they need help.

Economies of Scale

With an improved management system, decentralization can promote accurate and
timely decision-making. However, there will still be a need for central policy guidance
on equipment levels and technical specifications, because it will not be economical to
develop such knowledge at district level. This is an example of how the economy of
scale for technical knowledge will challenge the decentralization process.

A second example of a challenge to decentralization is the economy of scale required in
procurement. Procurement of small quantities increases the initial cost and the life­cycle costs of equipment (Section 3.3), because you cannot benefit from the savings
that bulk-buying offers. More details of procurement options are provided in Guide 3.

When making a needs assessment for one hospital, you are likely to arrive at low
quantities of a broad variety of equipment. So undertaking calculations at facility
level will not enable you to benefit from economies of scale. Instead, by combining
procurement for several facilities at the same time, and gaining the resulting
standardization, you can obtain significant advantages. These include better prices
for new equipment and spare parts, shared training costs and improved after-sales
commitment from the supplier.

Thus it is preferable to:

◆ undertake equipment management and needs assessment at district or regional

level, and merge procurement needs for a number of facilities or districts. This
will result in the ideal combination of accurate management and procurement
advantages, proportional to the economy of scale.

You may face problems with this rationalization and savings strategy when donors
target funds at individual facilities or districts. Thus it is preferable to:

◆ ensure donors follow your Model Equipment Lists, Generic Equipment

Specifications, and standardization policy, in order to overcome the drawbacks.

Box 4 contains a summary of the issues covered in this Section.

2.2 Background conditions specific to this guide

38

BOX 4: Summary of Issues in Section 2 on Framework Requirements

Government

Quality Health Services

◆ 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

◆ adopts suitable standards for quality health services, in general

◆ 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 comply with the standards

◆ establishes public or quasi-public supervisory bodies to enforce regulations and

standards.

Continued opposite

39

Section 2 summary

BOX 4: Summary of Issues in Section 2 on Framework Requirements (continued)

Ministry
of Health

All Health
Service
Providers
in general

Quality Health Services

◆ develops national policies for health services

◆ specifically develops a Healthcare Technology Policy to cover all healthcare

technology management activities including:

- a Vision

- an element of standardization

- the provision of maintenance

- provision of finances for all HTM activities

- the organizational structure for an HTM Service

◆ regulates on these issues (if required)

◆ develops an HTM Service made up of a network of teams and working groups

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

ensure that HTM policies are implemented

◆ provides sufficient inputs to ensure the HTMS is effective

◆ uses strategies to manage the changes involved carefully, so that they can be successful.

◆ conform to regulations and guidelines provided by government

◆ conform to the standards set by government

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

◆ develop their own internal Healthcare Technology Policy and expand strategies

◆ develop their own HTM Service made up of a network of teams and working groups,

with sufficient inputs to ensure it is effective, in order to ensure that HTM policies
are implemented

◆ follow MOH regulations on the HTMS if regulated to do so

◆ 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, training workshops,

etc. with the staff that will implement them

◆ include all parties involved in the network of HTM teams and working groups in the

development of the HTMS

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

Continued overleaf

40

Section 2 summary

BOX 4: Summary of Issues in Section 2 on Framework Requirements (continued)

All health staff
and managers

Health Service
Providers

Managers
(at each
level of your
organization)

Planning and Budgeting

◆ Conform to regulations and guidelines provided by relevant bodies on:

- equipment planning and budgeting

- decommissioning and disposal of equipment

- accounting policies and procedures

- budgetary limitations and criteria set for different activities

- financial policies and procedures that govern stock management and
expenditure accounting

- co-financing schemes.

◆ Provide central guidance on:

- the Vision for the health service and Essential Service Packages

- equipping levels for your facility (Model Equipment Lists)

- purchasing, donations, replacement, and disposal policies

- the development of Generic Equipment Specifications.

◆ only undertake planning and budgeting at suitable decentralized levels in your

organization where sufficient management skills are present

◆ use economies of scale to your advantage by:

- making use of technical skills and guidance from levels where the knowledge exists

- combining forces with other levels to undertake needs assessment, and
bulk-buy equipment and supplies in order to gain from procurement savings
and standardization.

41

3. How to discover your starting point – planning tools I

3. HOW TO DISCOVER YOUR STARTING
POINT – PLANNING TOOLS I

Why is This Important?

In order to manage your equipment effectively, you need to have a clear picture
of your current stock and supplies – it is very difficult to manage an unknown.

You need to know the value (quantity and cost) of your equipment, so that
financial planning is not guesswork. You also need to understand your likely
expenditure on equipment-related activities such as training and maintenance.

Finally, to help you budget effectively, you also need to determine your rate of
use of equipment. In this way, you can draw up a realistic estimate of the
inputs you need.

Before you can carry out any planning or budgeting, it is necessary to know where you
are starting from. Thus you need some baseline data which will help you to
understand your present equipment situation.

To analyze your equipment situation effectively, you need to draw upon some
important ‘planning tools’. This Section covers four such tools, and discusses how to
determine your starting point by:

◆ keeping an up-to-date Equipment Inventory (Section 3.1)

◆ knowing the value of your stock of equipment (Section 3.2)

◆ having budget lines that are sensitive enough to show equipment expenditures

(Section 3.3)

◆ discovering your rate of use of equipment-related consumable items (Section 3.4).

Some health providers may already know a great deal about their equipment. This
will vary, depending on how much planning and budgeting of equipment has already
been carried out. Your level of equipment knowledge will depend upon:

◆ your country

◆ your health service provider

◆ which level of the health service you work at

◆ the degree of autonomy of your health facility.

This Section describes how to undertake one-off exercises to establish the tools
needed to plan and budget for your equipment. Different activities are described for
the different health service levels. This work will help you to analyze your own
present situation.

How to use these tools in the planning and budgeting process is described in Section 7.
Section 8 discusses how to monitor and review these tools.

42

3.1 The equipment inventory

3.1 THE EQUIPMENT INVENTORY

3.1.1 Understanding Inventories

One planning tool you need is an Equipment Inventory. This provides you with all
the details of the equipment that you currently own.

Usefulness of Having an Inventory

It is very important to know all about your current stock of equipment, so that:

◆ any allocation of resources is an objective assessment, and not guesswork;

(therefore budgets are based upon the actual quantity of equipment owned)

◆ you can manage equipment effectively, because you are not dealing with unknown

quantities; (for example, the HTM Manager knows how many suction pumps to
include in the planned preventive maintenance programme)

◆ you can calculate what you can afford to operate or run; (therefore you do not

overestimate or underestimate the consumables required, and set your recurrent
budgets accurately)

◆ you can develop realistic plans for the future, because you know your current

equipment situation; (therefore you do not waste funds procuring new equipment
while neglecting the replacement of existing essential items).

As an example, we can consider the importance of an inventory for planning
maintenance activities:

◆ if you want your equipment to function, you must maintain it

◆ if you want to maintain your equipment stock, you must budget for maintenance

◆ to be able to budget adequately, you must have an idea of the value of what you own.

Did you know?

Knowing what you own means:

knowing - what there is type/sorts

- how much of it there is quantity

- where it is location

- what condition it is in status

- how far it is in its life-cycle age/expected life

having - some way of updating the information accuracy

The method for doing this is to keep an Inventory of your equipment.

3.1.1 Understanding inventories

43

An Equipment Inventory is an important tool because it enables you to:

◆ identify the shortfalls in your equipment stock (once you have developed a Model

Equipment List to compare it to – Section 4.3)

◆ implement your equipment replacement and disposal policies (Section 4.4)

◆ implement your equipment purchasing and donations policies (Section 4.4)

◆ calculate the new value of your equipment stock (using up-to-date prices) which

will be used for calculating your budgets (Sections 3.2, 5 and 6).

What is an Inventory?

An inventory can consist of several separate lists of specific types of equipment
(such as medical equipment, plant, furniture or workshop tools), or a combined list
of all equipment types.

Box 5 (overleaf) shows the sort of information to gather when taking the
equipment inventory as a minimum. Additional information can be gathered and
either kept with the inventory or separately (see Box 6). Your inventory can be:

◆ simply a compilation of these record sheets, containing lists of the equipment

found in each department

◆ or you can enter the information gathered onto an Inventory Form for each piece

of equipment

◆ or you can enter the information into a computer program.

Such a listing can then be organized and sorted in many ways. This is easiest if you
have a computerized inventory, although sorting information is possible with a card
index system. You can sort the information in ways which are of use to you, such as:

◆ alphabetically by product (for example, defibrillator, microscope)

◆ by location

◆ by manufacturer

◆ by use/function

◆ by age

◆ by your inventory code number.

If your Equipment Inventory covers a wide range of facilities or many items, you may
have to prioritize what to include on the listing. For example, are you going to list every
scalpel and stethoscope? Or can you simply list the number of different surgical sets
(so long as the contents have been agreed), or only list items above a certain value?

44

3.1.1 Understanding inventories

BOX 5: Record Sheet for taking the Equipment Inventory (showing the basic essential data to gather)

Your property

or leased?

Status/

Condition

Supplier

bought from

Your property

or leased?

Leased

Status/

Condition

working OK

Supplier

bought from

AB & Sons

Own

working OK

BCD Company

Your property

or leased?

Own

Status/

Condition

replace 1 plate

Supplier

bought from

Vulcan Ltd

Own

OK but old

Vulcan Ltd

Year made

or bought

(factory

Manufacturer's

Model name

Date Inventory Taken:

Name of

Inventory

number)

serial number

and/or number

manufacturer

code number

(your own

number)

Year made

or bought

2000

1999

Manufacturer's

serial number

HNE-863b

760-819-MN

Model name

and/or number

FD II

VP35

Name of

Date Inventory Taken:

manufacturer

HNE Diagnostics

Inventory

code number

GR 123456

Eschmann

GR 123029

Year made

or bought

1995

1990

Manufacturer's

serial number

435R/Z6

1357-2468C

Model name

and/or number

model 6

MCC 660

Name of

Date Inventory Taken:

manufacturer

Vulcan

Inventory

code number

BD 198765

GEC

BD 198123

Description:

Type of

Facility: Department: Section:

Location/

equipment

Room

Example 1:

Type of

equipment

Green Rural Hospital Maternity Labour Ward

Facility: Department: Section:

Location/

Room

Foetal doppler

suction pump

Examination

Delivery

Example 2:

Type of

Blue District Hospital Kitchen/Canteen Kitchen

Facility: Department: Section:

Location/

equipment

stove

refrigerator

Room

Cooking area

Food prep

45

3.1.1 Understanding inventories

Other information about the equipment should also be kept on file, but does not
necessarily have to form part of the inventory. Box 6 shows the types of other data
that need to be kept. You may choose whether to keep this information on the
inventory itself, or to enter it into the maintenance Service Histories for the
equipment (see Guide 5).

One factor which will help you in deciding what data to include in the columns of
the record sheet, is the level of knowledge of those filling in the sheet. If there is
data which is kept by a different department (such as the purchasing department),
or is only known by specialists (such as HTM Managers), this information could be
kept in a separate record system.

BOX 6: Other Types of Equipment Information to Keep

◆ the address of the manufacturer and local agents

◆ the address of the supplier and local representative

◆ technical ratings

◆ date when the warranty expires

◆ the price paid

◆ any external funding agency involved

◆ stocks of consumables, accessories, and spare parts received

◆ results of inspection tests undertaken on commissioning

◆ the frequency of planned preventive maintenance required

◆ details of any maintenance contract and maintenance contractor

◆ maintenance history.

Experience in Kenya

The Aga Khan Foundation (private) hospital found that if they listed everything, the

contents of their Equipment Inventory would be quite comprehensive. Thus they decided

to agree on an accounting definition of what should be called a ‘capital item’. For

equipment, they chose a ‘capital item’ to be anything which:

◆ has a cost of US$250 or more

◆ has a life of at least one year; and

◆ is a distinct tangible object.

An initial exercise will be required to establish both the Equipment Inventory and
the inventory code numbering system. However, decisions on code numbers should
not delay the establishment of the Equipment Inventory. Specialist support may be
required to assist with these processes.

After the initial exercise, the upkeep of the Equipment Inventory and the inventory
code numbering system is part of the routine work of the HTM Teams, as part of
their equipment management activities (Section 8.1).

3.1.2 Establishing the Equipment Inventory

Who is Responsible for the Equipment Inventory?

Many health service provider organizations have a General Inventory for their
facilities kept by Stores personnel. This covers everything found in each
department (including such items as furniture, plastic and glassware, waste bins,
notice boards, wall clocks). A record of the contents of each room is kept on a card
(often found on the back of the door), and a paper copy is held in the Stores. Items
are often painted with their Stores code number.

However, the details contained within this General Inventory are generally
insufficient to enable equipment or maintenance plans to be made. Also, the data is
not easily updated or manipulated on a computer. For this reason, a separate record is
required, which is known as the Equipment Inventory. This covers technical
details and is restricted to items of equipment – in other words, those items which
require maintenance throughout their lives.

Preference

You should aim to introduce an equipment inventory system that is uniform across the whole
of your health service organization. This is preferable to allowing each facility to collect
different details and use different forms (though even that is better than having no inventory
at all). If all facilities collect the same type of information, the data can be compiled at some
point to form an inventory for the whole organization, and can more easily be entered into a
computer system using common software.

46

3.1.2 Establishing the equipment inventory

3.1.2 Establishing the equipment inventory

47

Tip

•

Your health service provider might not have developed a service-wide inventory. Do
not let this prevent you from having an Equipment Inventory at your health facility.
You can encourage your central HTM Service to establish an inventory system, but in
the meantime you can gather your own inventory data and use it for planning purposes.

Takes what action?

Manage the equipment inventory

Takes what action?

- Ideally, designs the inventory system (the forms
plus the data collection process).

- Probably computerizes the system as the team
must be able to manipulate data for the whole
health service.

- Shares a paper or computer version of the
inventory with each facility and district/region.

Gather the data, keep a paper copy of their
inventory, update the information annually, and feed
back any changes to the centre.

Who?

HTM Teams (Section 1.1)

Which level?

Central HTM Team

Facility and/or District
HTM Teams

How to Create the Inventory

An initial inventory should take place, in which a team of staff (including technical
personnel) visits each department, physically checking each piece of equipment,
and writing down all the details. Box 5 shows an example of a record sheet which
can be used for taking an inventory. A list of tasks involved is highlighted in Box 7.
The amount of work involved in undertaking such an exercise should not be
underestimated. This is a large task, since every room, cupboard, drawer, worktop,
shelf, and store room must be investigated. If you are undertaking an inventory for
the first time for a whole district or country, you may need to hire specialist support
to help you with the task.

The inventory can consist of a manual paper record or a computerized file. It does
not matter which, because the sort of data that you must record is the same whether
you are designing the layout of a card or the fields on your computer screen. The
master copy of the Equipment Inventory can be stored on computer, so that data
manipulation and updating is easy. However, for daily referral to the inventory, hard
copy print-outs can be used.

Annex 2 provides references which discuss the possibility of computerizing your
inventory, and provides details of some inventory software products that are available.

To ease the workload for the small HTM Teams, support from secretarial and
computing staff can be used to assist with data entry.

48

3.1.2 Establishing the equipment inventory

HTM Service

Inventory Team

HTM Teams

Creates and updates the

Equipment Inventory

Carries out the Equipment

Inventory at each facility

Compile the Equipment

Inventory.

Make hard copies.

Organizes the gathering of inventory data.

Visits each department in the health facility, and:

◆ looks in all rooms, cupboards, etc.

◆ physically checks all equipment for the details

required (see Box 5)

◆ fills in the Equipment Inventory Record Sheets

(see Box 5).

If existing records are available:

◆ modifies or expands the information as

necessary to cover new items

◆ fills in any gaps

◆ corrects entries

◆ updates data in order to make the Equipment

Inventory as accurate as possible.

◆ Enter the data gathered, either onto an

inventory card or a computer screen, for each

individual machine.

◆ Create summaries, prepare and print out hard

copies

◆ Provide a copy of the Equipment Inventory to

the Stores Controller for inclusion in the

General Inventory held by Stores.

Either by:

◆ facility staff for their own facility

◆ district/regional staff for the facilities in their

district/region

◆ central staff for the health service as a whole

◆ using specialist help.

Due to the workload and knowledge required, it

is useful for the team to be made up of:

◆ two maintenance staff (from the relevant

HTM Team)

◆ a senior equipment user from the facility

◆ a member of staff from the department being

studied (who changes as you move from

department to department).

As a bare minimum you could try using one

member of maintenance staff and one member

of departmental staff (who changes as you move

from department to department).

Make use of trained technical staff and

secretarial/computing support to assist with data

entry.

BOX 7: Taking the inventory

Body Responsibility Activity People involved

Continued opposite

49

3.1.2 Establishing the equipment inventory

Central-level

HTM Team

Develops the Equipment

Inventory as an active (regularly

updated) computer file, as well as

a hard copy print-out.

Analyzes the Equipment

Inventory for planning purposes

(Section 7.1).

◆ Uses the computer software packages required

for this purpose (for example, word-processing

spreadsheets or specific commercial inventory

products – see Annex 2), which staff have been

trained on.

Makes use of support from staff trained in

keeping computerized records.

BOX 7: Taking the inventory (continued)

Body Responsibility Activity People involved

50

3.1.2 Establishing the equipment inventory

Periodic Updating of the Inventory

An inventory is an active record – in other words, it must be kept up-to-date if it is to
be of any use. Data used for planning purposes is of little use if it is out of date. You
should update your inventory periodically throughout the year, whenever new data is
received which is relevant to the inventory. There should also be a formal annual
updating process (Section 8.1).

The HTM Teams should use the many opportunities during their work throughout
the year to regularly gather data for updating the Equipment Inventory, such as:

◆ when new equipment purchases and donations arrive, information will be entered

onto the Equipment Inventory when the equipment is commissioned and the
‘Acceptance Test Logsheet’ is completed (see Guide 3 on procurement and
commissioning)

◆ whenever equipment is serviced or repaired throughout its life (see Guide 5 on

maintenance management)

◆ whenever equipment is taken out of service (see Guide 4 on operation and safety).

Possibly every month or quarter, HTM Managers should oversee the inventory
updating process and make sure the following happens:

◆ A record of any changes is kept on the hard-copy print-out of the Equipment

Inventory.

◆ The computer inventory file is regularly updated by entering into the computer

any comments from the hard-copy print-out, as well as removing from the
inventory any ‘written-off’ (condemned) items (see Guide 4).

◆ A formal annual inventory update is organized (Section 8.1).

3.1.3 Establishing Inventory Code Numbers

What is an Inventory Code Numbering System?

Inventory codes are numbers that the HTM Service uses to label each separate
piece of equipment, so that individual machines can be identified from among many
similar items. It is important to be able to do this so that, for example, you could
consider the service history (see Guide 5) of a specific suction pump, for example,
compared to the performance of all suction pumps in general.

Various types of inventory code numbering systems can be used, and Box 8 shows
the advantages and disadvantages of the various options. It is possible to make your
system as sophisticated (complicated and informative) or as basic (simple but less
informative) as you like.

51

3.1.3 Establishing inventory code numbers

BOX 8: Types of Inventory Code Numbering Systems

Options Advantages Disadvantages

Basic Sequence Number

The inventory code numbers simply
start at ‘one’ and continue endlessly
into the thousands. Each new item is
simply allocated the next number on
the list, whatever type of equipment
it is or wherever it is going to be
located.

‘Speaking’ Numbers

This is a system where a code number
is used, which tells you something
about the equipment. Different parts
of the code are used to mean certain
things. For example, the code could
be T1 199 02. In this case, the first
part of the code (T1) tells you about
the location (Theatre 1).
The second part tells you the
equipment type (199 being your
code for suction pumps), and the
third part identifies the individual
machine (i.e. your second suction
pump in Theatre 1).

A Barcode

Commercial barcode stickers are
purchased, which can be read by
barcode readers. The information is
then transferred to a computer.
Software programming is required to
link the reading from the barcode to
details about the equipment.

By looking at the number you cannot
tell anything about the machine.

You need to have a centralized
master list to see which is the next
number to be allocated.

The list of numbers which make up
different parts of the code (e.g. 199
= suction pumps) has to be agreed,
allocated, and understood by the
HTM Teams.

If the location of the equipment
changes, the number will also have to
be altered.

By looking at the barcode, you cannot
tell anything about the machine.

It can only be used with a
computerized system.

You need a regular supply of barcode
stickers, barcode readers, and a
software program.

Ideal for computerized
inventories.

The number is used to
search the computer
database to reveal all the
data stored about that
particular machine.

From the code number
you can identify the
location of the
equipment, the
equipment type, and
which specific machine
you are dealing with.

Speaking numbers can be
made with as many parts
as you like which tell you
additional things about
the equipment (such as
the facility or the region)

You don’t need to paint
large sequences of
numbers onto the
equipment.

This is a computer-based
system.

52

3.1.3 Establishing inventory code numbers

Who is Responsible for Inventory Code Numbers?

Preference

You should aim to introduce an inventory code system that is uniform across the whole of
your health service organization. This is preferable to allowing each facility to use a different
code system (though that is better than having no system for identifying equipment at all).

Country Experiences

The central health ministry in Malawi uses a basic six-digit sequence number that refers

to the equipment record kept in a computerized database. Whenever work is undertaken

on a piece of equipment, typing in the basic number into the computer means that the

inventory details and maintenance history of that item are displayed on the screen.

The Central Maintenance Department of the public health service in El Salvador developed

a sophisticated 13-digit inventory code numbering system, which contained details of the

type of equipment and its location. This required a great deal of knowledge (technical,

medical, and administrative) among the staff responsible for allocating the numbers.

However, using the skills of the knowledgeable personnel, they were able to develop a

small code booklet, which is now used by technicians to look up the correct numbers.

The central health ministry in Namibia decided to stick barcodes onto their equipment,

instead of having an inventory code number painted onto each item. They acquired a

commercial barcoding system to program and install on their computers, and scanners

with which the technical staff can read the codes.

Tip

•

Your health service provider might not have developed a inventory code numbering
system. Do not let this prevent you from using some method of identifying
equipment at your health facility. You can encourage your central HTM Service to
establish an inventory code numbering system, but in the meantime you can label
your own equipment.

Takes what action?

Manage the inventory code numbering system

Takes what action?

Ideally, designs the inventory code numbering
system, and shares it with each facility and
district/region.

Implement the system, and put the numbers on the

Who?

HTM Teams

Which level?

Central HTM Team

Facility and/or District
HTM Teams

53

3.1.3 Establishing inventory code numbers

How to Create the Inventory Code Numbering System

The HTM Service should undertake an exercise to develop an inventory code
numbering system, and should consider the options available as shown in Box 8.
Specialist support may be required to assist with these processes. Once a system has
been set up:

◆ Existing machines and maintenance records (see Guide 5) must be labelled with

their inventory codes (stickers or marker pen can be used).

◆ New equipment must be allocated a code during the commissioning and

acceptance testing process (see Guide 3).

Tip

•

Never label your surgical instruments by scratching or etching letters onto them
(such as the name of the facility). This removes the protective layer and causes dirt
and water to collect in the grooves, which results in corrosion, staining, or rusting.
Rust weakens instruments and will eventually cause them to break. Also the grooves
make it very difficult to decontaminate the instruments adequately (see Guide 4).

3.2 STOCK VALUE ESTIMATES

It is preferable to have a planned approach to the financing of healthcare technology.
Many calculations which can help you to decide the finances required for equipment
are based on a percentage of the equipment stock value. For example, in Section 6.1
when calculating maintenance costs for your equipment you will use an internationally
recognized percentage of your equipment stock value. This is necessary because your
maintenance budget must be based on the capital value of your equipment.

If you do not know the value (quantity and cost) of the equipment you own, any
planning is likely to be purely guesswork. Therefore it is necessary to calculate your
Equipment Stock Value (your second planning ‘tool’). Once you have worked out
this figure, any other calculations you make will be directed towards providing the
resources needed to sustain your existing stock.

In many countries no equipment stock values have been estimated, usually because
no equipment inventories exist. This means that all equipment budget allocations
are based largely on guesswork, rather than being based on calculations of the real
finances required to keep equipment functioning.

Tip

•

When calculating stock values, it is best to use current and up-to-date prices for the
equipment. It is much more difficult to calculate the actual present value of the stock
because you will have to allow for depreciation in value over time, and decide which of
the many depreciation methods to use. Also, by basing your calculations on the price
you originally paid for the equipment, you will always be out-of-date. By calculating
Equipment Stock Values ‘as new’, your replacement and maintenance estimates will
always be linked to current prices.

54

3.2 Stock value estimates

Who is Responsible for Stock Value Estimates?

Takes what action?

Is responsible for developing equipment price lists
and stock values.

Takes what action?

Can develop stock value estimates.

Who?

The HTM Working Group,
or possibly a smaller pricing
sub-group (Section 1.2)

Which level?

Any level of the health
service (central,
region/district, facility)

How to Make Stock Value Calculations

Anyone can develop stock value estimates if they have access to two things:

◆ the Equipment Inventory (Section 3.1)

◆ a Reference Equipment Price List.

A Reference Equipment Price List is useful as you can look up the typical
approximate prices for any type of equipment. A list of possible types of
equipment, together with their expected product lifetimes, is given in Annex 3.
In the same way, you can also develop a list of typical prices against different
equipment types. You can develop this by:

◆ starting slowly with the prices of recent and known purchases

◆ building it up over time as you get further quotes

◆ researching current prices over time, for example on the internet (see Annex 2).

The next step is to calculate equipment stock values. Details of how to do this are
given in Figure 8.

55

3.2 Stock value estimates

Figure 8: How To Estimate Total Equipment Stock Values

Box 9 shows a rough estimate of equipment stock values by equipment category, for
an imaginary 120-bed district hospital. We recognize that, in some countries, the
contents listed would be for a larger hospital, or for a hospital offering secondary level
healthcare services.

Process Activity

The HTM Working Group (or its pricing sub-group) at facility, district/regional, or central level:

Gathers data on current
equipment prices

Compiles a Reference
Equipment Price List

Makes a stock value
estimate for your health
facility, or each facility type

Use purchase contracts,
supplier information, data
from service contracts,
manufacturers’ websites etc.

List typical prices for
different equipment types.

Use one of the following
three calculations for your
facility:

If you want a rough
estimate of the ‘new’

stock value

If you want a more
exact estimate

If you want an

estimate for the
future

Estimate the major expensive equipment
categories (for medical equipment, plant,
furniture, etc.) for the health facility. Then
multiply their approximate numbers by the
reference prices, as shown in Box 9

Cost the Equipment Inventory (Section 3.1)
using the reference prices

Cost the Model Equipment List for your
facility (Section 4.3) using the reference
prices

Improves planning and
budgeting

Ensures the information is
kept up-to-date

When making estimates for
more than one facility:

Ensure the correct stock
value is always used for
planning and budgeting
purposes (Sections 5 and 6).

Revise the prices regularly in
order to provide a database
of current equipment prices.

Revise the stock values
periodically (Section 8.2).

Take the stock value for a facility type and
multiply it by the number of facilities of that
type in your district, region, country, or
organization.

56

3.2 Stock value estimates

BOX 9: Example of Equipment Stock Values for a 120-bed District Hospital (in 2003)

Medical Equipment US$

X-ray machines (one suite, one mobile) and film processors 250,000

Anaesthetic machines with vaporizers, and anaesthetic ventilators (three theatres) 110,000

Laboratory equipment, assorted 120,000

Operating tables (one each for three operating theatre suites) 90,000

Operating lights (one each for three operating theatre suites) 50,000

Infant incubators (six) 40,000

Transport incubators (one) 15,000

Monitors (one each for three operating theatre suites) 60,000

Defibrillators (one) 20,000

Diathermy units (one each for three operating theatre suites) 45,000

Ultrasound scanner (one for maternity cases) 15,000

Beds (120) and hospital furniture 200,000

All other medium to low technology medical equipment and instruments 200,000

Plant

Autoclaves (two large units) 25,000

Laundry equipment (one small set) 165,000

Incinerator (one) 70,000

Kitchen equipment (one small set) 45,000

Air-conditioning (10 individual units) 25,000

Mortuary (nine-body capacity) 20,000

Refrigeration (eight individual units, one cold room) 10,000

Electrical generator (one small set covering the whole facility) 50,000

Electrode boiler (one small set) 45,000

Water storage and treatment tanks 20,000

All other various plant items such as geysers, pumps, compressors 100,000

Assorted

All other furniture and office equipment 250,000

Vehicles (three) 90,000

Communication equipment (telephones or radios) 10,000

Total 2,140,000

There will also be the buildings, and service installations such as the plumbing, sewage, and electrical
distribution routes.

57

3.3 Budget lines for equipment expenditures

3.3 BUDGET LINES FOR EQUIPMENT EXPENDITURES

If you want to plan the finances for your equipment correctly, you must have:

◆ a clear idea of what you currently spend, and

◆ a realistic estimate of what you need.

To do this, it is necessary to have expenditure records of sufficient detail to enable
you to identify equipment-related costs.

By introducing Budget Lines for Equipment Expenditures, you can record and
monitor the many different ways in which money is spent on equipment. This
planning tool means that you will be able to analyze the financing required adequately.

In many countries it is very difficult to identify what is spent on equipment, as there
are no specific equipment expenditure records. Nor is it possible to analyze in any
detail how funds are being spent, because of the ill-defined structure of health
budgets (both centrally and at facility level).

There are a variety of costs related to healthcare technology, and most of them are
hidden. This can be illustrated by using the image of an iceberg as shown in Figure 9.
An iceberg is known for only having a small portion of its bulk showing above water,
with the vast majority of its bulk hidden dangerously below the surface. All of these
expenses together are known as the ‘life-cycle costs’ for healthcare technology.

Country Experiences

Many countries face the following problems with analyzing their equipment expenditure:

◆ Running costs of equipment (i.e. consumable costs) cannot be identified as they fall

under a recurrent budget code covering all general and medical supplies.

◆ Maintenance costs for medical equipment cannot be identified as they fall under a

budget code which covers maintenance of everything – buildings, vehicles, office,

plant and general equipment.

◆ Planned development expenditure on plant and large installed items of medical

equipment (such as X-ray machines) cannot be identified as they are rolled into total

budget allocations for construction costs.

◆ Budgets for the replacement and maintenance of the buildings and plant of the

government health service are allocated to the Ministry of Works, but they cannot be

identified for the Ministry of Health as the budgets are not divided by facility or even by

client ministry.

Figure 9: The Iceberg Syndrome of Life-Cycle Costs for Healthcare Technology

Source: Damann, V. and H. Pfeiff (eds), 1986, ‘Hospital engineering in developing countries’,

GTZ, Eschborn, Germany

As we have illustrated, there are many different equipment-related costs, and it is
common for only the purchasing costs to be remembered and allocated. It is difficult
to plan if:

◆ the various spending allocations cannot be specifically identified or monitored

within a facility’s budget, and are lost among other expenditures

◆ central budgets do not show how these funds for equipment are allocated to

individual cost centres (facilities, districts or health service providers).

Therefore, it is important to have budget lines (or sub-divisions) for each type of
equipment expenditure, at each service level.

Different Types of Expenditure

It is important to recognize the different types of expenditure for equipment and
what they are used for:

◆ Capital Funds are required to cover large one-off expenses. They are normally

planned for annually. The sorts of expenses covered by capital funds depend on
the size of the task and whether it is linked to the purchase of new equipment.

58

3.3 Budget lines for equipment expenditures

Purchasing
costs

Maintenance
costs

Operating
costs

Staff
costs

Training
costs

Transport and
installation
costs

Costs of
Removal
from service

Cost of recording
and evaluating
data

Administration
and Supply
costs

59

They usually include:

- replacing existing equipment

- buying additional equipment

- pre-installation work (site preparation and associated lifting and warehousing
expenses)

- support activities so you can start to use your purchases and donations

(installation, commissioning, and initial training)

- rehabilitation of equipment and the fabric of buildings which will be major works
and require large sums of money.

◆ Recurrent Funds are required to cover smaller regular expenses in order to keep

equipment functioning and running. They are normally planned for on a weekly or
monthly basis. The sorts of expenses covered by recurrent funds depend on the
size of the task and whether it takes place at times other than the purchase of new
equipment. They usually include:

- buying consumables for equipment operation

- buying spare parts and technical support for equipment maintenance, repair, and
minor works

- administrative expenses for equipment operation and maintenance services,
including energy costs

-training expenses for ongoing skill-development requirements.

In order to be able to monitor the different allocations and expenditures for these
equipment requirements, you will need to develop a variety of different budget
elements (or sub-divisions). These will need to be presented for each cost centre
(facility, region/district, or health service provider)

Tip

•

Whenever equipment is purchased it is essential to budget for its running costs.
Therefore, there must be a link between the budget lines for planned capital
expenditure and recurrent budget estimates for maintenance, consumable items,
and training.

We recognize that many poor countries find it difficult to set aside funds for
equipment needs from the small recurrent budgets available, as they are continually
re-allocated to meet other prioritized needs. This is especially the case if primary
healthcare is the priority of health services, and public health programmes take
precedence over institutional care services.

3.3 Budget lines for equipment expenditures

60

Who is Responsible for Creating Budget Lines?

Preference

Your health service provider should develop a budgetary system containing a variety of budget
elements for different equipment expenditures, which can be used across the whole of the
health service.

Tip

•

Your health service provider might not have developed a budgetary system with
various equipment-related budget elements. Do not let this prevent you from doing
so at your health facility or district level. You can encourage your health service
provider to do this centrally, but in the meantime you can start analyzing how you are
spending your money.

How to Create Budget Lines for Equipment Expenditure

It is possible to develop budget elements that will show how money is being spent
on the different equipment expenditures. Box 10 provides some strategies
necessary to do this.

3.3 Budget lines for equipment expenditures

Experience in Ghana

Seventy per cent of the capital budget for the Ministry of Health (MOH) is funded from

external sources, and these capital funds are more readily available than funds from the

recurrent budget. Thus the MOH has adopted a strategy that links more of the ‘life-cycle

cost’ of equipment (daily operation, maintenance, and administrative needs for running

the equipment) into the capital budget over a number of years.

It has achieved this by considering these running costs as part of the ‘total cost of

ownership’ (purchasing cost) of the equipment which can be covered by the capital

budget. In this way, Ghana ensures that the cost of using equipment is covered for a few

years after commissioning. In the meantime, the recipient facility accumulates enough

monies from their internally generated funds so that they can support the equipment after

this initial grace period is over.

Takes what action?

Develop the new budget lines.

Takes what action?

Can develop budget elements that will show
how money is being spent on the different
equipment expenditures.

Who?

Finance Officers

Which level?

Any level of the health
service (central,
region/district, facility)

61

3.3 Budget lines for equipment expenditures

BOX 10: Strategies for Developing Budget Lines for Equipment Expenditure

People Responsible Action

Establish different budget lines (sub-divisions) as itemized below:

a. capital funds to cover equipment replacement (depreciation)

b. capital funds to cover additional new equipment requirements

c. capital funds to cover support activities which ensure equipment

purchases can be used (installation, commissioning, and initial training)

d. capital funds to cover pre-installation work for equipment purchases

e. capital funds to cover major rehabilitation projects

f. recurrent funds to cover equipment maintenance costs, including

spare parts, service contracts, and minor works

g. recurrent funds to cover equipment operational costs, including

consumable items and worn out accessories

h. recurrent funds to cover equipment-related administration, including

energy requirements

i. recurrent funds to cover ongoing training requirements.

Start using these budget lines to analyze how money is allocated and
spent for equipment purposes.

Ensure that budgets are presented by cost centre so that it is clear what
allocations are made between central, region/district, and facility level. In
this way, you can see what money is spent on equipment activities at each
level of the health service.

Lobby other bodies involved (such as Ministry of Finance, Works) to also
show equipment expenditures by cost centre, so that you can see what is
allocated by other agencies for equipment activities in the health service.

Finance Officers, at all levels
of the health service (central,
region/district, facility)

HTM Working Groups

Health service providers

3.4 USAGE RATES FOR EQUIPMENT-RELATED
CONSUMABLE ITEMS

If equipment is to keep functioning, you must ensure that reasonable stocks of
consumable items are held at all times, and that these form part of recurrent
budgets. You therefore need to calculate the Usage Rates for Equipment-related
Consumable Items. By doing this, you can base your recurrent budgets on the
actual ‘lifetime costs’ (daily operational, maintenance and administrative
requirements) of the items in your Equipment Inventory.

Recurrent budgets covering equipment-related consumable items are required to ensure
that equipment continues to function. Equipment-related consumable items are:

◆ equipment consumables (for example, electrodes, gels, paper)

◆ replacement accessories (for example, handpieces, probes, lenses)

◆ spare parts (for example, filters, o-rings, bearings)

62

◆ maintenance materials (for example, lengths of pipe, paint, paper for the

record system)

◆ equipment cleaning materials (for example, cotton wool, detergents, disinfectants)

◆ safety materials (for example, protective clothing, refilling fire extinguishers,

calibrating test instruments)

◆ energy supplies (for example, fuel, oil, gas, electricity).

If recurrent budgets for equipment are too small, it will not be possible to use or
maintain many pieces of equipment because you will have run out of the necessary
consumable items.

It may be the case that, in the past, equipment-related consumable items have not
been ‘stockable’ items in the Stores system, in other words items which, when stocks
run low, are automatically replenished and therefore always ‘in stock’. (Details of
how to implement such a system are contained in Guides 4 and 5).

If this is the case, you are unlikely to have sufficient information available on which
to base estimates concerning requirements and rates of use of equipment-related
consumable items. To rectify this, you need to carry out assessments of their
requirements and rates of use. Based on these assessments, you can then estimate
adequate recurrent budgets for the operation and maintenance of equipment, and
calculate correct stock reordering times. This information is useful for:

◆ improving budget allocations

◆ planning the correct timing for the procurement of supplies

◆ providing feedback on the choice of equipment.

Who is Responsible for Determining Usage Rates?

3.4 Usage rates for equipment-related consumable items

Takes what action?

Is responsible for establishing usage rates

Takes what action?

Make these calculations, use the information for
planning and budgeting purposes, and share it with
higher administrative bodies within the health service.

Use the information to ensure more appropriate
budget allocations are provided to the facilities.

Who?

The HTM Working Group,
or a smaller stock sub-group
(Section 1.2)

Which level?

Facility level

District/regional and central
health authorities

63

How to Discover your Usage Rates

An initial exercise will be required to establish the usage rates and requirements of
equipment-related consumable items, as described in Figure 10.

Figure 10: Exercise to Establish your Usage Rates and Requirements for Equipment-related

Consumable Items

3.4 Usage rates for equipment-related consumable items

Once you have undertaken the one-off exercises to establish the planning tools, as
described in this Section, you can use them to make your long-term plans (Section 7)
and to undertake annual planning (Section 8.1). You will also need to update the
tools. This is described in Section 8.2.

Process Activity

The HTM Working Group (or its stock sub-group) at facility level:

Investigate the actual annual requirements and rates of use

Undertakes an initial one-off
exercise to establish usage rates
and requirements for
equipment-related consumable
items

across the facility for:

• replacement accessories

• equipment consumables

• spare parts

• maintenance materials

• energy supplies

• equipment cleaning materials.

Identifies:

• the actual requirements (i.e. the
types of items, makes, sources,
and descriptive/identifying part
numbers)

• the rates of use for these
recurrent items by department
(e.g. quantities needed per day,
week, or month in order to
deliver the required health
service to the patients expected).

Makes use of the information
gathered for planning and
budgeting purposes.

Provides feedback to the Stores
Controller

Provides feedback to the
Specification Writing Group and
the Tender Committee

By:

• consulting with departments

• talking to equipment operators and maintainers

• referring to departmental statistics and records on patient
attendance

• referring to Stores records

• using information from suppliers.

To :

• calculate more realistic annual recurrent funding requirements
to cover consumable items

• supply the Health Management Team with sufficient
information to set more realistic budgets.

Supply the Stores Controller with sufficient data to:

• enter onto the Stores' Stock Cards (Bin Cards)

• calculate correct re-ordering quantities and times

• make equipment-related consumable items ‘stockable’ items
(see Guides 4 and 5).

Provide them with information for more appropriate selection of
models during procurement (see Guide 3).

Updates the information regularly.

Undertake an annual review as part of your equipment
management activities (Section 8.2)

64

Section 3 summary

BOX 11: Summary of Procedures in Section 3 on Discovering your Starting Point

HTM Service
(at central level)

Facility and
District/
Regional
HTM Teams

HTM Working
Groups
(or pricing
sub-group)

Health
Management
Teams

Finance Officers
(at each level
of your
organization)

Health Service
Provider

HTM Working
Groups
(or stock
sub-group)

Health
Management
Teams

Usage Rates Budget Lines Stock Values Inventory

◆ designs the inventory system, and the code-numbering system

◆ computerizes it

◆ gather inventory data, keep it, update it, and pass it onto the centre

◆ use the inventory code-numbering system

◆ develop a Reference Equipment Price List, and calculate the equipment stock values

◆ revise the prices regularly in order to ensure that an up-to-date database of current

equipment prices is available

◆ revise the stock values periodically

◆ use the information for planning and budgeting purposes

◆ establish a variety of different budget elements (see Box 10), so that it is possible

to see how money is allocated and spent for equipment purposes

◆ ensures that health allocations are presented for central, region/district, and facility

levels, clearly showing what is spent on equipment activities

◆ lobbies other bodies involved (such as Ministry of Finance, Works) to clearly show

what is allocated for equipment activities in the health service

◆ undertake an exercise to discover more realistic usage rates and requirements for all

equipment-related consumable items (see Figure 10)

◆ use the information for planning and budgeting purposes

Box 11 contains a summary of the issues covered in this Section.

65

4. How to discover where you are headed – planning tools II

4. HOW TO DISCOVER WHERE YOU ARE
HEADED – PLANNING TOOLS II

Why is This Important?

To manage your healthcare technology effectively, you need to have a clear
idea of your goals and targets, and the context in which you are operating.
It is very difficult to manage without knowing what you are trying to achieve.
Equipment, for example, should not be viewed in isolation – it is there for a
purpose, and must be managed according to set objectives.

To plan effectively, you require access to a wide range of information and
reference materials. You also need a clear vision of the direction your health
service is going in, plus a definition of what equipment is required to help you
achieve the health service goals.

To ensure any equipment purchasing is planned and rational, you will need to
have good policies and procedures in place. These will provide guidance on
the valid reasons for buying equipment, as well helping you to decide what
equipment to buy.

It is better to plan and budget with specific goals in mind. You therefore need to
gather information which will help you to understand the goals and objectives for
your equipment.

To help you analyze your future equipment needs, you need some further ‘planning
tools’. This Section covers five additional tools, and discusses how to discover the
direction you are going in, by:

◆ having access to information and reference materials (Section 4.1)

◆ developing a Vision for health service delivery (Section 4.2)

◆ translating that Vision into Model Equipment Lists (Section 4.3)

◆ agreeing what your equipment purchasing, donations, replacement, and disposal

policies are going to be (Section 4.4)

◆ writing Generic Equipment Specifications (Section 4.5).

Different health service providers will have reached different stages in deciding on
the direction to go in, depending on the amount of planning they have already
carried out. The direction you take will depend on:

◆ your country

◆ your health service provider

◆ which level of the health service you work at

◆ the degree of autonomy of your health facility.

66

This Section describes how to undertake one-off exercises to establish these tools.
Different activities are described for the different health service levels. This work
will help you to discover where you are headed.

The use of these tools in the planning and budgeting process is provided in Section 7,
and Section 8 discusses how to monitor and update the tools.

4.1 REFERENCE MATERIALS

To increase their skills in planning and budgeting for the equipment stock, health
service providers need to expand their information and knowledge base concerning
equipment and its management. Therefore it is useful to develop a library of
equipment literature, covering a broad range of types of documents. These are
known collectively as reference materials, and provide background advice for
equipment planning and budgeting.

To keep up-to-date, it may be useful to subscribe to regular equipment information
sources, such as hazard reports and monthly journals. Due to the cost, you may need
to ask for assistance from external support agencies. Information regarding the
sources of some useful literature is given in Annex 2.

It is advisable for some data to be kept in every health facility and maintenance
workshop, so that staff can be encouraged to read and learn from reference material
which is available close at hand.

Who is Responsible for Gathering Reference Material?

Preference

For information to be available at all levels of the health service.

4. How to discover where you are headed – planning tools II

Takes what action?

Organize the gathering of reference material

Takes what action?

Is in a much better position to finance subscriptions,
to ask for assistance from external support agencies,
and to share information around all levels of the
health service.

Should pursue strategies to gain more information,
and develop their own equipment libraries.

Who?

Health Management Teams

Which level?

The Central Health
Management Team

Health Management Teams
at individual facilities and
districts

67

How to Obtain Reference Materials

There are several ways of obtaining reference materials. Box 12 provides a variety of
strategies for trying to get hold of different types of data and expand your library.

Some data which costs a lot of money to obtain may only be collected by the central­level HTM Team, and they should pursue the strategies listed for sharing this
information around the HTM Service network.

4.1 Reference materials

BOX 12: Strategies For Sourcing Useful Literature and Advice (see Annex 2),

and Expanding your Library

Strategy Type of Material/Information Action

Obtain literature which is
usually available free of
charge.

Obtain literature from
neighbours which, with
negotiation, may be
available for the cost of
photocopying and postage.

Obtain information
available internationally
which can be paid for as
one-off items, or by annual
subscription (depending
on the material type and
source). This material may
come as a hard copy or as
part of a software package.

For existing equipment, find as many
of these as possible.

Contact as many other health
facilities and health service provider
organizations in your country and
neighbouring countries as possible,
to obtain existing resources.

Try to get hold of these resources,
perhaps subscribe to them, and look
for help to pay for them.

◆ manufacturers’ brochures

(from manufacturers and their
representatives)

◆ procurement catalogues from

bulk suppliers

◆ lists of the manufacturers

registered nationally with the
central Ministry of Health.

◆ Model Equipment Lists

◆ equipment specifications

◆ copies of manufacturers’

operator and service manuals
for older machines

◆ lists of registered

manufacturers.

◆ text books on a variety of

subjects (including advice on
planning and budgeting)

◆ manufacturers’ operator and

service manuals

◆ Equipment Evaluation Reports

and Product Comparison data

◆ technology assessment

literature

◆ Equipment Hazard Reports

and safety literature

◆ journals

◆ internationally available advice

on equipment issues.

Continued overleaf

68

4.2 DEVELOPING THE VISION OF SERVICE
DELIVERY FOR EACH FACILITY TYPE

As Section 2.1 explains, the Vision for your health facility tells you the direction of
healthcare delivery (in terms of the interventions and procedures to be carried out).
By referring to the Vision, you can determine what type of equipment you require.

When developing the Vision for a certain level of health facility, it is very important
to be reasonable and realistic in your goals. As Section 2.2 explains, you need to be
aware of the cost implications associated with any of your proposed goals (such as
developing Essential Service Packages).

4.1 Reference materials

BOX 12: Strategies For Sourcing Useful Literature and Advice (see Annex 2), and Expanding

your Library (continued)

Strategy Type of Material/Information Action

Make sure you order
relevant literature when
purchasing all your new
equipment (see Guide 3).

Investigate other sources
for getting literature/
information which you do
not have.

If material is no longer
available on paper, find a
more accessible format.

Scan single copies of
printed documents into a
computer and keep them
as electronic copies.

◆ when the manuals arrive, store the

original copies in a safe place (such
as the HTMS library, the facility
library, the workshop library)

◆ make photocopies of the operator

manuals, and give one copy to the
relevant user department, and
one copy to the HTM Team or
relevant workshop

◆ make photocopies of the service

manuals, and give one copy to the
HTM Team or relevant workshop.

Make use of internet (world wide
web) contacts where possible, as this
method will become more and more
important in future.

Investigate these alternative sources
of information. Make copies and
print-outs of the material and make
it available to other facilities.

Scan these documents into your
computer system and make them
more easily available to maintenance
technicians at many locations.

◆ operator manual

◆ service manual.

◆ suppliers

◆ manufacturers’ local

representatives

◆ international agencies

◆ links with health facilities

abroad.

◆ CD-Rom

◆ video

◆ DVD.

◆ user manuals

◆ service manuals

69

For example, you might decide that decentralizing your services provides a fairer
level of access for the surrounding population. However, great care must be taken to
ensure that any such move is affordable. If not, you run the risk of putting funding
for existing services in danger.

Who is Responsible for Developing the Vision?

The body or organization responsible for developing the Vision will vary from country
to country. This will depend upon:

◆ your health service provider

◆ which level of the health service you work at

◆ the degree of autonomy of your health facility.

Preference

It is unhelpful to have lots of individual facilities pulling in different directions, and no
coordinated plan for the health service as a whole. It is easiest for all concerned if your health
service provider at central level considers what sort of healthcare will be provided at each
level of your health service. They should collaborate with the Ministry of Health and follow
MOH guidance.

Tip

•

Your health service provider at central level might not be undertaking a Vision
exercise. Do not let this prevent you from working on the Vision for your health
facility, as long as you stay within sensible goals for your level of the health service.

4.2 Developing the vision of service delivery for each facility type

Experience in South Asia

The Ministry of Health in a Southern Asian country felt pressured by manufacturers,

professional staff, and the example set by private health service providers to develop

public services in a certain direction. Such a development was dependent on the

purchase of sophisticated technologies, such as CT scanners, MRI scanners, cardiac-

angiography machines and video endoscopes.

However, in a recent survey they discovered that the utilization of these items is less

than 10 per cent due to the lack of available manpower and recurrent budgets. This

shows how important it is not to allow realistic decision-making to be undermined by

outside pressures.

70

4.2 Developing the vision of service delivery for each facility type

Takes what action?

Organize special meetings of different types of staff
at each level to discuss the Vision.

Advises the Health Management Team on all
technology issues during this process.

Takes what action?

Takes the first step and develops the overall Vision
for the direction of the health service as a whole.

Once this Vision has been completed or updated,
takes the second step and defines the services to
be provided by individual health facilities. By:

- studying the map of facilities for their area

- considering how their region/district varies from
the norm described by the centre.

Once the services have been defined for the district,
takes the third step and looks at the possibilities
they have for providing the defined services.

Who?

Health Management Teams
at each level

HTM Working Group
(Section 1.1)

Which level?

Central Level

Regional/District Level

Facility Level

How to Develop your Vision

The Health Management Team at each level should organize a series of meetings to
discuss the development of the Vision. These meetings should include a cross­section of different types of staff from their level (facility, district/region, or service
as a whole). As well as involving staff, it is also important to ask questions of your
customers (as far as is possible), especially when they contribute to covering the cost
of the health service provided.

At these meetings you should discuss:

◆ the direction that the service should be taking

◆ the sort of care that should be provided now and in the future

◆ the sort of interventions and procedures that will be carried out; and

◆ the type of healthcare technology required.

These meetings should take into account:

◆ healthcare trends

◆ demographic data

◆ epidemiological profiles

◆ priority health problems

◆ the clinical and referral features of the target area

◆ the infrastructure, finances, and human resources available

◆ local strengths and weaknesses

◆ the support available from external support agencies.

To inform the technology part of the debate, the HTM Working Group (at each
level) should consider the equipment implications of the healthcare interventions
suggested, and then offer technical advice to their Health Management Team.

Box 13 shows some of the issues that the Central Level HTM Working Group
should consider.

71

BOX 13: Equipment Considerations for the Vision at Central Level

Issues Examples

What expansion of services
is necessary or feasible?

What are the implications
in terms of staff, skills,
resources, patient referral
networks?

Are desired expansions
financially affordable?

Do the services suggested
fit into the overall Health
Service in the country?

4.2 Developing the vision of service delivery for each facility type

◆ What should be the role of a hospital (central, referral, district, or rural), in

terms of the interventions and procedures to be carried out? What does
this mean in terms of equipment availability?

◆ What type of care can be offered by rural, district or town health centres?

Can any types of care be transferred over to them? What does this mean in
terms of equipment availability?

◆ It may be best to locate certain specialized services (such as intensive care

units) only at certain hospitals. Some specialized services, such as
radiotherapy, may only ever be offered at national/central level. With
pressures to reduce costs, improve efficiencies, and possibly to reduce
staff numbers, can service provision be rationalized? Is expansion based
only on needs that can be realistically met?

◆ Introducing a new service has knock-on implications for human, material,

and financial resources. Why buy eye instruments for a facility if there is
no eye surgeon, or prospects of one becoming available?

◆ If the referral system is such that dialysis is only undertaken and

supported at a central facility, think carefully before placing dialysis
machines at, for example, 10 further locations. Such a move would have
major and costly knock-on effects. For example, at each of the 10 locations
you would need to:

- recruit or train renal doctors and surgeons

- finance and supply dialysis machines, water treatment systems,
specialized laboratory services and equipment

- provide renal nurses and after care services

- provide regular supplies of consumables and maintenance support, as
well as recurrent budgets.

◆ Although many hospitals may ideally wish to have fluoroscopy facilities

(for example), at a cost of approximately $500,000 per suite is this a
feature each hospital can necessarily invest in?

◆ Is it possible to develop a Vision which fits in with the other health service

provider organizations?

72

4.2 Developing the vision of service delivery for each facility type

BOX 14: Equipment Considerations for the Vision at Regional/District/Diocesan Level

Issues Examples

Are some services
duplicated in facilities
near to each other and
therefore over-provided?

Are there alternative ways
to provide healthcare
interventions?

Do the services
suggested fit into the
overall health service in
the surrounding area?

◆ Each facility may wish to offer all services, but this may not be practicable.

In many cases, it may be necessary and important to share service
provision. Which healthcare interventions can be shared with other types
of facility in the neighbouring area (such as the referral hospital, the town
clinic, rural outreach services)? Can you reduce your equipment
requirements by sharing services?

◆ Are there neighbouring facilities or health services (such as a flying doctor

service) which are better able to offer certain interventions – for example
services for Ear Nose and Throat, eye specialists, sophisticated imaging? If
they are better equipped to provide such services, you might agree that
they will be the source of those services and limit your equipment
requirements in those areas.

◆ Are there other providers who could supply you with services you require,

such as hot meals, clean linen, incineration? If so, would the reduction in
equipment capital and recurrent costs outweigh the cost of buying in
those services?

◆ Is it possible to develop a Vision which fits in with the neighbouring

regions/districts and other health service provider organizations?

Box 14 shows some of the issues that the Regional/District Level HTM Working
Group should consider.

4.2 Developing the vision of service delivery for each facility type

73

Following these considerations, the Health Management Teams should:

◆ develop a reasonable and realistic Vision for the health service in terms of the

procedures and interventions to carry out, and produce it as a formal document; and

◆ ensure the approved written Vision is used as the basis of subsequent equipment

planning and budgeting decisions.

4.3 MODEL LISTS OF EQUIPMENT PER
INTERVENTION

Once the Vision for the direction of health service delivery for a facility has been
developed (Section 4.2), you will know the healthcare interventions and procedures
you will be offering. Based on this information, you can then develop Essential
Service Packages, which should translate the Vision into:

◆ human resource requirements, and training needs

◆ space requirements, and facility and service installation needs

◆ equipment requirements.

BOX 15: Equipment Considerations for the Vision at Facility Level

Issues Examples

Are some services
duplicated within
the facility itself?

Are there alternative
technology strategies
for providing the
services required?

Do the services suggested
fit into the overall
health service in the
surrounding area?

◆ Perhaps your facility was built with three operating theatres, but are they

all in use all of the time? Can the use of the theatres be rationalized and
operating times maximized, so that new theatre equipment does not need
to be purchased three times (in this example) for many separate theatres?

◆ Some countries have introduced fee-paying systems. This can result in a

difference between fee-paying (high cost) and non-fee-paying (low cost)
services, causing duplication of services. Can the difference between high
and low cost be based on factors such as more prompt service, more
experienced staff, better food? In this way, can you avoid two physically
separate sets of facilities which lead to duplication of expensive equipment,
especially in areas such as intensive care, labour, or dental units?

◆ Does your geographical area lend itself to different ways of providing

services which may be more cost-effective or reliable? For example, can you
use solar energy for your electricity, a biogas plant for your sewage system, a
borehole water supply, radio communication, oxygen concentrators?

◆ Is it possible to develop a Vision which fits in with the neighbouring

facilities and other health service provider organizations?

Box 15 shows some of the issues that Facility Level HTM Working Groups should
consider.

4.3 Model lists of equipment per intervention

74

This Section concentrates upon equipment requirements, and considers the process
of defining what equipment is needed for each healthcare intervention. The
planning ‘tool’ used to do this is the Model Equipment List.

What is a Model Equipment List?

A Model Equipment List is:

◆ a list of equipment typically required for each healthcare intervention (such as a

healthcare function, activity, or procedure). For example, health service providers
might list all equipment required for eye-testing, delivering twins, undertaking
fluoroscopic examinations, or for testing blood for malaria

◆ organized by activity space or room (such as reception area or treatment room),

and by department

◆ developed for every different level of healthcare delivery (such as district,

regional and central), since the equipment needs will differ depending on the
Vision for each level

◆ usually made up of everything including furniture, fittings and fixtures, in order

to be useful for planners, architects, engineers and purchasers

◆ a tool which allows you to see if your Vision is economically viable.

The Model Equipment List must reflect the level of technology of the equipment.
It should describe only technology that the facility can sustain (in other words,
equipment which can be operated and maintained by existing staff, and for which
there are adequate resources for its use). For example a department could have:

◆ an electric suction pump or a foot-operated one

◆ a hydraulic operating table or an electrically controlled one

◆ a computerized laundry system or electro-mechanical machines

◆ disposable syringes or re-usable/sterilizable ones.

As Section 2.2 explains, it is important that any equipment suggested:

◆ can fit into the rooms and space available. You should therefore refer to any

building norms which define room sizes, flow patterns, and requirements for
water, electricity, light levels and so on

◆ has the necessary utilities and associated plant (such as the power, water, waste

management systems) available for it on each site. If such utilities are not
available, it is pointless planning to invest in equipment which requires these
utilities in order to work

◆ can be operated and maintained by existing staff and skill-levels, or for which the

necessary training is available and affordable.

Due to these factors, Model Equipment Lists will vary from country to country.

Usefulness of the Model Equipment Lists

A Model Equipment List is an aid to the planning process. In order to plan what
equipment to purchase, you will need to be aware of any shortfall in equipment. To
determine such shortfalls, you will need to compare your Equipment Inventory
(Section 3.1) with your Model Equipment List. This will enable you to determine
whether any equipment is currently missing or needs to be purchased.

Thus, the Model Equipment List will help you determine what equipment is:

◆ necessary

◆ surplus

◆ extravagant

◆ missing

in relation to the Vision for your facility.

Who is Responsible for Developing Model Equipment Lists?

Who has responsibility for developing the Model Equipment Lists will vary from
country to country. It will depend on:

◆ your health service provider

◆ which level of the health service you work at

◆ the degree of autonomy of your health facility.

Although at district or hospital level there may be sufficient medics, often there are
limited economists and technical personnel with management skills for the facilities
and districts to complete the task of developing Model Equipment Lists alone
(Section 2.2). It is very important that this task is undertaken by a multi­disciplinary team, so that decisions benefit from the skills and views of all
disciplines, not just one or two.

4.3 Model lists of equipment per intervention

75

4.3 Model lists of equipment per intervention

76

Preference

Your health service provider at central level should consider developing Model Equipment
Lists in collaboration with staff from each level of the service. It is not helpful to have lots of
individual facilities pulling in different directions, with no coordinated plan for the health
service as a whole.

Tip

•

Your health service provider at Central level might not be undertaking an equipment
list development exercise. Do not let this prevent you from working on the Model
Equipment List for your health facility, as long as you stay within sensible goals for
your level of the health service.

How to Create Model Equipment Lists

When each level works on the Model Equipment List, the HTM Working Group
should organize a consultation exercise for staff. The best way to do this is by
arranging a series of meetings. A cross-section of different types of staff should be
brought together, from across all the various levels the HTM Working Group is
responsible for (such as facility, district/region, or service as a whole). In these
meetings, each discipline needs to decide the types of equipment required to
provide the healthcare interventions described in the written Vision (Section 4.2).

Takes what action?

Organizes special meetings of different types of staff
to work on the Model Equipment List. Then reports
back to the Health Management Team.

Takes what action?

Takes the first step and runs specific exercises to
establish the Model Lists of Equipment for each
clinical and support area, at each operational level.

Takes the second step and adjusts the list on a
regional/district basis to cover local variations.

Takes the third step and assesses:

- how they can provide the healthcare interventions

- what numbers of equipment they require
depending on how they organize their work.

Organizational decisions influence the quantity of
equipment. For example, the timing of clinics can
reduce or increase the workload in the laboratory.
Before ordering new equipment, you will need to
assess its level of use. (For example, as a microscope
is used for a number of tests, the work pressure
upon it must first be established, before deciding
whether there is a need for additional microscopes).

Who?

HTM Working Group
at each level

Which level?

Central Level

Regional/District Level

Facility Level

4.3 Model lists of equipment per intervention

77

During these meetings, it is important not to simply look at the space available and
draw up a list of equipment to fill it. The idea is to consider:

◆ the disease burden that the facility faces

◆ the healthcare interventions that are required at that level of facility

◆ the equipment needed to provide those interventions and the technology level

that can be sustained

◆ the quantities of each type of equipment required. Factors to consider include:

- which interventions can share equipment (for instance, could several surgical
procedures share an operating table?)

- whether the location of activities requires duplication of equipment (for example,
the number of resuscitations per year may only call for one resuscitation bag, but
clinically it is safer to have a resuscitation bag available at several locations).

Tip

•

To begin with, the task of creating Model Equipment Lists may appear to be
overwhelming. A simple way to start might be to take a critical look through the
equipment lists of neighbouring countries. Disease patterns do not fluctuate that
much between neighbouring developing countries, and financial and technological
capacity are likely to be largely similar. (Further information on Model Equipment
Lists developed by a variety of agencies and countries is given in Annex 2). You
could simply adapt existing Model Equipment Lists for your own situation, if you do
not have the resources or central support for a full exercise

For HTM Working Groups at Regional/ District and Facility Level where there may
be limited management skills (Section 2.2), making comparisons with other
countries’ Model Equipment Lists may be the most effective way of working.

At Central level you may require some computer software to assist you when
undertaking the clinical, technical, and economic analysis. This would also be
beneficial if the centre is responsible for compiling and overseeing lists for the rest of
the health service. Annex 2 provides further information on how to computerize
your Model Equipment Lists, together with some equipment analysis software
products that are available.

Tip

•

The WHO recommends the use of the ‘Essential Healthcare Technology Package’
(EHTP) approach for determining equipment lists. Annex 2 provides details of
EHTP software which would usually be applied at central level.

4.3 Model lists of equipment per intervention

78

Box 16 describes an exercise for consulting staff that can be undertaken to develop Model
Equipment Lists.

Continued opposite

BOX 16: Exercise to Develop your Model Equipment Lists

People and Steps Example Activities

The HTM Working Group
gathers useful reference
materials from various
sources which can stimulate
discussions, and can be
modified according to
local needs.

The HTM Working Group
sets up a series of small
working groups of different
types of staff for different
working areas, until all
departments have
been covered.

Each working group
undertakes a series of tasks
so that they can develop an
Equipment List for their
working area.

◆ uses the Equipment Inventory as a starting point, in order to develop a list

for each department

◆ draws upon any existing Equipment Development Plan for the facility

(Section 7.1)

◆ uses Model Equipment Lists from neighbouring countries as a reference

point, which can be modified to suit the health service’s own working
practices (see Annex 2)

◆ seeks guidance from the central health service provider organization on

the Vision for the health service

◆ refers to any international guidance available

◆ uses any computer software programs available (if you have access to

them).

◆ surgeons, theatre nurses, CSSD staff, and medical equipment technicians

to discuss equipment required for theatre interventions

◆ different grades of laboratory staff, maintenance staff and doctors to

discuss the needs for laboratory services

◆ doctors, physiotherapy staff, maintenance personnel to discuss

physiotherapy needs

◆ the Support Services Manager, a range of kitchen staff, ward managers,

maintenance staff, and employee representatives to discuss kitchen and
canteen requirements,

and so on.

◆ considers the reference materials obtained

◆ discusses what equipment is required for each of the healthcare

interventions offered in the written Vision for the facility/service level, for
their department or area

◆ provides a realistic estimate of the type of equipment required to provide

the service to be offered, being careful not to create a wishlist which can
never be attained

◆ provides a realistic estimate of the level of technology which can be

sustained

◆ determines the numbers of each item required for the existing patient

throughput, staffing levels, and work organization

◆ considers all the items required to work effectively, including –

equipment, furniture, hardware (clocks, waste bins, kidney bowls),
instruments and utensils

◆ creates a departmental list of all items and their quantities, on an ‘activity

by activity’ and ‘room by room’ basis.

4.4 PURCHASING, DONATIONS, REPLACEMENT,
AND DISPOSAL POLICIES

4.4.1 General Issues

Having gone through a detailed planning and budgeting process, you will then be in a
position to acquire equipment, either through procurement or donations. In order to
ensure you obtain only what you need, you must undertake an acquisition process
which is both rational and planned.

Any new or additional equipment must be acquired according to good policies and
procedures. When planning, you should consider both the costs of replacement and
disposal of existing equipment, and also the costs of purchase and donation of
additional items. A useful planning tool is the Purchasing, Donations,
Replacement, and Disposal Policies. These are a series of policies which guide
you on the process of decision-making for new acquisitions and help you to
determine what equipment you should obtain.

Ideally the Ministry of Health will have developed a Healthcare Technology Policy
which other health service providers can use as guidance, or follow if regulated to do
so (Section 2). Central authorities of all health service providers should be actively
involved in expanding these details and developing policies of their own, which cover
all aspects of the life of equipment. The Purchasing, Donations, Replacement, and
Disposal Policies will thus form one part of a wider Healthcare Technology Policy.

Alongside the policies for internal use, health service providers also need to develop
donor regulations (see Guides 1 and 3) to ensure that all equipment received
through foreign aid and donations complies with existing standards and policies.
Guidance on developing and implementing such regulations is provided in Annex 2.

4.4 Purchasing, donations, replacement, and disposal policies

79

BOX 16: Exercise to Develop your Model Equipment Lists (continued)

People and Steps Example Activities

The HTM Working Group
prepares and reviews
the final list.

The Health Management
Team gives overall approval
for the proposals.

◆ compiles the clinical/support area lists

◆ determines quantities, by identifying where several interventions can

share an item of equipment, and highlights areas where the location of
activities means that duplication of equipment is necessary

◆ finalizes the Model Equipment List for that facility

◆ develops a mechanism for updating the lists over time.

◆ approves the Model Equipment List

◆ ensures it is used as the basis of equipment planning and budgeting

decisions.

4.4.1 General issues

80

Who is Responsible for Developing Purchasing/Replacement Policies?

Tip

•

Your health service provider may not have developed such policies. Do not let this
prevent you from doing so for your health facility.

4.4.2 Purchasing and Donations Policies

To make the best use of your finances, you should only acquire equipment according
to rational, reasonable arguments and not according to random or wild demands.
Therefore it is useful to develop policy statements for purchasing and donations of
equipment. These will fall into two parts:
i. when to purchase

ii. what to purchase.

When to Purchase

Each facility should acquire equipment for valid reasons only and according to an
order of priority, both of which should be defined. Box 17 provides an example of
suggested valid reasons and an order of priority.

If there is a shortage of funds, acquisition should then take place in the same order of
priority as shown in Box 17. This will:

◆ protect acquisitions which cover equipment as it fails at the end of its life; and

◆ ensure that, as a bare minimum, the existing status quo is maintained.

Otherwise, the existing health service provided will start to deteriorate.

Takes what action?

Approve the equipment policies

Takes what action?

Should develop Purchasing, Donations,
Replacement, and Disposal Policies for equipment,
and share them with each facility and district/region.

Can develop and implement policies.

Who?

Health Management
Teams, with advice from
their HTM Service on
technical issues.

Which level?

The central HTM Service

Any health service level
(central, region/district,
facility) with the help of
their HTM Service

4.4.2 Purchasing and donations policies

81

BOX 17: Example of Valid Reasons and Order of Priority for Purchasing and Donations of

Equipment

There are four reasons for procuring/donating equipment, each of which provides a different goal which will
dictate when to acquire equipment. These can be placed in the following order of priority:

1. To cover depreciation of equipment. Equipment is replaced as it reaches the end of its life and is taken
out of service. This is necessary in order for the level of healthcare you currently deliver to be sustained.

Note: This means that the size of your existing equipment stock remains the same, and does not imply

an expansion of the health service.

2. To obtain additional equipment items which are missing from the basic standard requirements.
Additional equipment may be required in order to provide a basic standard level of care.

Note: Missing items are identified by comparing the Equipment Inventory with the Model Equipment

List for the facility.

3. To obtain additional equipment items beyond the basic standard. This is done in order to upgrade
the level of health service provided by the hospital. For example, new equipment may be needed to
provide a new service, build a new special unit, or increase the level of care offered.

4. To obtain additional equipment items outside the facility’s own plans. This will only be applicable
if the additional items have been called for by directives from the central health service provider
organization or a national body and cannot be stopped/refused for political reasons, such as ‘out of the
ordinary’, high profile, or political projects.

Within each of the four categories shown, priorities will have to be set. The priorities can be based on
indicators which measure your progress with attaining the goals. These are discussed in Section 7.1 on
Equipment Development Planning.

Equipment acquisition should only occur under the umbrella of an Equipment
Development Planning Process, so that it is rational and planned (Section 7.1).
Any acquisition should also be guided by the priorities laid out in any annual
development plans (Section 8.1).

Experience in South Asia

The public health sector of a Southern Asian country does not have a Healthcare

Technology Policy or standards. It finds it difficult to control the purchase of equipment.

Ministry of Health officials face the following problems:

◆ Requests from influential clinicians or politicians to buy inappropriate equipment,

which need to be challenged.

◆ When funds are refused for such items, use of the mass media to override the official

decision and appeal to the public for donations.

◆ The high turnover rate of the Minister and Permanent Secretary of Health means the

new incumbents continually want to make gestures for their electorate of new and
sophisticated equipment projects.

◆ Often, the MOH may be forced to succumb to such public and political pressures and

fund such projects.

4.4.2 Purchasing and donations policies

82

What to Purchase

To help you to obtain only equipment which is appropriate to your needs, your
purchasing and donations policies should clearly specify the ‘good selection criteria’
to employ. All equipment should:

◆ be appropriate to your setting

◆ be of assured quality and safety

◆ be affordable and cost-effective

◆ be easily used and maintained

◆ conform to your existing policies, plans, and guidelines.

Tip

•

Only select equipment that is suited to your needs. For example:

There is little point in acquiring an expensive piece of equipment which:

- has capabilities that are hardly ever utilized

- is almost impossible to keep in running order

- is difficult to operate safely and effectively.

There is little point in acquiring a cheap or poor-quality piece of equipment which:

- does not have the capabilities that your staff require

- falls apart easily and must be replaced quickly

- is of poor design and cannot be operated safely.

The selection process is described in full in Guide 3 on procurement and
commissioning.

Box 18 summarizes good selection criteria.

BOX 18: Example of Good Selection Criteria for Purchasing and Donations of Equipment

Indicators of appropriateness Criteria

Appropriate to setting

Equipment should be:

◆ suitable for the level of facility and service provided

◆ acceptable to staff and patients

◆ suitable for operator skills available

◆ suitable for the local maintenance support capabilities

◆ compatible with existing equipment and consumable supplies

◆ compatible with existing utilities and energy supplies

◆ suited to the local climate, geography and conditions

◆ able to be run economically with local resources.

Continued opposite

4.4.2 Purchasing and donations policies

83

BOX 18: Example of Good Selection Criteria for Purchasing and Donations of Equipment

(continued)

Indicators of appropriateness Criteria

Assured quality and safety

Affordable and cost-effective

Equipment should be:

◆ of sufficient quality to meet your requirements and last a

reasonable length of time

◆ made of materials that are durable and hard-wearing (for example,

aluminium bends easily compared to iron or stainless steel)

◆ made from material that can be easily cleaned, disinfected, or

sterilized without rusting (for example, a polymerized finish or an
epoxy coating)

◆ made of materials that do not easily break (for example,

polycarbonate rather than glass)

◆ manufactured to meet internationally recognized safety and

performance standards (see Guides 1 and 3)

◆ suitably packaged and labelled so that it is not damaged in transit

or during storage

◆ provided by reputable, reliable, licensed manufacturers, or

registered suppliers.

Equipment should be:

◆ available at a price that is cost-effective. Quality and cost often go

together (for example, the cheaper option may be of poor quality
and ultimately prove to be a false economy)

◆ affordable in terms of costs for freight, insurance, import tax, etc.

◆ affordable in terms of installation, commissioning, and training of

staff to use and maintain them

◆ affordable to run (for example, cover the costs of consumables,

accessories, spare parts and fuel over its life-time)

◆ affordable to maintain and service

◆ affordable to dispose of safely

◆ affordable in terms of the procurement process (for example the

cost of a procurement agent or foreign exchange)

◆ affordable in terms of staffing costs (for example, costs of any

additional staff or specialization training required).

Continued overleaf

4.4.2 Purchasing and donations policies

84

BOX 18: Example of Good Selection Criteria for Purchasing and Donations of Equipment

(continued)

Indicators of appropriateness Criteria

Ease of use and maintenance

Conforms to existing policies, plans
and guidelines

You should choose equipment:

◆ for which you have the necessary skills in terms of operating,

cleaning, and maintenance

◆ for which instructions and manuals are available to you in a

suitable language

◆ for which staff training is offered by the supplier

◆ for which local after-sales support is available with real technical

skills

◆ which offers the possibility of additional technical assistance

through service contracts

◆ which comes with a warranty/guarantee, covering a reasonable

length of time, for which you understand the terms. (For example,
does it cover parts, labour, travel, refunds or replacements?)

◆ which offers a supply route for equipment-related supplies (for

example, consumables, accessories, spare parts)

◆ which offers assured availability of these supplies for a reasonable

period (up to 10 years).

You should choose equipment:

◆ according to your purchasing and donations policy

◆ according to your standardization policy

◆ according to the technology level described in the Model

Equipment Lists and Generic Equipment Specifications
(Sections 4.3 and 4.5)

◆ which is deemed to be suitable, having studied available literature

and compared products (see Box 12 and Annex 2)

◆ which is deemed to be suitable, having received feedback

regarding previous purchases (Section 8.2).

If the equipment fails to meet these ‘good selection criteria’ (Box 18), you will have
to find ways around all the drawbacks that will arise. Alternatively, you could decide
not to acquire equipment which does not meet the selection criteria, and choose
another type, make, or model.

Introducing an element of standardization in the equipment purchased will help you
to limit the wide range of makes and models of equipment found in your stock
(Section 2.1). By introducing standardization, your technical, procedural and
training skills will increase, and your costs and logistical requirements will decrease
(see Guide 1). If procurement is carried out on an individual facility basis, you will
almost certainly be left with items of equipment which are uneconomic to maintain.
For this reason, it is extremely important to try to collaborate and procure
equipment at a central or regional level (Section 2.2).