Vaccine refrigerators awaiting repairs in Mozambique in 2016. (Photo courtesy of Nexleaf Analytics)
As COVID-19 has raised our collective awareness of the importance of robust health care systems, innovators are hard at work designing new ways to deliver everything from vaccines to oxygen.
Though quickness is an important aspect of the pandemic response, a decade of working on public health issues in Africa and Asia has taught us that innovators and health care providers must be thoughtful when pursuing technological solutions. They must account for the many factors that can determine whether equipment will achieve what is intended.
Among the threats to success are broken supply chains, inappropriate design, difficult maintenance, and a mismatch between the technology and local needs. Without accounting for these and other concerns, the best-intentioned solutions arising during the COVID-19 crisis risk joining unused or broken devices that sit idle in equipment graveyards around the world.
As public health stakeholders around the globe continue to respond to the COVID-19 crisis and others like it, here are a few practices to keep in mind in the design, deployment, and scaling of technological solutions. Following these guidelines, we believe, will help ensure vulnerable people in low- and middle-income (LMIC) countries get the aid they need.
Understand Local Needs
It is worth repeating the well-known concept that solutions providers need to understand problems and their resolutions through the eyes of the people experiencing them. Time and time again, we have learned that engaging leading stakeholders at the country level–and doing so early and often–is critical to aligning with local communities and designing solutions that can scale responsibly.
Given that ministries of health (MoH) extensively coordinate health care in LMICs, they should be first on the list of organizations with which to collaborate. They can complement or perhaps augment additional efforts to find and support local innovators, engineers, and social leaders who can offer solutions that are contoured to local needs.
Nexleaf has worked with the MoH in Kenya and Mozambique for the development of monitoring devices that track the temperature of refrigerators used to store vaccines, which can become ineffective unless they're kept at a temperature ranging from 35.6 to 46.4 degrees Fahrenheit. We approached the MoH in Kenya with a prototype of the device and installed it in a few clinics, taking the time to observe and learn from how health care workers handled the technology. Collaborating with the MoH early and learning from health care workers helped us improve upon the design of the hardware and update features to account for limited connectivity and security issues. The redesigned device was deployed in vaccine storage sites across Kenya. It has led to a huge reduction in the exposure of vaccines to damaging temperature levels.
Prepare for Fluctuations in Power Supply
Given that many health facilities in lower-resource countries lack access to reliable power grids and often can't get fuel for back-up generators, machines meant to save lives must be able to accommodate power outages and voltage fluctuations. A study of ours on refrigerator performance across 27 health clinics in Mozambique found that power outages caused 16 percent of the devices' failures. This was a serious problem—the refrigerators were used to hold a variety of vaccines, all of which are temperature sensitive. However, gaps in power are dangerous in many scenarios.
To address this challenge, consider equipment-level design improvements, such as built-in rechargeable backup batteries and more robust power circuits. Solutions can also go to the level of facilities, and include providing an uninterruptible power supply (UPS), which allows a device to continue running on battery power when the primary source is lost. Voltage stabilizers, which regulate the incoming supply voltage to protect devices from under and over voltage, are another option. More broadly, public health practitioners must examine ways to get power to resource-limited or hard-to-reach areas. Options include mini grid solar power, off-grid solar, and other renewable energy sources. Or they could simply improve people's access to fuel to run generators. In Tanzania, for example, a local health official mandated that health facilities had extra cylinders of liquified petroleum gas for backup power.
Provide Open Source or Standardized Designs
Most life-saving equipment is designed in more developed countries, which are more likely to have a robust supply of consumable components and spare parts—filters, nasal catheters, and other objects that are used in the operation of ventilators, for example. But many LMICs have for years lacked access to robust supply chains that can provide such components, without which the machines are rendered useless. The problem is made even more complicated by a failure of different manufacturers to standardize the design of the consumable components or replacement parts.
Standardizing design, or allowing designs to be flexible based on localized supply chains, allows local stakeholders to source and use equipment more effectively. One take on this approach was a ventilator prototype from the Jet Propulsion Laboratory.
If agreeing on common designs seems too far-fetched of a solution, another option would be to borrow a concept from the software world and make the designs open source. This would at least give organizations and individuals with sufficient resources the ability to craft functional replacement parts on their own. Italian engineers, for example, used 3D printers to construct disposable valves to keep respirators running.
The concern with design should also extend to the data that devices may produce about their own operation, from simple records about power fluctuations to errors and alerts. Given the rate of technological change, the data should be structured in an open way that makes it usable to a variety of other hardware and software. Popular services, from Facebook to Twitter to Airtable, use this concept—called an application programming interface (API)—to make the data they capture useful for applications other than their own. Our team has used an open API to organize data from vaccine refrigerators that are in different locations and made by multiple vendors. We then aggregate it into an information dashboard, called the Intelligent Maintenance and Planning Tool (IMPT), that health officials can use to monitor the devices.
Assess the Availability of Other Goods That Are Essential to the Device
Ventilators are considered to be a powerful life-saving tool for COVID-19 and for other urgent medical needs, such as surgery and treatment for lung disease. However, ventilators don’t work alone. They need oxygen, which is in short supply and difficult to distribute to where it is needed. As more ventilators are produced and shipped around the world, public health stakeholders also need to assess oxygen supply chains. In this case and often in others, there is more than one way to get all of the necessary elements for a device. If access to oxygen in cylinders is limited, for example, hospitals can use oxygen concentrators, which come with the bonus of being more economical, prolific, and versatile when it comes to providing health care. Oxygen concentrators, however, also need power and regular maintenance. Each piece of equipment has its positives but also shortcomings. When distributing equipment to facilities, we shouldn’t assume there is a panacea for all health needs.
Add Smart Signaling and Diagnostic Capabilities to the Devices
For countries and regions with reliable telecommunication networks, public health stakeholders should consider devices equipped with SIM cards that are able to collect data and signal for help. Our team has worked with health officials for the past eight years on adding such sensors to refrigerators in which vaccines are stored. The sensors detect when temperatures are dangerous to vaccines and then send an SMS alert to health care workers. They then take action to prevent vaccines from spoiling, from closing a door that was accidentally left open to moving vaccines out of a refrigerator that is chronically failing. It’s through these measures that health care workers can feel confident that the vaccines they administer are safe.
However, alerts are not enough. Health care workers need to be able to understand what is wrong with a device so they can develop a fix. Manufacturers can be part of the solution by making sure devices can output data about themselves. This information can include on or off status, power availability, error codes, performance metrics, and very basic insight into whether the device is working at all. With this data made available, users of the device can call in appropriate help, and those tasked with repairs can organize themselves to efficiently respond to different and better-classified problems.
In an assessment conducted with the MoH in Mozambique, Nexleaf discovered that technicians with access to diagnostic data could remotely assess a refrigerator and talk health care workers through simple fixes, such as temperature adjustments, over the phone. This saved the technicians notable time and money that would otherwise be spent on traveling to distant facilities. In Mozambique, remote diagnosis led to big gains in warding off problems: From August 2014 to May 2015 the number of times refrigerators reached risky levels of warmth fell by 78 percent, and problems with being too cold were reduced by 60 percent.
Make Sure Health Workers Are Trained and Know Their Options
Operating ventilators requires specialized training, including intubation. But an insufficient number of health care workers know how to do the procedure as demand for it skyrockets in response to COVID-19. There should be a greater focus on comprehensive training to maximize use of resources on hand. Training can ensure none of the existing or newly designed equipment sits idle. When Nexleaf observed health care workers failing to make use of remote temperature monitoring technology, the team investigated the causes and learned that workers were, despite an initial training program, intimidated by the technology. In response, we provided more hands-on training, which led to an increase in use.
Before You Ship
As this pandemic continues to unfold, the risk of producing and distributing devices that end up in growing equipment graveyards is all too real. Asking a few questions up front can ensure that the best-intentioned plans to distribute medical gear also come with the best results. Before shipping equipment, make sure it works well for the people it is intended to help.
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Read more stories by Marym Mohammady, Erin Ross, Bernard Olayo & Dickson Otiangala.