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Manuscript Number: JINJ-D-15-00251R1
Title: Assessment of the Availability of Technology for Trauma Care in Nepal
Article Type: Original Paper
Keywords: trauma care; trauma technology; low income country; nepal; essential trauma care;
essential surgery; healthcare equipment; south east asian healthcare.
Corresponding Author: Dr. Mihir Shah,
Corresponding Author's Institution: Academy Of Traumatology (India)
First Author: Mihir Shah
Order of Authors: Mihir Shah; Suraj Bhattarai; Norman Lamichhane; Arpita Joshi; Paul LaBarre; Manjul
Joshipura; Charles Mock
Abstract: Background: We sought to assess the availability of technology-related equipment for trauma
care in Nepal and to identify factors leading to optimal availability as well as deficiencies. We also
sought to identify potential solutions addressing the deficits in terms of health systems management
and product development.
Methods: Thirty-two items for large hospitals and sixteen items for small hospitals related to the
technological aspect of trauma care were selected from the World Health Organization's Guidelines for
Essential Trauma Care for the current study. Fifty-six small and 29 large hospitals were assessed for
availability of these items in the study area. Site visits included direct inspection and interviews with
administrative, clinical, and bioengineering staff.
Results: Deficiencies of many specific items were noted, including many that were inexpensive and
which could have been easily supplied. Shortage of electricity was identified as a major infrastructural
deficiency present in all parts of the country. Deficiencies of pulse oximetry and ventilators were
observed in most hospitals, attributed in most part to frequent breakdowns and long downtimes
because of lack of vendor-based service contracts or in-house maintenance staff. Sub-optimal oxygen
supply was identified as a major and frequent deficiency contributing to disruption of services. All
equipment was imported except for a small percent of suction machines and hemoglobinometers.
Conclusions: The study identified a range of items which were deficient and whose availability could be
improved cost-effectively and sustainably by better planning and organization. The electricity deficit
has been dealt with successfully in a few hospitals via direct feeder lines and installation of solar
panels; wider implementation of these methods would help solve a large portion of the technological
deficiencies. From a health systems management view-point, strengthening procurement and stocking
of low cost items especially in remote parts of the country is needed. From a product development
view-point, there is a need for robust pulse-oximeters and ventilators that are lower cost and which
have longer durability and less need for repairs. Increasing capabilities for local manufacture is
another potential method to increase availability of a range of equipment and spare parts.
Suggested Reviewers:

*Cover Letter (inc. author declaration as per Guide for Authors)

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Dear Dr. Civil,

Thank you for your email of March 30, 2015 and for the opportunity to revise this manuscript.
The co-authors and I have edited the manuscript in response to the comments from the reviewers,
as indicated in the uploaded revision note and in the highlighted areas of the manuscript.
We have highlighted the major changes in the paper. Due to the extensive nature of the changes
in the discussion, we have not highlighted this. Likewise, the renumbering of references and
tables are not highlighted.
Please let us know if you would like any further edits to the manuscript.
Sincerely,
Dr. Mihir Shah

*Revision Note (Blinded)

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Dear Dr. Civil,

Thank you for your email of March 30, 2015 and for the opportunity to revise this manuscript.
The co-authors and I have edited the manuscript in response to the comments from the reviewers,
as indicated below and in the highlighted areas of the manuscript.
Comments to the Author:
Reviewer #1: This is an interesting and necessary paper. If every LMIC did this it would reveal
a very sad state of affairs. Knowing what the problems are is the first step to solving them.
My only serious criticism is the English which needs a thorough revision. Other than that the
discussion should start with a summary of the findings of the study. Specifically the discussion
could be cut by about 30%.

RESPONSE: We have reviewed the paper for English and grammar and made multiple
changes. We have revised the discussion so that it starts with a summary of the findings of the
study. We have also decreased the length of the discussion by about 30% from 1096 words
before to 768 after.
Reviewer #2: Assessment of the Availability of Technology for Trauma Care in Nepal
Reviewer's Comments
This is a very important and pertinent subject and I applaud the authors in not just performing a
study to characterize the problem "We sought to assess the availability of technology-related
equipment for trauma care in Nepal" but also to seek "possible potential solutions" which is
the most novel, important and innovative component of this article. In particular, a study to
assess the factors that influence availability of resources and hence, identify potential solutions is
a much needed subject. However, I do have a few questions that if answered/included would
work to make this article publishable.
Comments
1) The last sentence in paragraph one of the Introduction which starts with "This discrepancy
in trauma deaths" - it is a statement about the attributable factors in this discrepancy but it is
neither referenced as to where this statement comes from or if it is the author's belief,
understanding, assumption or experience which should be reflected better in the wording.

RESPONSE: We have revised the sentence to be clearer and have added the corresponding
reference.

2) As noted above the objective of this study is extremely noteworthy, timely and needed.
However, I am unclear why the authors choose to separate the potential solutions into two
categories and in particular, why the second category of product development? Is there not more
immediate and local (i.e. health system level) solutions that can be considered before jumping to
a solution that would take years and much investment to see impact in a meaningful way? Or if
the authors disagree with this point, can they include in their discussion specific examples of
local product development that have already been accomplished successfully?

RESPONSE: We agree that the health systems solutions are likely to produce results more
quickly than product development. We did look at these as the first category of potential
solutions. However, we continue to feel that longer term product development solutions should
also be sought. We had already included in our discussion mention of the gains made in the
neighboring country of India in terms of improved supply of several items of equipment and
supplies through local manufacturing. In light of the reviewers comments, we have:
i.
ii.

Highlighted the importance of the health systems solutions, including mention that
they will bear more immediate benefit.
Included an example of a local Nepali product development of an indigenous transfemoral prosthesis adapted to local needs manufactured solely using local products.

3) Why would you not survey facilities just because of their basic level of care? Is that not the
whole point of WHO essential trauma care - to ensure basic care at all levels - with differences
that reflect the level. Are these health care levels where a large volume of trauma is seen? This
should be explained in the methods as to what role these facilities that are not surveyed do or do
not play in trauma care.

4) As the survey was focused on the hospital levels of care - comments describing the health
care access patterns of patients is warranted. Do all patients go to the nearest facility first
irrespective of severity? Is there a referral system in place that would dictate patient facility
utilization? Etc
RESPONSE TO ITEMS 3 AND 4: The primary health care (basic) level cares for very little
trauma in Nepal. Furthermore, while the WHO Guidelines for Essential Trauma Care do provide
guidance for trauma care at all levels (from rural clinics (when they do care for trauma) to small
hospitals to large hospitals), in our particular study we decided to focus specifically on the
hospital levels, so as to focus on the aspects relating to physical resources (equipment, supplies,
technology). Regarding the health care access patterns: there is no formal referral system in place
in Nepal. Patients with serious injury (and also other serious illnesses) typically are brought to

the nearest hospital level, bypassing the primary health care clinics, which are primarily for
outpatient care and preventive health services. In light of the reviewers comments, we have:
i.
ii.

Clarified in the methods why we focused on hospital based care.

Clarified health care access patterns in Nepal, including providing a reference on this
topic.

5) "Only facilities which were government-operated or government-affiliated were evaluated

because they provide the majority of trauma care in the country"needs a reference if
possible or a statement of expert opinion etc
RESPONSE: Several of the co-authors are clinicians who are active with trauma care in Nepal.
The low level of involvement of private health care facilities (which are small in number and in
scope in Nepal in general) is well known to them and other trauma care clinicians. Information to
this effect and the fact that it is expert opinion has now been added to the manuscript.

6) How were the hospitals chosen? Or maybe better asked why the other hospitals left were
out of the survey or not chosen?
RESPONSE: Further details on site selection have been added to the methods section.

7) Was the presence of a piece of equipment verified by the interviewer? Or just taken by
interviewee verbal report? Was the score assigned equipment found, from 0 to 3, assigned by the
interviewer based on interviewee answers or directly from the interviewee after explanation of
the scoring system? Was there internal validity or reliability between answers given by different
interviewees at the same hospital about the same piece of equipment? Was this analyzed at all?
RESPONSE: Each individual piece of equipment was verified and directly inspected by the
interviewers. The score was assigned by the interviewer based on interviewee answers and was
not assigned by the interviewees themselves. Anecdotally, we were not often faced with a
discrepancy between staff report of item availability and item availability by direct inspection.
However, we were often able to help identify factors contributing to item non-availability
through individual discussions with multiple staff members that interact with the same item and
by direction inspection. In response to the reviewers comments, further information on the
hospital inspection process has now been added to the methods.

8) What was the relationship if any between the interviewers and interviewees? It is not clear
who exactly the interviewers were?

RESPONSE: There was no professional or personal relation between the interviewers and the
interviewees. In the overwhelming majority of cases, they met for the first time during the interview.
Two of the authors (SB, NL) carried out the interviews at all the hospitals themselves. Information on
this has now been added to the methods.

9) There is no mention of IV catheters, IV fluid, chest tubes but surely these are in the
essential and desirable list? There seems to be an inordinately large number of times the state of
the pulse oximetry equipment is mentioned?
RESPONSE: The WHOs Guidelines for Essential Trauma Care contain recommendations on
260 individual items of human resources (skills, training, staffing), physical resources
(equipment, supplies), and medications needed for trauma care. The lower cost, simple supplies
such as IV catheters and IV fluids are of course very important. Multiple studies have been done
in many countries utilizing the Guidelines for Essential Trauma Care in a broad fashion, looking
at all or most of the 260 items. These have been very important and similar future studies will
continue to be important. However, there is also a need for studies that look in a more indepth
fashion at specific components of the recommended items and to delve into more depth on
factors that contribute to their availability or non-availability. This study, in similar fashion to a
recent study in India, was designed to specifically go into more detail on the technology related
items. Furthermore, prior studies have, in general, not gone into detail on contributing factors.
This study helps to advance the field of trauma care capacity studies by going into more depth on
factors that contribute to deficiencies. We feel that this is an important contribution to
complement the other more general studies. In light of the reviewers comments we have
clarified the connection between the current technology-related study and the existing more
general essential trauma care studies.

10) Though your comments about ATLS , in the discussion, are likely pertinent to the
improvement of trauma care in general in Nepal it does not seem to be appropriate for the study
objective at hand and as this is not a review article but a scientific article about equipment
availability, I would stick to the topic at hand.

RESPONSE: The section on ATLS has been deleted.

11)

A good conclusion - a nice summary of the points.

Reviewer #3: This is a study assessing 56 small and 29 large hospitals across Nepal for their
trauma related capacity based on the WHO guidelines. It identifies the major lacks in equipment,

personnel and infrastructure across the whole country. The paper is well written but is too long
with too many tables in its present form. Tables 4 and 7 add little to the information provided in
the text and both could be omitted.
RESPONSE: We have decreased the length of the paper, especially the discussion (which was
also recommended by reviewer 1). We agree that it would be useful to decrease the number of
tables. We think it would be best to delete Table 1 (the information for which has now been
incorporated into the text of the results) and Figure 1 (the information for which had already
been mentioned in the text of the results). If the reviewer wishes us to delete Table 4, we could
do so. However, incorporating this information into the text would likely not be as efficient as
keeping the information in the table. Nonetheless, we are prepared to do so, if the reviewer
wishes this. If at all possible, we would prefer to keep Table 7. As discussed in the response to
reviewer 2 (point 9), the most innovative part of this study (and how it builds on the prior
essential trauma care surveys done in other countries) is that it focusses on technology-related
physical resources and goes into depth on factors contributing to deficiencies. Thus, we feel that
the information contained in 7 represents important new information for the field.

There are several areas where changes would make the text more readable. page 9 Para 3 stock
outs should read 'lack of stock'
RESPONSE: Edited as suggested.

Page 9 Para 3 'In keeping with government guidelines' in the last sentence does not seem to make
sense. should this read "In breach of government guidelines...'?
RESPONSE: This actually had meant in keeping with the government guidelines, indicating that
the government guides were at a lower level than the WHOs recommendation. We agree that
this phasing was somewhat confusing. In light of the reviewers comments, we have rephrased
this section.

Page 12 first line 'the types of alarms made by the machines' should read 'the machine alarms'.
This paper does highlight the difficulties faced by clinicians trying to treat trauma patients in any
hospital and gives some suggested ways to try to bring about an improvement.

RESPONSE: Edited as suggested.

We have highlighted the major changes in the paper. Due to the extensive nature of the changes
in the discussion, we have not highlighted this. Likewise, the renumbering of references and
tables are not highlighted.

Please let us know if you would like any further edits to the manuscript.

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Manuscript type: Original Manuscript

Title: Assessment of the Availability of Technology for Trauma Care in Nepal
Authors: Mihir Shah1, 2, Suraj Bhattarai3, Norman Lamichhane4, Arpita Joshi2, Paul LaBarre5,
Manjul Joshipura1, Charles Mock 6
Author Affiliations:
1
Academy of Traumatology (India), Ahmedabad, India
2
Smt. NHL Municipal Medical College, Ahmedabad
3
B.P. Koirala Institute of Health Sciences, Dharan, Nepal
4
Tribhuvan University Teaching Hospital, Kathmandu, Nepal
5
PATH, Seattle, USA
6
Department of Surgery, University of Washington, Seattle, USA
Corresponding Author:
Dr. Mihir Tejanshu Shah
65 B Swastik Society,
Navrangpura, Ahmedabad
India- 380009
Phone: +91 9904434900
Email: mihir.28290@gmail.com
Number of figures: 0
Number of tables: 6
Conflict of interest: No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this article.
Financial support: This study was funded in part by a grant from the University Of Washington
Department Of Surgery Research Reinvestment Fund. Support was also provided by private
foundations and individual donors to PATHs Health Innovation Portfolio.
Keywords:
trauma care, trauma technology, low income country, nepal, essential trauma care, essential surgery, healthcare equipment, south east asia healthcare

Page 1

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Abstract
Background: We sought to assess the availability of technology-related equipment for trauma
care in Nepal and to identify factors leading to optimal availability as well as deficiencies. We
also sought to identify potential solutions addressing the deficits in terms of health systems
management and product development.
Methods: Thirty-two items for large hospitals and sixteen items for small hospitals related to the
technological aspect of trauma care were selected from the World Health Organizations
Guidelines for Essential Trauma Care for the current study. Fifty-six small and 29 large
hospitals were assessed for availability of these items in the study area. Site visits included direct
inspection and interviews with administrative, clinical, and bioengineering staff.
Results: Deficiencies of many specific items were noted, including many that were inexpensive
and which could have been easily supplied. Shortage of electricity was identified as a major
infrastructural deficiency present in all parts of the country. Deficiencies of pulse oximetry and
ventilators were observed in most hospitals, attributed in most part to frequent breakdowns and
long downtimes because of lack of vendor-based service contracts or in-house maintenance staff.
Sub-optimal oxygen supply was identified as a major and frequent deficiency contributing to
disruption of services. All equipment was imported except for a small percent of suction
machines and hemoglobinometers.
Conclusions: The study identified a range of items which were deficient and whose availability
could be improved cost-effectively and sustainably by better planning and organization. The
electricity deficit has been dealt with successfully in a few hospitals via direct feeder lines and
installation of solar panels; wider implementation of these methods would help solve a large
portion of the technological deficiencies. From a health systems management view-point,
strengthening procurement and stocking of low cost items especially in remote parts of the
country is needed. From a product development view-point, there is a need for robust pulseoximeters and ventilators that are lower cost and which have longer durability and less need for
repairs. Increasing capabilities for local manufacture is another potential method to increase
availability of a range of equipment and spare parts.

Page 1

INTRODUCTION
Worldwide over 5 million people die each year as a result of trauma [1]. Traumatic injuries are a
rising cause of mortality especially in low- and middle-income countries (LMICs) [1-4]. In
Nepal a low-income country, trauma-related deaths account for 10% of the total mortality [5, 6].
The age-standardized mortality rate for injuries in Nepal is 119 compared to the worldwide rate
of 84 (per 100,000 population per year) [7, 8]. It has been previously noted that this discrepancy
in trauma deaths between LMICs and high-income countries is partly attributable to inadequacy
of hospital and community-based emergency care.[9]
In an attempt to reduce this disparity, the World Health Organization (WHO) published the
Guidelines for Essential Trauma Care (EsTC) in 2004 [10]. This was done with intent to
standardize the system of trauma care in every country regardless of the economic status. These
guidelines include 260 human and physical resources required for the management of a victim of
trauma. An important component of the physical resources is technology related.
Many countries have been assessed under the EsTC guidelines, which has enabled the
recognition of shortcomings and formulation of cost-effective recommendations to improve
national trauma care systems [11-19]. In these prior evaluations, the factors responsible for the
absence of trauma-related technological resources had not been explored in sufficient depth. We
feel that this is an important contribution to complement the other more general EsTC studies.
An evaluation of the availability of technology for trauma care has thus far been carried out only
in India [20].
Building upon that prior study, the current study seeks to delve into greater depth to assess the
factors influencing the availability of resources for the technology of trauma care in Nepal. In so
doing, we have attempted to identify potential solutions to insufficiencies in two broad
categories: health system management (e.g. procurement, stock management, financing) and
product development (e.g. development of medical devices that are more durable and require less
maintenance).
METHODS
Site selection
Nepal has a per capita income of 694 USD and a population of 27 million and is classified as a
low-income country [21, 22]. The country is divided into administrative units called zones which
are further divided into districts. Twelve out of the fourteen zones of Nepal were selected with an
aim to cover the wide spectrum of geographic and economic diversity of the country. Districts
have wide variations in their level of development and are ranked according to the Overall
Composite Index of development [23]. The Overall Composite Index is a cumulative index of 29
indicators used to grade the development of the 75 districts. The 75 districts are divided into 3
developmental categories- high, medium and low development districts, with 25 districts in each.
In an attempt to represent the diversity of the country, districts at all developmental levels were
purposively selected to be studied [23].
The public healthcare delivery system includes a spectrum of facilities including: Sub Health
Post (SHP), Health Post (HP), Health Centre (HC), Primary Health Care Centre (PHC-C),
District Hospitals, Zonal Hospitals, Central and Regional Hospitals, medical colleges and
teaching hospitals with residency programs, public health & medical institutes and other
specialist hospitals [24]. The basic level of healthcare is delivered via clinics, which tend to have
only one doctor and provide only out-patient requirements and provide no or very preliminary inpatient care. There is no formal referral system in place in Nepal and patients with serious injury
Page 2

(and also other serious illnesses) typically are brought to the nearest hospital level, bypassing the
primary health care clinics, which are primarily for outpatient care and preventive health
services. [25] As the trauma care provided by these facilities is of an extremely basic
technological level, these facilities were not surveyed in this study. Small hospitals in Nepal
have a capacity of 30-100 beds and were assessed in the study. These hospitals are uniformly
managed and controlled by the Nepal government and hence, vary only on the basis of
geographical and developmental factors. Large hospitals having a bed capacity of 100-1000 beds
were also surveyed for this study. These hospitals not only varied based on geographical and
developmental factors as the small hospitals, but also according to the regulations imposed upon
them by the Nepal Medical Council for medical school and residency program licensures [26].
For this study, a total of 56 small hospitals and 29 large hospitals were purposively selected out
of a total of about 74 small hospitals and 55 large hospitals countrywide, to represent the
diversity of trauma care development, geography and local socioeconomics. [24]. Only facilities
which were government-operated or government-affiliated were evaluated because they provide
the majority of trauma care in the country, in the expert opinion of the two authors (SB, NL) who
are trauma care clinicians in Nepal.
Criteria for evaluation
In this study, the essential and desirable resources described in the Guidelines for Essential
Trauma Care, were evaluated together. Essential items are those that are particularly inexpensive
and cost-effective and should always be available for optimal trauma care, irrespective of the
economic status. The desirable items are those which add extra value, but are not as costeffective as the essential items [10].
Out of all these resources, the technology-related items were shortlisted and evaluated in every
facility. The form used to survey small hospitals had 16 items listed and the form used for large
hospitals had 32 items. They included equipment used for both diagnosis and treatment.
Site visit process
Interviews were conducted by two of the authors (SB, NL) with key staff at each hospital. These
included hospital directors; heads of departments of surgery, orthopedics, and other relevant
specialties; emergency department (ED) head; nursing matron/head; and clinicians (doctors and
nurses) on duty in the ED, intensive care unit (ICU), operating rooms (OR) and wards; and
biomedical engineers and maintenance staff. Direct assessment of amenities and equipment in
ORs, EDs, ICUs and wards were carried out. Direct inspection included visually determining
presence of absence, examining equipment for functionality (e.g. assessing whether the item
worked, was not missing components/reagents, was not prohibitively expensive for patients) and
in cases of deficiencies, assessing why it was not rated 3 (e.g. stock management, training
deficiencies, breakdowns), Factors contributing to proper availability were also recorded. Open
ended questions were also asked to allow a more comprehensive assessment of the issues faced
by the hospitals. The duration of the visits was around 4 hours in clinics and small hospitals and
10 hours at large hospitals. Each of the resources was assessed as:
Absent: 0
Inadequate: 1 Less than half of those who need this service receive it when required
Partly adequate: 2 Most, but not all, of those who need this service receive it when needed
Adequate: 3 Virtually all of those who need this service receive it when needed
Page 3

Resources were evaluated based on their timely availability for those in need, and not just their
mere physical presence. For each item recorded as 0 - 2, reasons for lack of full-time availability
were given, including one or more of: not present, lack of reagents, lack of trained staff, awaiting
repairs, need for prepayment and others. When differing scores were given by different
respondents, an average/consensus value was recorded. One score for each institution for each
category was thus derived. Names of respondents were not recorded. The study was approved by
the health departments of the involved districts and zones and/or senior management of the
specific facilities surveyed, as appropriate.
RESULTS
Small hospitals
Fifty-six small hospitals were evaluated in this study. These include eighteen, twenty-two and
sixteen each from low, medium and high development districts respectively. Most of the
technology-related resources for trauma care were inadequate, if present at all, in a majority of
the hospitals [Table 1]. In many of the small hospitals, certain equipment had a 0 rating as it
should have been available according to the Guidelines for Essential Trauma Care, although the
hospitals met the countrys criteria for availability of services at the basic level of healthcare.
Most small hospitals had notable deficiencies in low-cost items like basic airway equipment,
bag-valve-masks and urinary catheters with mean ratings of 1. Chest tubes were unavailable in
most small hospitals, especially those located in low- and middle-development districts; having a
mean rating of 0 across development levels. Pulse oximetry was absent in low- and middledevelopment districts (0 rating) and although present in high-development districts, the supply
was inadequate at best (rating-1). Capabilities for definitive care were almost completely absent
with mean ratings of 0 for operative equipment for spinal and extremity injury.
Large hospitals
Twenty-nine facilities were evaluated. These included thirteen, six and ten each from hospitals
without a medical school or residency program, those with only a medical college and those with
both a medical school or residency program respectively. The hospitals without a medical school
or residency program further comprised of three, five and five hospitals at low, medium and high
development districts respectively. Overall, the technology for trauma care was inadequate in
most large hospitals with only the institutions at the top end of the spectrum having partly or
completely adequate capabilities. Availability was also influenced by the economic status of the
institutions district [Table 2 and Table 3]. For example, most of the items needed for acute
resuscitation had mean ratings of 0 1. Even large hospitals with medical schools and residency
programs had a mean rating of 2 (partly adequate) for these low cost items. Several key
capabilities were available at only the highest level of hospitals: ventilators, radiography
equipment (X-rays, ultrasonography and CT scan machines) and even there they had mean
ratings of 0 - 2. Operative procedures for general surgery and orthopedics were only partly
adequate (rated as 2) at the top end of the spectrum and generally absent at the lower end.
Factors contributing to deficiencies: Small hospitals
In Table 4, the absence of equipment implies that the equipment was never available and in most
cases not intended to be stocked. In contrast, shortage of equipment means that the equipment
was stocked and planned for but had inadequate units to meet the needs.
Page 4

A key deficiency in small hospitals pertained to infrastructure due to frequent power outages and
no backup generator. Absence of equipment was an important issue as regards availability of
basic diagnostic facilities like ultrasonography (98% of hospitals reported complete absence of
this item) and pulse oximetry (57% reported none available). Very often, even those hospitals
which had functional machines were unable to provide the service because of shortage of
materials. Owing to the inhospitable terrain, remote hospitals in mountainous regions and those
in low-development areas had frequent lack of stock. Functional equipment in well-staffed
hospitals lay unused for prolonged periods of times because of lack of supplies. Another
consequence of the hostile landscape was the inability of maintenance and repair personnel to
reach most parts of country. For example, it was a frequent observation to see broken down
pulse-oximeters (32% of small hospitals reported this as a contributing factor) and X-ray
machines (48%) lying unrepaired for months to years because of lack of engineers. Following
government guidelines, most small hospitals did not have provisioning for staffing at night and
on weekends for X-rays and hemoglobin estimation. Many patients did not get such basic
diagnostic services at those times. In part related to this, around 50% of hospitals reported
staffing issues as a cause for deficiencies of availability of X-rays and hemoglobin estimation.
Factors contributing to deficiencies: large hospitals
As with the small hospitals but to a lesser extent, large hospitals in remote locations also faced
difficulty with maintaining supply lines and with engineering manpower for repairs. This
contributed to deficiencies for pulse oximeters (66% of facilities reported breakdowns as a factor
contributing to deficiencies) and ventilators (48%). Lack of trained staff for ultrasonography was
an important issue (31% of facilities reported this as a factor contributing to deficiencies) and in
most cases functional ultrasonography machines were were used exclusively for obstetrics and
were not used for trauma management. .
Many facilities required payment of user fees at point of delivery which reduced the timely
availability of hemoglobin measurement (24%), electrolyte analysis (28%), ventilators (31%),
CT scans (34%), X-rays (21%) and ultrasonography (31%). For all of these items, between 2134% of facilities reported training as a factor contributing to deficiencies. Intracranial pressure
monitors and prosthetics were not planned for in any of the hospitals surveyed. Staffing was a
major issue in many remote areas. In a few large hospitals in remote low development areas,
funds had been used to purchase expensive equipment like CT scan, which were never used
because of lack of radiologists and/or technicians. A notable infrastructural issue was the absence
of dedicated intensive care units (ICU). Many hospitals (especially in remote areas) had bought
but never used expensive ventilators because of the lack of an organized ICU. On the contrary,
many hospitals in high development areas could not provide this service on a timely basis due to
shortage of ventilators (62%).
Origin of manufacture
Most of the equipment used in both small and large hospitals was imported. In the small
hospitals only a small proportion of the equipment used was locally manufactured which
included about 12% of hemoglobinometers and 31% of the suction equipment. The rest of the
equipment consisting of machinery for X-rays, ultrasound and pulse oximetry were entirely
imported. All equipment in the large hospitals was imported with the exception of suction
equipment, 24% of which was locally sourced.
Engineering problems
Page 5

The engineering problems encountered in the various types of equipment are shown in Table 5.
Some of the leading problems in suction machines included plumbing (52-61% of hospitals
reporting this as a problem) and motor problems (34-41%). The most common problems seen
with pulse oximetry were electrical (62-73%) especially being related to detachment of the
probe-wire junction and mechanical (28-57%) especially being related to breakage of the probes.
All of the above problems were more pronounced at small hospitals. Engineering issues seen
with hemoglobin analysis, electrolyte and arterial blood gas measurements, and ultrasonography
were mechanical in nature and related to breakage and bending of probes within the machine.
Cheaper, locally-made probes for ultrasound machines were frequently used, but had shorter
lifespans as compared with the original parts. X-ray equipment had frequent breakdowns due to
electrical (45%), mechanical (34%) and motor (10%) issues.
In large hospitals, ventilators most commonly broke down and required maintenance because of
installation and usage errors (52% of large hospitals reporting this problem). The operators of
ventilators were not well acquainted with the equipment, especially the messages indicated by
the machine alarms. Without training, these were often misinterpreted, leading to inappropriate
usage of the equipment despite its physical presence. Also, the lack of training led to improper
assembly of the equipment parts causing leakages.
Causes of disruption of services [Table 6]
Open ended questions were asked related to the causes of service disruption to allow a more
comprehensive assessment of the issues faced by the hospitals. The most frequent technological
problems overall were delayed lab reporting in both small (48% of small hospitals reporting this
in the top three most common problems) and large (59%) hospitals. Pulse oximeter breakdown
was also a commonly cited cause of disruption (41% of small hospitals, 55% of large hospitals).
Power cuts were a frequent cause of disruption in small hospitals (43%).
In small hospitals, the technological problems that led to the most severe disruptions were
insufficient oxygen supply (54% of small hospitals listing this as one of the top three most severe
problems), misplaced equipment (46%), and delayed lab reporting (46%). In large hospitals, the
technological problems that led to the most severe disruptions were insufficient numbers and
frequent breakdowns of ventilators (55%), insufficient oxygen supply (45%), and periods of
breakdown and deficiency of CT scans (38%).
Discussion
The purpose of this study was to identify priorities for affordable and sustainable methods to
improve availability of technology for trauma care in LMICs like Nepal, in terms of both health
system management (e.g. procurement, stock management, financing) and product development
(e.g. development of medical devices that are more durable and require less maintenance). This
study found that the availability of most resources for the management of trauma care in Nepal
especially was lower in comparison to other similar LMICs. in the low-development areas [1217]. The most significant contributing factors included lack of power supply and consumables in
remote parts of the country. Hospital assessments also demonstrated a dearth of in-house
maintenance staff or equipment manufacturer service contracts in larger hospitals. An increased
focus on health system management would mitigate many major deficiencies and would be able
to yield benefits in the short term.
Another leading cause of unavailability related to health system functioning was lack of trained
staff to operate equipment, especially in rural hospitals. For example, 73% of small hospitals
Page 6

reported lack of training as a cause unavailability of suction and 54% reported lack of staff to
operate X-ray equipment. Such competence mismatches resulted in wasteful expenditure.. Nepal
faces a severe shortage of doctors with a doctor: population ratio of 17 per 100,000
[27].Moreover, a recent survey of graduates shows that around 50% plan on emigrating from the
country upon graduation. [28]. Creative solutions need to be developed to confront this brain
drain to the West.
Another contributing factor was the rugged terrain which decreases the accessibility of many
areas [29]. Addressing problems like repeated breakdowns which were seen frequently with
equipment like X-rays and pulse oximetry becomes challenging. For example, most of the
problems faced in the case of pulse oximetry were electrical and mechanical. Forty-one percent
(41%) of small hospitals and 55% of large hospitals reported the breakdown of their pulse
oximeters to be one of the most frequent causes of disruption of their services. These difficulties
are compounded by a dearth of biomedical engineers, with Nepal currently producing 36
biomedical engineers a year [30].
Compounding specific health system issues, infrastructural issues also contributed to
deficiencies. For example, frequent power outages have been reported to lead to disruption of
healthcare services in general [31, 32]. Forty-three percent (43%) of small hospitals and 33% of
large hospitals stated that frequent power cuts were a major cause of interferences. Possible
solutions include better availability of generators or direct power lines. Some hospitals have
installed solar systems which work well in Nepal due to its topography [33, 34].
In addition to the health system issues which require more immediate attention, longer term
improvements in engineering aspects of trauma technology would improve their availability. As
stated , frequent breakdowns of equipment in remote areas resulted in long periods of
unavailability while awaiting repairs. Equipment that needs infrequent servicing and which is
more durable is a potential solution.
Ventilators, especially, were problematic. The majority (62%) of large hospitals reported an
inadequate number of units and 48% reported breakdowns as a reason for suboptimal services.
Deficiencies in oxygen supply were reported by many hospitals. In Ghana, oxygen concentrators
were found to be a cost-efficient solution to the problem of irregular oxygen supply [35]. Wider
use of this technology can address such shortfalls.
A major finding was that most of the equipment was imported. Many of the technological
problems for trauma care stem from reliance on imported technology. Despite previous studies
advocating better local manufacturing, stronger policies have yet to be formulated to encourage
this in developing countries [36]. In a study in India, there was greater availability of items that
were locally manufactured, suggesting the importance of local manufacturing in improving
availability [20]. One notable example of Nepali local product development comes in the form of
a trans-femoral prosthesis manufactured solely using local products. [37] Encouraging such
product development would yield benefits in the longer term.
Before drawing conclusions, the limitations of the study must be addressed. First, although
physical inspection of equipment and supplies were fairly objective, information on the process
of care depended mostly on informant interviews. Ratings (03) were usually based on
subjective opinions of the interviewer. This is especially the case for ratings on knowledge and
skill. Second, the private sector is fairly well developed and, runs at a higher level than the
government system. However, the government system takes care of most trauma patients.
Despite these limitations, the study provides a comprehensive assessment of trauma care

Page 7

technology for a low-income country and allows us to draw some reasonable conclusions about
ways to strengthen it.
Conclusions
This study has identified several successes (such as fairly good availability of services at
hospitals with medical schools and residencies) as well as deficiencies in the availability of
technology-related resources in Nepal. An overarching cause of low functional availability of
technology was the frequent power outages which plague the country. Direct feeder lines and
solar panels for generation of electricity at the hospital level were some of the solutions that have
successful overcome this deficiencies in a few local areas and that need to be expanded upon.
There were also a range of items whose availability could be increased by health system
management improvements, such as by: better procurement and stock management for lower
cost items, especially strengthening supply chains for more remote areas; eliminating mismatch
of resources, including through optimizing training for use of existing resources; and by
strengthening in-house repair capabilities for critical items. High cost, low durability and need
for frequent repairs of pulse oximeters and ventilators was found to be a major factor leading to
deficiencies that could be addressed from a product development viewpoint. A potential solution
to these deficiencies could be increased local manufacturing of the equipment and equipment
spare parts.

Page 8

Acknowledgements
Click here to download Acknowledgements: acknowledgements.docx

This study was funded in part by a grant from the University Of Washington Department Of
Surgery Research Reinvestment Fund. Support was also provided by private foundations and
individual donors to PATHs Health Innovation Portfolio.

*Conflict of Interest Statement

Click here to download Conflict of Interest Statement: Conflict of Interest statement.docx

Conflict of interest: No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this article.

Table
Click here to download Table: Tables.docx

Table 1. Ratings of availability of trauma care technology at small hospitals.

LowMediumHighdevelopment development
development
districts
districts
districts
18
22
16
Number of facilities assessed
Airway
1

0
1

1
1

0
1

0
1

0
1

0
0
Operative equipment

0
0

1
0

0
Extremity injury

0
0
Spinal injury

0
0

0
0

Basic airway equipmenta

Advanced airway equipmentb

0
Breathing

Oxygen supply
Chest tubes and underwater seal
bottle
Pulse oximetry
Bagvalvemask
Blood transfusion capabilities
Urinary catheter
Laboratory facilities for
hemoglobin

0
1
Circulation

Imaging
X-rays
Ultrasonography c

General surgical proceduresd

Skin grafting
Closed reduction
External fixation

Materials for spinal

0
0
0
immobilizatione
The ratings of availability of items in the table are: 0 (absent), 1 (inadequate), 2 (partly adequate), 3
(adequate). Values in the cells indicate the mean value.
a
Oral or nasal airway; suction. bLaryngoscope, endotracheal tubes
c
Ultrasonography, especially for diagnosis of hemoperitoneum.
d
General surgical procedures, including laparotomy, neck exploration
e
For spinal immobilization: C collar, back board.

Page 1

Table 2. Ratings of availability of technology for acute resuscitation at large hospitals

No medical school or residency program

Number of facilities assessed

Lowdevelopment
districts
3

Mediumdevelopment
districts
5
Airway

Highdevelopment
districts
5

Medical school
only

Medical school
and residency
program

10

Basic airway equipmenta

Advanced airway equipmentb

1
0

1
0
Breathing

1
1

1
1

2
2

Oxygen supply
Chest tubes & underwater seal
Pulse oximetry
Arterial blood gas
Bagvalvemask
Mechanical ventilator

0
0
1
0
1
0

1
1
0
0
1
0
Circulation

1
1
1
0
1
0

2
1
1
1
2
1

2
2
2
2
3
1

0
0
1
1
2
Blood transfusion capabilities
1
1
1
2
3
Urinary catheter
0
1
1
2
2
Lab facilities for hemoglobin
0
0
1
1
2
Electronic cardiac monitoring
0
0
1
1
2
Lab facilities for electrolytes
0
0
0
0
1
Lab facilities for lactate
The ratings of availability of items in the table are: 0 (absent), 1 (inadequate), 2 (partly adequate), 3 (adequate). Values in the cells
indicate the mean value.
a
Oral or nasal airway; suction
b
Laryngoscope, endotracheal tubes

Page 2

Table 3. Ratings of availability of technology for imaging and operative equipment at large hospitals
No medical school or residency program

Number of Facilities assessed

X-rays
Portable X-ray
Ultrasonography a
CT scan
Angiography diagnostic
Angiography therapeuticb
Basic neurosurgical
proceduresa
Advanced neurosurgical
procedures
Spinal injury
General surgical proceduresb
Vascular grafts
Skin grafting

Lowdevelopment
districts
3

Mediumdevelopment
districts
5

Highdevelopment
districts
5

0
0
0
0
0
0

1
0
0
0
0
0

Medical
school
only

Medical
school
and
residency
program

10

1
0
0
0
0
0

1
1
1
1
0
0

2
1
2
1
0
0

0
0
0
0

0
1
0
0
Head injury

1
2
0
0

1
2
0
0

1
2
0
1

Monitoring ICP

0
Extremity injury

Closed reduction
Skeletal traction
External fixation
Internal fixation
Compartment pressure
measurement
Image intensification
Prosthetics for amputees

0
0
0
0

1
1
1
1

2
2
2
1

2
2
2
2

2
2
2
2

0
0

0
0

0
0

1
0

1
0

The ratings of availability of items in the table are: 0 (absent), 1 (inadequate), 2 (partly adequate), 3
(adequate). Values in the cells indicate the mean value.
a
Basic neurosurgical procedures include Burr holes (drill or other suitable equipment) and treatment of
open depressed skull fractures.
b
General surgical procedures, including laparotomy, neck exploration
ICP: Intracranial pressure.

Page 3

Table 4. Factors contributing to deficiencies in technology for trauma care at small and large hospitals

Equipment type

Training

Suction
Pulse oximetry
Hemoglobin
X-ray
Ultrasonography

73%
23%

Staffing

Breakdowns/
maintenance

46%
54%

14%
32%
23%
48%

User
Infrastructure
fees
& logistics
Small hospitals

21%

23%
27%
32%
27%

2%

Shortage of
materials

Shortage of
equipment

Absence of
equipment
18%
57%
29%
38%
98%

23%
48%
2%

Large hospitals
Suction
Pulse oximetry
Hemoglobin
Electrolytes
Arterial blood gas
Ventilator
X-ray
Ultrasonography
CT scan
ICP measurement
Prosthetics
Image intensifiers

17%
41%

21%
7%
31%
3%

34%
21%
10%
10%
17%
17%
7%

17%
66%
34%
17%
14%
48%
38%
24%
21%

14%

17%

24%
28%
24%
31%
21%
31%
34%

14%
17%
24%
17%
14%
21%
14%
21%
7%

38%
7%
10%
10%
17%

3%
62%
3%
17%

10%

10%

3%
17%
3%
34%
55%
38%
17%
38%
66%
100%
100%
55%

Each row shows percent of that type of health facility that reported that type of contributing factor. More than one factor may be present;
hence row totals may be more than 100%. ICP: Intracranial pressure.

Page 4

Table 5. Engineering problems leading to breakdowns/maintenance issues for equipment in large hospitals
EQUIPMENT
TYPE

SOFTWARE
ISSUES

HARDWARE ISSUES
Electrical

Mechanical

Plumbing

Installation/
Usage errors

Motor

Small Hospitals
Suction
Pulse oximetry
Hemoglobin
X-ray
Suction
Pulse oximetry
Hemoglobin
Electrolytes
Arterial blood gas
Ventilator
X-ray
Ultrasonography
CT Scan
Image intensifiers

73%
41%

62%

31%
45%
24%
21%
31%

18%
57%
27%
34%
24%
28%
24%
31%
24%
17%
34%
52%
38%
41%

61%

41%
21%
18%

Large Hospitals
52%

24%

34%

52%

28%
10%
3%

17%

Each row shows percent of that type of health facilities which had the physical presence of the equipment and which reported that type of
contributing factor for equipment deficiencies. More than one factor may be present; hence row totals may be more than 100%.

Page 5

Table 6. Most common and most severe causes of disruption of services

Technological problem
Percentage of
Technological problem
Percentage of
listed amongst the 3
facilities that listed listed amongst the 3 most
facilities that
most common causes of the cause amongst
severe causes of
listed the cause
disruptions in a facility
the top 3
disruptions in a facility
amongst the top 3
Small Hospitals
Delayed Lab reporting
Frequent power cuts
Pulse oximeter
breakdown
Routine sterilization not
undertaken
Unaccountability of
equipment leading to
frequent misplacements
Hospitals large in area
and understaffed
Equipment once
misplaced takes a long
time to find
X-ray machine
breakdown
ECG machine breakage
of probes
Oxygen supply

48%
43%
41%

Oxygen supply
Misplaced equipment
Delayed lab reporting

54%
46%
46%

34%

Pulse oximetry

38%

30%

Malfunctioning of ECG
monitoring

27%

29%

Untrained personnel
treating patients

25%

23%
20%
Large Hospitals

Delayed lab reporting

59%

55%

55%

Ventilator breakdown and

less number
Oxygen supply

Pulse oximeter
breakdown
Cardiac monitor and
ECG wire breakage
Suction device
X-ray breakdown
Frequent power cuts
USG probe breakage
CT scan

48%

CT scan

38%

45%
34%
33%
31%
24%

Defibrillator malfunction
Suction
USG breakdowns
X-ray

31%
24%
21%
14%

Page 6

45%

Page 7