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Received August 12, 2021, accepted May 5, 2022, date of publication May 24, 2022

COVID-19, a blessing in disguise: the experience of a 
Nigerian radiotherapy engineer

By Oluwasegun O. Adio, Iyobosa B. Uwadiae, Alaba O. Adewumi 

Department of Radiation Oncology, University College Hospital, Ibadan, Nigeria

ABSTRACT

The health technology sector of low- and middle-income countries (LMICs) is bedeviled by performance failures that make it a 
significant obstacle to effective patient healthcare interventions. The predominant factors behind the sector’s poor performance 
have been identified as (a) inadequately trained technical personnel and (b) the unserviceable condition of medical equipment. 
Past studies show that after adequate training, there is an increase in the proficiency of in-hospital biomedical engineers, but 
the studies have been limited to the maintenance job description of the engineers. We present a case study of the successful 
installation of sophisticated medical equipment by an in-hospital engineer to demonstrate that comprehensive training can 
also develop the installation expertise of local engineers. The installation, which is usually accomplished by the equipment 
manufacturer, was delegated to the trained in-hospital engineer due to the COVID-19 pandemic.
Furthermore, the bulk of medical equipment in LMICs is imported, which has led to an over-dependence of their health sectors 
on non-indigenous technology to the detriment of local alternatives and know-how. The World Health Organization estimates 
that 7 out of 10 sophisticated medical equipment imported by LMICs are unserviceable due to the issue of compatibility and 
adaptability with the setting. Previous research focuses on equipment subsidy, frugal innovation, and health technology man-
agement to better adapt foreign equipment to the environment. Still, this paper explores the option of indigenous technology 
and expertise to provide in-country development of suitable and sustainable medical equipment.  

Keywords – COVID-19, medical equipment, engineer, LMIC, training, installation, local production.

Copyright © 2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY): Creative Commons - Attribu-
tion 4.0 International - CC BY 4.0. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) 
are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is 
permitted which does not comply with these terms.

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23 J Global Clinical Engineering Vol.5 Issue 1: 2022

Adio, Uwadiae, Adewumi : COVID-19, a blessing in disguise: the experience of a Nigerian radiotherapy engineer

INTRODUCTION

As the world’s nations grappled with the COVID-19 
pandemic, several unprecedented measures were ad-
opted to limit the spread of the disease. Social distancing, 
quarantines, flight restrictions, lockdowns, and other 
routine-disrupting changes were imposed by govern-
ments at all levels. 

On the 21st of March 2020, Nigeria went into lockdown, 
and restrictions were introduced on travel by land and 
air.1 This, however, had only a partial impact on hospital 
activities because health workers, as essential service 
providers, were exempted from the restrictions. Doctors, 
nurses, and other hospital personnel kept working to 
provide medical care and manage the increasing patient 
volume due to coronavirus. Treatment of the disease 
required many types of lifesaving medical equipment, 
especially in intensive care units; therefore, more than 
ever, clinical engineers were needed to ensure the unin-
terrupted operation of medical devices.2

The job function of clinical engineers includes equip-
ment maintenance, acceptance testing, user training and 
education, clinical research and development, quality as-
surance, and productivity assessment.3 It is important to 
note that clinical engineering began in the late 1960s to 
address patient-safety concerns as increasing numbers of 
medical devices deployed in teaching hospitals. Not long 
after that, a preponderance of electrical safety failures 
brought the maintenance job description of in-house 
engineers to the fore.4

Clinical engineers develop their maintenance and 
troubleshooting skills through a combination of a hands-
on learning experience, in-service training, and short 
courses designed to equip them with the skills to handle 
a wide range of medical devices. However, when hospitals 
acquire new or sophisticated technology with mainte-
nance requirements beyond the engineer’s general skills, 
maintenance contracts are signed, or equipment-specific 
training is sought. Hospitals typically opt for maintenance 
contracts with the original equipment manufacturers 
(OEMs) or their agents in high-income countries. On the 
other hand, hospitals in low- and middle-income coun-
tries (LMICs) opt for training because of the long distance 
between them and the OEMs.5 

Unfortunately, the equipment-specific training is ad-
equate on most occasions, and the hospitals are forced 
to resort to high-priced maintenance programs that still 
involve the OEMs or their third-party agents.3,6 The local 
engineers are authorized to carry out only run-of-the-mill 
repairs while the heavy-duty maintenance is performed 
by the OEMs, usually after long waiting periods with a 
likelihood of poor treatment outcomes for the patient.7 

Delay in cancer treatment leads to increased patient 
distress, increased risk of local recurrence, and reduced 
patient survival over time.8,9 In LMICs, where delayed 
treatment is common, it can be attributed to late presen-
tation in patients, inadequate radiation therapy facilities, 
insufficient trained manpower, and machine downtime.10,11 
Therefore, the goal of the in-house engineer is to minimize 
downtime so that patients can avail themselves of the 
already limited therapy units. 

A previous paper has shown that with adequate train-
ing, in-house radiotherapy engineers (RE) could develop 
improvisation skills to reduce machine downtime in a 
Nigerian radiotherapy center.12  This paper is a case study 
that shows that in-house RE can go beyond the usual 
maintenance tasks to installing sophisticated equipment 
that preserves OEMs and their agents with comprehensive 
training. However, it is worthy of note that the case study 
could not have arisen but for the advent of COVID-19.

A SUCCESS STORY

Before the COVID-19 lockdown, High Dose Rate (HDR) 
brachytherapy equipment was set for installation in four 
radiotherapy centers across Nigeria. The equipment, a 
25-channel Saginova HDR After loader Brachytherapy 
system (Figure 1) manufactured by Eckert & Ziegler BEBIG 
GmbH Germany, had been shipped in, and engineers from 
the company were scheduled to follow for the installation 
work when the pandemic struck, and a restriction was 
placed on traveling.

As travel restrictions lingered, the situation became 
worse because, at the time, the country had only one 
functional brachytherapy center for its growing number 
of oncology patients. Moreover, the delay grew costlier 
with each passing day as the cancer cases worsened 
from lack of treatment and the radioactive decay of the 



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Adio, Uwadiae, Adewumi : COVID-19, a blessing in disguise: the experience of a Nigerian radiotherapy engineer

expensive Co-60 sources.13,14 It was therefore imperative 
to find a quick solution. 

The equipment manufacturer reached out to an RE in 
the Radiation Oncology Department, University College 
Hospital Ibadan (UCH), who had undergone training at 
their company factory (Figure 2). The training was spon-
sored by UCH after installing the same brachytherapy 
equipment in the hospital by the manufacturer in 2019. 

The training

The five-day course gave the trained technical special-
ists level A and level A+ proficiencies. For example, the 
level A certification authorized them to carry out standard 
maintenance and basic interventions on the equipment as 
advised by the manufacturer, while the level A+ certification 
authorized them to load and unload radioactive sources.

Each trainee was provided with a full-color illustrated 
manual containing step-by-step information on how to 
unpack the equipment, install it, test it while inactive, 
load the Co-60 source, test it while active, and adjust the 
equipment settings. It also included schematic and circuit 
diagrams and layout diagrams of the standard control 
and treatment rooms. The teaching method employed 
was hands-on learning, where trainees first observed 
the instructors and then practiced the lessons. Common 

real-life faults were simulated, and the trainees were 
instructed on how to solve them. 

Each training module ended with a Q and A and a quiz 
to test for mastery of the module. The trained and autho-
rized engineers were then awarded certificates of training.

The installation

The RE successfully installed the equipment, loaded the 
Co-60 source, and conducted acceptance testing in the four 
radiotherapy centers (Figure 3). Barring the occasional 
logistic problems, the installation was uneventful and did 
not lead to problems the German engineers would not 
have encountered, such as broken cables and a damaged 
SafeLogic compact arising from inadequate packaging.

The OEM provided remote guidance throughout the 
installation process, and the equipment was installed 
and handed over to the centers in good time. The RE also 
worked with the resident medical physicists to ensure that 
all technical parameters of the equipment were within 
acceptable limits.

The trainee becomes a trainer.

Before embarking on the training, the goal of the RE 
was to be reasonably proficient in maintaining the equip-
ment in his center and other centers in the country that 
may require his service. In addition, having witnessed the 
long waiting periods that LMIC hospitals are subjected 
to when working with OEMs and agents, he planned to 
become an alternative service engineer with the least 
response time. This desire was made known to the train-
ers, and they provided as much instruction as possible 
within the limited training period. 

FIGURE 1. A 25-channel Saginova HDR afterloader brachytherapy 
unit installed by the local engineer.

FIGURE 2. The radiotherapy engineer at the training facility 
in Germany.



25 J Global Clinical Engineering Vol.5 Issue 1: 2022

Adio, Uwadiae, Adewumi : COVID-19, a blessing in disguise: the experience of a Nigerian radiotherapy engineer

However, the engineer’s goal was flawed because it 
took up to two days to arrive at some centers, and if he 
were their service engineer, the equipment would be out 
of order for that long. Consequently, he rethought his plan 
and decided to train the centers’ in-house engineers as 
much as possible so that they could independently main-
tain their equipment. 

One center sponsored their engineer to join in install-
ing the equipment of another center after participating 
in the installation at his center. The aim was to use the 
opportunity to further hone the expertise of their engineer.

BENEFITS ENJOYED FROM THE SUCCESSFUL 
INSTALLATION

Asides from the obvious benefits of timely brachytherapy 
treatment for cancer patients and obtaining value from 
the expensive Co-60 source, installing the equipment 
by a local RE had significant economic benefits for the 
hospitals. The two-way airfares for OEM engineers were 
eliminated, and the per diem was considerably reduced, 
saving the government some foreign exchange earnings. 
In addition, the experience boosted morale and increased 
the technical skills of the RE and his colleagues. It also 
gave him the expertise for guiding the prepurchase and 
procurement planning process of medical equipment in 
his department.

Finally, the trip to other radiotherapy centers helped 
develop a strong collaborative relationship between the 
RE and the in-house engineers of the centers. 

LOOKING AHEAD

The healthcare needs in LMICs are tremendous, as 
is the quantity of medical equipment required to meet 
them. However, the bulk of medical equipment in these 
regions is imported or supplied by foreign donors. For 
example, a survey of 1,242 equipment in ten Indonesian 
hospitals revealed that only 4.2% were manufactured in 
that country.15 The figures for Nigeria show the country 
is dependent on importation for about 99% of its medi-
cal equipment needs, and the small local production in 
the country is limited to simple devices like syringes. 
Regrettably, the impact of the country’s $170m medical 
equipment market on patient care is still underwhelm-
ing as large numbers of imported medical equipment 
are unusable.16 

Up to 70% of sophisticated medical equipment im-
ported into LMICs is nonfunctional because of a mismatch 
between the equipment design and the setting where they 
are used. These “off-the-shelf” products fail to meet the 
environmental profile needs of LMICs already suffering 
from an unstable power supply, lack of clean water, an 
abundance of dust, and a hot and humid climate.17 Even 

FIGURE 3. Setting up a treatment console (left). A fully installed treatment console (right).



J Global Clinical Engineering Vol.5 Issue 1: 2022  26

Adio, Uwadiae, Adewumi : COVID-19, a blessing in disguise: the experience of a Nigerian radiotherapy engineer

when the equipment is stripped down, they are still not 
explicitly designed to meet the 4 As for preventing equip-
ment mismatch to a market: availability, accessibility, 
appropriateness, and affordability.18 

In view of the above, LMICs should begin exploring 
the local production of low-resource medical equipment, 
starting with non-complex ones. Such equipment would 
be designed with the environmental profile in mind and 
consider practitioner/end-user input to meet the appro-
priateness factors. It would be made from locally available 
raw materials and stripped of nonessential features to 
solve availability and affordability problems.19 However, 
this option remains only an aspiration until the many 
barriers facing local production are surmounted. 

One of the principals but unintended barriers is the 
influx of donated foreign medical equipment. Low cost 
or donated medical equipment leads to aid dependency 
in LMICs and a stifling of the country’s development.20 
Another barrier is the absence of an atmosphere conducive 
to R&D and innovation in LMICs.18 R&D is funded mainly 
by industries in high-income countries, but in LMICs it is 
publicly funded through academic institutions. However, 
in Nigeria, for example, the better part of the time and 
activity of universities is devoted to teaching and assess-
ing students, while research work is a secondary activity. 
Reasons like poor funding, insufficient research personnel, 
extraneousness of research focus on societal needs, and 
a delink between the academia and productive sectors 
have been attributed to the situation.21

To reverse this trend, the government needs to reap-
praise its allocations to the education sector, where the 
2021 expenditure on salaries and overhead is 429% of the 
capital budget of the Federal Ministry of Education.22 It 
also needs to double the funding for the Federal Ministry 
of Health to meet its 2011 Abuja Declaration of committing 
at least 15% of the annual budget to the health sector.23 
The two ministries and the Federal Ministry of Science 
and Technology must also work together to midwife the 
all-important collaboration among academic institutes, 
medical practitioners, and industries to kick off the pro-
duction of domestically-designed medical equipment 
from locally-sourced raw materials for use in the nation’s 
hospitals. 

Other challenges that must be addressed before local 
production can begin in LMICs include establishing a 
regulatory framework for health technology assessment, 
harmonization of device classification, standardization 
for product safety and quality, and creating an enabling 
business environment. 23 

In-house hospital engineers can also contribute their 
quota to the local production of medical equipment in 
LMICs through additive manufacturing. A few hospitals 
have pioneered 3D printing laboratories for the fabrica-
tion of person-specific needs that are not on the market. 
These so-called hospital factories use additive manufac-
turing to make products like individualized prosthesis for 
patients and anatomo-functional models used for surgi-
cal planning and patient education.24 Other areas where 
3-D medical printing is used include the production of 
microfluidic devices for laboratory test, meal assistance 
devices for spinal cord injury patients, immobilization 
devices for radiotherapy and fixation plates implanted 
by orthopaedics surgeons.25-27  Hospitals in LMICs can 
equip their biomedical engineering departments with 
3-D printing labs to fabricate some of these personalized 
medical products.

The essence of locating the laboratory in the hospital 
is to foster collaboration between medical practitioners, 
patients (end users), and the engineers from the design-
ing to production stages. While setting up the lab may 
be initially cost-intensive, hospitals can recoup their 
investments with a good business model, and patients 
can get apropos service at a fraction of the cost of getting 
it from OEMs.

CONCLUSION 

Achieving adequate health technology in LMICs is 
long and fraught with many difficulties. Progress in the 
sector has come in fits and starts and has barely made a 
dent in providing healthcare facilities with the resources 
they need to provide patients with the care they need. 
But with a strategic plan to develop the local ‘man and 
machine’ and an unflinching determination to commit 
time and financial resources to the plan, LMICs too can 
begin the journey towards self-sufficiency in their practice 
of medicine.



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