









































J Global Clinical Engineering Vol.2 Issue 2: 26-36 ; 2020  26

Received February 15, 2019, accepted May 20, 2019, date of publication March 1, 2020

Logistics of Medical Devices for Indigenous Health Care 
Attending in Remote Sites in the Brazilian Amazon Rain 
Forest 
By R. P. Ferreira, F. O. Andrade, A. A. Ramos, R. Bernardes, S. J. Calil

 Center for Biomedical Engineering, UNICAMP, Campinas, São Paulo, Brazil

ABSTRACT

Background and Objective
In Brazil, there are 896,917 Indigenous people with 47% dwelling in the Amazon rainforest region. To avoid expensive 
displacement of this population, especially for surgeries such as hernias and cataracts, the Expedicionários da Saúde non-
governmental organization (NGO) has visited this specific group 3 times per year since 2003. The visit is done through 
a field hospital (FH) and is supported by clinical engineering (CE). This article outlines the characteristics of logistics as 
well as the operation of medical and hospital devices in remote sites of the Amazon region. The object of this paper is 
to describe the transportation processes, installation, operation, and maintenance involved in ensuring the safe use of 
medical devices in one FH in the Amazon forest and to present solutions to adverse conditions encountered throughout 
the course of several expeditions.

Material and Methods
Initially, a survey of the processes used for transportation, installation, operation, and maintenance of medical devices was 
collected from 28 expeditions to the Amazon forest over a period of 10 years since the implementation of CE the team. 
A task-analysis process was performed to systematically identify the process used during these expeditions. To better 
understand the complexity and the specifics of each expedition, an evolutive planning process based on a Software Devel-
opment Spiral Model was used to describe a continuous activity flow that was used to implement and test improvements 
in each new expedition. Besides continuous improvement, the model also takes in consideration budget solutions once 
all the voluntary work by the NGO is done. The efficacy of the method was evaluated from indicators of use of medical 
equipment, the assessment of reported adverse events, and interviews with the professional from the CE team, the users 
of the medical devices, and the opinion of those responsible for managing of the expedition.
Results
Several improvements were observed specifically in the transporting and installation processes, mainly through the adop-
tion of customized packages and manuals for assembly and disassembly of the medical equipment. Further enhancements 
were obtained through customizations and adaptations of the devices to the hostile characteristics of the environment. 
Both physicians and nurses were satisfied with the performance of the devices, and few procedures for repair and calibra-
tion were required after the equipment was installed.
Conclusion
The CE team is crucial to the implementation of FHs, being essential in the management of medical technology and in the 
planning and operation of this type of health structure. The spiral planning method was shown to be very helpful mainly 

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27 J Global Clinical Engineering Vol.2 Issue 2: 26-36 ; 2020

Ferreira, Andrade, Ramos, Bernardes, Calil: Logistics of Medical Devices for Indigenous Health Care Attending in 
Remote Sites in the Brazilian Amazon Rain Forest

because it takes into account the experiences and needs 
of the past expeditions and for allowing the continuous 
improvement of the already used processes. Given the 
great complexity of the rainforest environment in which 
the technologies will be used and the unpredictability of the 
risks and challenges faced by the EC team the evolutionary 
work approach presents itself as an applicable solution 
when planning future expeditions.

Keywords – clinical engineering, field hospital, medical 
devices, Amazon Rain Forest, Expedicionarios da Saude. 
Copyright © 2021. This is an open-access article distributed under the terms of the 
Creative Commons Attribution License (CC BY): Creative Commons - Attribution 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.

INTRODUCTION
In Brazil, there are 896,917 Indigenous people with 

47% of them dwelling in a reserve forest in the Amazon 
region.1 Basic healthcare for this population is provided 
through the use of specialized health teams sent to their 
villages.2,3

For cases requiring specialized care, patients are sent 
to urban regions.4 However, this involves a significant in-
crease in costs and great discomfort for patients because 
of the distance and difficulty associated with traveling to 
the closest specialized medical center.

To reduce displacement of patients, especially for 
surgeries such as hernias and cataracts (prevalence of 
2.1%),5 the non-governmental organization (NGO) Expe-
dicionários da Saúde (Brazilian Health Expeditions) has 
attended to this specific population 3 times per year since 
2003. There were 44 expeditions with a total of 97,060 
nonsurgical patient encounters and 8,773 surgeries.6 

All of the work is done by voluntary professionals who, 
in addition to the provided care, also assist with the as-
sembling of the field hospital (FH) used for this service. 
This FH contains a specialized surgical center, sterilized 
material center, and ophthalmology, pediatrics, odontol-
ogy, gynecology, and general clinical medicine outpatient 
facilities.7 The FH is defined as a mobile, self-contained, 
self-sufficient health care facility capable of rapid deploy-
ment and expansion or contraction to meet immediate 
emergency requirements for a specified period.8,9 As 

with permanent structures, this hospital needs medical 
devices for patient diagnostics and therapy. According 
to Finestone, the FH must be equipped appropriately to 
function independently.10 Therefore, it should have all 
necessary external resources needed to function such as 
medical instruments, operational material, infrastructure, 
and additional equipment.

Support from the clinical engineering (CE) team is 
crucial to the implementation of FHs and is essential to 
the planning, management, and support not only of the 
structure but also of the facilities and the medical tech-
nologies used.11

The CE team is composed of 3 engineers who travel 
one at a time for the expeditions and one engineer who 
give support to the routine work in maintenance of medi-
cal devices.

Among the diverse medical technologies involved, it is 
necessary to recognize their technological complexities. 
Consequently, the CE team is in charge of the transportation 
and assembling of items including electrosurgical units, 
physiologic monitors, imaging ultrasound, phacoemulsi-
fication machines, surgical microscopes, surgical lamps, 
portable laboratory, autorefractors/keratometers, pulse 
oximeters, colposcopes, slit lamps, and ocular biometers.

A total of 15 tons of materials and pieces of equipment 
for the FH are transported to their remote sites in the 
Amazon.12 The route includes roads, rivers, and airports 
with most lacking proper conditions for the landing of 
big-load aircraft and the transportation of delicate medi-
cal devices.

All of the material is vulnerable to weather and local 
environmental conditions such as high humidity, tempera-
ture, sun exposure, dust, strong winds, and impacts related 
to loading and unloading of boats, trucks, and aircrafts.13

The main role of technology management done by CE 
team is to make sure the medical devices are available 
and are working properly and safely. This process is done 
through assembling, installation, maintenance, and very 
importantly, by the protection of medical devices to avoid 
damage during transportation.14

However, the high complexity transportation of medi-
cal devices in the Amazon forest and the lack of available 
financial resources due to the project’s often philanthropic 



Ferreira, Andrade, Ramos, Bernardes, Calil: Logistics of Medical Devices for Indigenous Health Care Attending in 
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J Global Clinical Engineering Vol.2 Issue 2: 26-36 ; 2020  28

origin demanded the development of a structured and 
evolutionary work process aiming for low-cost solutions.

OBJECTIVE
The object of this paper is to describe the transporta-

tion installation, operation, and maintenance processes 
used to ensure the safe use of medical devices in one FH 
in the Amazon forest and to present proposed solutions 
to overcome adverse conditions throughout the course 
of several expeditions.

METHODS

Task Analysis 
Initially, a survey of the processes used for transporta-

tion, installation, operation and maintenance of medical 

devices was done using the method called Task Analysis.15 
Data from planning, preparation, transport, and operation 
of medical devices were collected from 28 expeditions 
to the Amazon forest over a period of 10 years since the 
implementation of the CE team. To facilitate the visual-
ization of these process, see Figure 1 and the survey of 
processes and description of stages.

Description of the stages of processes:
1.1 MD Selection: The amount, type and characteristics 

of the required medical devices depend on their estimated 
demand and on the types of patients and procedures that 
will need them. A contingency plan to have a 25 to 50% 
higher stock of medical devices is established. The correc-
tive maintenance has a low chance of success in case of 
failures due to the lack of resources, such as spare parts, 
test equipment, tools, training, and more.

FIGURE 1. Process diagram of medical devices.



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Ferreira, Andrade, Ramos, Bernardes, Calil: Logistics of Medical Devices for Indigenous Health Care Attending in 
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1.2 MD Request to Partners: Partner companies 
provide equipment that is lacking. The number of devices 
requested is based on demand and the number of devices 
currently available.

1.3 Own MD Stored: Owned MD equipment is stored 
in the distribution center (DC) in the southeast of Brazil. 
This location was selected because of better availability 
of companies to perform maintenance, access to better 
storage conditions, and easy access to equipment by the 
team. The management of expiration dates of accessories 
and materials is done at this stage.

2.2 Receipt of MDs on DC: Equipment lent by part-
ners is delivered to the DC where it is checked after being 
previously tested by their providers.

2.4 Proper Operation: Before the packing stage, the 
NGO’s equipment and accessories undergoe functional 
testing.

2.3 Proper Packaging: Equipment provided by 
partners is inspected to ensure quality and viability of 
the packaging and is placed in a 180-liter standardized 
container as necessary.

2.5 and 6.2 Corrective Maintenance: 30% of cor-
rective maintenance is done in house and managed by 
the CE team. However, the loaned MDs are repaired by 
MD’s partners.

2.6 and 4.5 Packaging: The equipment is preferably 
packed in foam, cut in its own format, sealed with plastic 
bags, and put inside the 180-liter standardized containers. 
The container has a weight limit of 30 kg (66.1 lb) to allow 
manual loading. Packages are recycled on their return.

3.1 and 4.6 Proforma Invoice: This is a checklist of 
the bill or goods (or items) to be included with the FH. All 
items receive numeric identification, sealing, and external 
identification with colored codes.

3.2 and 4.7 Transport: The equipment is transported 
by road, air, and on water (e.g., by river). Transportation 
from Campinas (southeast region) to Manaus (north 
region) can be by road or air, go through roads and high-
level airports with infrastructure, and via resources such 
as forklifts and warehouses. After Manaus, the load is 
carried by military aircraft, ferry boats, wooden boats 
adapted to the rain forest rivers, and sometimes on un-
paved roads which are subject to quagmires and dust. 

During transportation, the load can be exposed to rain. 
For this reason, it is protected by plastic tarps. When a 
load is delivered to the indigenous community or small 
towns that do not have proper infrastructure the unload-
ing is manually conducted at the riverbank.

4.1 Assembly: There is a visual inspection of each MD 
for integrity before assembly. Assembling procedures often 
differ from the original manuals as they are simplified to 
reduce assembling errors and the limited availability of 
trained manual labor.

4.2 Final Tests: Before use, MDs are tested and kept 
working in shifts of 2 hours. This testing ensures the func-
tioning of equipment and the generator when fully loaded.

4.3 Use of MD: The use regimen for MDs is that they 
will be available 13 hours a day for 6 days with the device 
operation monitored and controlled by the CE team.

4.4 Disassembly: The equipment is disassembled fol-
lowing the same procedures used in the assembly process.

6.1 and 6.5 Own MD: The partners’ pieces of equip-
ment are returned without going through internal main-
tenance procedures.

6.2, 6.3. and 6.4 Corrective Maintenance, Preven-
tive and Inspection: Before storage, owned pieces of 
equipment go through corrective maintenance when 
defects have been identified; after this, equipment goes 
through post-repair inspection or pre-storage preventive 
maintenance for devices not requiring repair.

Evolutionary Planning Cycle of Expeditions
We estimated through the 28 expeditions the equip-

ment was transported for more than 163,000 km (approx. 
101,000 mi). Due to the highly complex environment and 
great diversity of problems faced in each expedition, an 
evolutionary and cyclic work process was developed 
based on the software development in the spiral (Figure 
2). This model, widely used in software engineering for 
the development of prototypes, describes a continuous 
activity flow, which allows for improvements for each 
new expedition.16 The spiral method is similar to the 
PDSA (Plan, Do, Study and Act) method of continuous 
improvement, being chosen by the team involved in this 
study due to its familiarity with the method. The evolu-
tionary cyclic work process is divided into 4 stages and 



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J Global Clinical Engineering Vol.2 Issue 2: 26-36 ; 2020  30

always restarts from the last expedition where problems 
relating to transportation, installation, operation, and 
maintenance are identified.

In Stage 1 the identified problems are classified into 
3 groups: technological, operational, and environmental.

After classification, each problem is analyzed, and pos-
sible solutions are proposed based on its classification in 
Stage 2. The proposed solutions are evaluated and chosen 
according to their cost × benefit × effectiveness (Stage 3). 
This decision is influenced by limited financial resources 
and voluntary labor. In Stage 4, the chosen solutions are 
implemented and tested; if successful, they are incorpo-
rated into future expeditions.

Identification of Problems Found in Expeditions
According to the process presented previously, after 

each expedition, several problems are identified and 
registered for the improvement of future expeditions. 
Problems may be related to some of the following:
• Technological factors: related to the limitations of 

technology, the technology not being designed to the 
environment where it is used, such as the type of the 
material used in the equipment, design (size, weight, 
etc.), or device circuits not being compatible to the 
quality of energy available.17

• Environmental factors: related to the natural charac-
teristics of the environment which impacts both the 
use16 or transportation of devices, such as temperature, 
humidity, and condensation.

• Operational factors: related to the use of the device, 
such as operational, installation, transport, assembly, 
and disassembly errors.
Different processes of study and analysis were used 

to propose solutions for problems previously presented. 
Solutions to technology- and environment-related problems 
are proposed after studying device operation manuals and 
information from the manufacturer’s websites. This study 
aims to identify the technical characteristics of device 
functioning and which critical elements can be modified 
and which protective measures must be implemented.

Protective measures can be implemented by improving 
procedures. Operational problems are studied after task 
analysis and solutions are implemented with improvement 

of work processes and by modifying actual device-related 
protocols.

RESULTS 
In the first stage of the spiral cycle of evolutionary 

planning, problems were identified according to their 
characteristics.

In Table 1 it is possible to see the problems identified 
during a series of expeditions regarding the lack of docu-
mentation. This indicates the temporal relation between 
the cycle and the solution.

FIGURE 2. Representation of the evolutionary planning cycle 
of expeditions.

TABLE 1. Relation of Problems Identified According to 
Characteristics

Technological Factor Problems

Break of the fairing of the external part, premature break of 
the optic fiber, breaking of connectors during disassembly, 
assembly errors, bad internal contacts, equipment without 
battery backups, and external damage to the manufacturer’s 
packaging.

Environmental Factor Problems

Fungi in lenses, oxidation of parts, equipment not working in 
ambient temperature, incompatibility of power grids, burned 
out equipment due to lightning, wet equipment, condensation 
due to excess humidity.  



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In some cases, there was uncertainty about how to 
classify a problem. For example, an MD that was dam-
aged during transportation could have been classified as 
a technological problem for not being protected before 
being transported (technological) or as an operational 
problem for not being properly protected during trans-
portation. Table 2 presents solutions related to problems 
identified in Table 1.

Improvements that were part of an operational prob-
lem solution are:

1.1 MD Selection: Inclusion of required MD specifica-
tions, assessment, and field tests.

1.2 MD Request to Partners: Increase in quantity of 
contingency equipment, accessories, and inputs.

1.3 Owned MDs Stored: Increase in quantity of stra-
tegic equipment (essential equipment for the operation 

of the FH or where there are loaning difficulties between 
the partners).

2.3 Proper Packaging: Inclusion of provider’s packag-
ing assessment. In some cases, the provider’s packaging 
is not the most appropriate for the type of transportation 
used for the FHs. For example, cardboard packages that 
come without plastic protection, pieces of equipment 
without any packaging, wooden boxes without proper 
protection against storms.

2.4 Proper Operation: Inclusion of the testing criteria.
2.5 and 6.2 Corrective Maintenance: Inclusion of 

criteria for selection of maintenance providers and begin-
ning of in-house maintenance.

2.6 and 4.5 Packaging: Improvements in the processes 
and packaging of materials. Some pieces of equipment have 
to be disassembled to fit standardized plastic boxes and 
for those which disassembly was not possible, waterproof 
wooden boxes with external protection were made with 
key locks and handles for manual transportation. At the 
bottom of the containers, 8 cm of foam is used to protect 
against impacts and water infiltration. Internal protection 
is achieved with medium-density foams and bubble wrap.

3.1 and 4.6 Proforma Invoice: Computerization in 
the process of packing lists with double checking and 
logistical team training in the computer system.

4.1 Assembly: Increase in instructions and assembly 
training, simplification of the assembly procedures, use 
of devices with only one option for assembly, and stan-
dardization of electrical outlets.

4.2 Final Tests: More detailed tests such as the use 
of an eye phantom and testing of the generators with all 
equipment on.

4.3 Use of MD: In loco instructions to users and in-
frastructure improvement for generators and electrical 
facilities, such improvement and standardization of power 
distribution boards, standardization of AC cables, exchange 
of single-phase generators with three-phase generators 
with automatic voltage control

4.4 Disassembly: More training of staff on disassembly 
and improvement to disassembly instructions.

Operational Factor Problems

Operational errors, equipment lacking software configuration, 
lack of localization of accessories/errors in checklists, lack of 
contingency accessories, partner equipment not working (not 
previously tested), lost parts during transportation, damage 
during transportation (error in optical measurements).

TABLE 2. Solutions Presented According to Problems 
Identified

Technology-Related Solutions

Spare accessories, corrective maintenance, change to error-
free connectors, improvements in the process of corrective 
maintenance, acquisition of uninterruptible power supply and 
change to original packages.

Environment-Related Solutions

Change in preventive maintenance protocols, equipment 
climate control, equipment replacement, packaging 
improvement, avoiding taking equipment out of climate-
controlled areas, and implementation of lightning protection.

Operational Solutions

Improvement of processes (below).



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6.4 Preventive Maintenance and Inspection: Inclu-
sion of annual preventive maintenance and obligatory 
inspection for every expedition.

6.5 Partner MD Return: Inclusion of the checklist 
of MDs that are returned along with information of any 
intra-expedition failures.

DISCUSSION
It can be observed that the spiral method aided the 

improvement of the work processes involving the man-
agement of the MDs, allowing the implementation of 
solutions for each new expedition cycle. However, each 
new proposed solution still needed to be evaluated before 
being added as part of the work process. And, due to the 
characteristics of the use of temporary FHs, this process 
of improvement can be very slow. One way to reduce the 
time needed to evaluate the proposed improvements is 
to apply the proposed enhancements in simulated envi-
ronments. Once validated and tested they can safely be 
applied in the new expeditions cycle. The use of methods 
for risk assessment and risk mitigation during the selec-
tion and analysis of the proposals can also accelerate the 
process of adopting the improvements. Performing the 
risk analysis processes for the proposed improvements 
while taking into account the existing financial criteria 
of the expedition, the physical characteristics of the load 
(volume and weight), and the composition of the team 
at hand would considerably increase the success of the 
improvement proposals.

Still, some difficulties need to be assessed in each 
cycle, with the main difficulties being, scarce resources, 
continuous change of team members due to the voluntary 
nature of the work, and the continuous need for training, 
documentation, labeling, and warnings.

A critical part of the actual work process is the simpli-
fied documentation of the meetings themselves and the 
execution of improvements. Efforts have been made to 
improve the environmental conditions of the FHs, improve 
electrical generators, and use energy stabilizers for those 
more critical cases.

CONCLUSIONS
The use of the spiral method has shown positive 

results in the improvement of the work process, mainly 
within the assessment stages for every expedition, the 
implementation of modifications, and the posterior as-
sessment as a continuous improvement process. The 
CE action done outside the boundaries of the perennial 
health structure is necessary for environments where 
patients need healthcare, with the proper support of the 
technology available so that such care be provided with 
safety and efficacy.

This support has been crucial in the attending of the 
isolated population in the hostile and isolated environ-
ment of the Amazon forest. Concerning the FH, the CE is 
responsible for transport planning and for providing the 
proper conditions for storage, transportation, installation, 
operation, and equipment disassembly, even in environ-
ments with low availability of resources.

The planning related to MD must be careful, for both 
supplies and accessories and also for necessary contin-
gencies such as having a sufficient supply of replacement 
parts, spare pieces of equipment, and other equipment 
due to the geographical isolation. This isolation makes it 
difficult to search for solutions outside of the workplace.

Considering the unique characteristics of the FHs and 
the costs involved in the acquisition of specific MDs for 
this implementation, equipment acquisition must include 
the equipment standardization criteria and a reduction 
of device volume and weight, without any reduction in 
functionality.

This continuous improvement process is required be-
cause the variability found in remote sites in the Amazon 
challenges both transportation and implementation of FHs.

ACKNOWLEDGEMENT
Special thanks to EDS: Ricardo Ferreira (president), 

Marcia Abdala (general manager), Rogério Ulbrich (field 
engineer), João Galdino (local engineer) and Tiago Ro-
drigues (field engineer).



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APPENDIX

Examples of Transportation in the Rain Forest



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Equipment packaging examples

Field hospital



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Cataract surgery

General surgery

EC Team

Rogerio Ulbrich, João Galdino, Ryan Ferreira and Tiago Rodrigues


