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Received April 24, 2019, accepted June 6, 2019, date of publication June 29, 2019

Barriers to Availability of Surgical Equipment in 
Kenya: A Surgical Equipment Journey Approach

By R.M. Oosting1, L.S.G.L Wauben2, S.W. Mwaura3, J.K. Madete4, R.S. Groen5, J. Dankelman1

1Dept. Biomechanical Engineering, Delft University of Technology, The Netherlands
2Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
3Association of Medical Engineering of Kenya, Nairobi , Kenya
4Dept. of Electrical and Electronic Engineering, School of Engineering and Technology, Kenyatta University, Nairobi, Kenya
5Dept. Gynecology and Obstetrics, Johns Hopkins University, Baltimore, USA

ABSTRACT

Background and Objective
The need for surgery is currently not being met in Sub-Saharan Africa, requiring both extra workers and surgical equip-
ment. Currently, there is a gap in the availability of surgical equipment which limits the provision of safe surgery. To design 
strategies to increase availability the use of surgical equipment in this context needs to be understood. This study aims to: 
(1) identify the different phases surgical equipment goes through during its lifespan (i.e., the surgical equipment journey) 
in Kenya, and to (2) identify barriers that are perceived by biomedical equipment technicians (BMETs). 
Material and Methods
Seven semi-structured in-depth interview sessions were conducted with a total of 17 BMETs working in Kenya. Participants 
worked in 6 different hospitals (4 public, one private and one mission). Interviews were conducted between December 
2016 and December 2018. Participants were asked to describe or draw the surgical equipment journey and describe the 
perceived barriers during this journey. 
Results
The surgical equipment journey consists of 3 phases: procurement, usage, and disposal. Stakeholders involved in the 
surgical equipment journey are users, BMETs, procurement officers, local distributors, and in case of donations, donation 
agencies. Bureaucracy during procurement, difficulties to obtain consumables and spare parts (especially for donated 
equipment), cleaning with heavy chemicals, and usage in challenging environments were identified as barriers during 
the surgical equipment journey.
Conclusion
Sustainable interventions at multiple organizational levels are required to optimize the surgical equipment journey in 
hospitals in Kenya. Different strategies that can be applied in parallel to increase availability of surgical equipment in 
Kenya were identified by the participants in this study: policies on donations, procurement of durable equipment, more 
well-trained BMETs and university-trained biomedical engineers, and designs and business models that fit the local use 
in Kenya and presumably other countries in Sub-Saharan Africa.  

Keywords – Surgery, Surgical equipment, Sub-Saharan Africa, Kenya, Biomedical Equipment Technicians (BMETs), Maintenance. 

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Oosting, Wauben, Mwaura, Madete, Groen, Dankelman: Barriers to Availability of Surgical Equipment in Kenya: A 
Surgical Equipment Journey Approach

J Global Clinical Engineering Vol.1 Issue 2:35-42; 2019  36

INTRODUCTION
Surgery requires human resources, equipment, medi-

cines, and organized infrastructure. Several authors have 
already indicated gaps in the availability of surgical equip-
ment in low- and middle-income countries (LMICs) such 
as Malawi, Sierra Leone, Nigeria, Cameroon, Somalia, and 
Ethiopia.1–6 The gap in the availability of surgical equip-
ment is a large contributor to the unmet needs of surgical 
care in these countries.7 A large evidence-based study 
performed by Duke University estimated that for example 
up to 40% of equipment available in hospitals in LMICs 
is not usable.8 A report of the World Health Organization, 
“Managing the mismatch,” identified that consumables, 
spare parts, and other support systems are often limited 
in LMICs, resulting in equipment being unavailable.9 Lo-
cal use is not always considered during the donation of 
equipment. For example, Howie et al. described a case 
study in Gambia where the lifespan of donated oxygen 
concentrators did not exceed 30 minutes (as opposed to 
5–7 years in high- and middle-income countries [HICs]) 
because of the wrong voltage and frequency to match the 
electricity network in Gambia, leading to overheating.10

Limited access to maintenance, spare parts, and inap-
propriate donations have been documented before as bar-
riers to functioning equipment in LMICs.10–13 However, to 
design successful strategies for increasing the availability 
of surgical equipment, the root causes of these problems 
need to be understood. Installation and maintenance of 
equipment are often provided by biomedical equipment 
technicians (BMETs), which makes their perspective on 
surgical equipment very valuable. 

To understand the barriers to availability and function-
ing surgical equipment in LMICs, the situation in Kenya 
is used as a case study. This study aims firstly, to identify 
the surgical equipment journey (the different phases 
surgical equipment goes through during its lifespan), 
and secondly, to identify the barriers that are perceived 
by BMETs during the different phases. 

METHODS
Semi-structured in-depth interview sessions were 

conducted during hospital visits in Kenya with BMETs. 
Interviews were conducted from December 2016 to 

December 2018. Participants selection was done by 
snowball sampling. Participants were instructed that 
equipment, such as electrosurgical units, monitors, oper-
ating theatre lights, sterilizers, and anesthesia machines 
were identified as surgical equipment in this study. All 
interviews were done in English. 

Each session consisted of 2 parts in which participants 
were asked to describe: 
1. the different phases surgical equipment goes through 

during its lifespan within their hospital and which 
stakeholders are involved in each phase, and

2. how the following concepts are related to the sur-
gical equipment journey within their hospital: the 
supply chain, procurement, sterilization/cleaning, 
donation, policies, disposal, design, maintenance, 
costs, misuse, hidden costs, lack of infrastructure, 
spare parts, usage, management of equipment, 
training, and disposables.
This study was approved by the human research eth-

ics committee of the Delft University of Technology and 
informed consent was obtained from all participants.

DATA ANALYSIS
The interviews were recorded and transcribed. Data 

were analyzed with MASDAQ 2018. The concepts discussed 
during the interviews were used for coding the transcripts. 

RESULTS
In total, 17 BMETs participated from 6 different hospitals 

(Table 1). After 7 sessions data saturation was reached. 
Session 4 and 6 were in the same hospital. 

Table footnote: 
BMETs = biomedical equipment technicians.

# Surgical care in Kenya is provided by public, mission (non-
profit) and private hospitals. The public care system consists of 
4 national hospitals (Level 6) that fall under the responsibility 
of the national government, the county (Level 5) and sub-county 
hospitals (Level 4) fall under the responsibility of the 47 county 
governments.14 

*Certificate includes 1 year of training, diploma 3 years of train-
ing, and higher-level diploma 5 years of training at a technical 
college in Kenya



37 J Global Clinical Engineering Vol.1 Issue 2:35-42; 2019

Oosting, Wauben, Mwaura, Madete, Groen, Dankelman: Barriers to Availability of Surgical Equipment in Kenya: A 
Surgical Equipment Journey Approach

EQUIPMENT JOURNEY
Participants within this study identified 3 phases 

within the surgical equipment journey: procurement, use 
and maintenance, and disposal (Figure 1). Stakeholders 
that were identified in the equipment journey were: the 
user, the BMET, the procurement officer, local distribu-
tors of the medical device company, and in the case of 
donations, the donation agency. The user refers to the 
healthcare worker (nurse, surgeon, etc.) who operates the 
equipment. BMETs are responsible for maintenance and 
the procurement officer is responsible for procurement. 
Donation of equipment to a hospital can be organized by 
either a foreign hospital, non-governmental organizations 
(NGOs [e.g. AMREF]), or a foreign government. 

PROCUREMENT PHASE
All participants indicated the following procurement 

process: when a healthcare worker (a user in the equipment 
journey) requires new equipment, a need assessment is 
done by the user and the procurement officer. When the 
need is defined, the BMETs are consulted to define the 
equipment specifications. Thereafter, a tender request 
is placed in the local newspaper and on the hospital’s 
website for local distributors or medical device companies 
to respond. All public hospitals are obliged to procure by 
tenders. The highest referral level hospitals (Level 6) can 

FIGURE 1. The surgical equipment journey according to BMETs 
in Kenyan hospitals.
User = healthcare worker (e.g., nurse, surgeon) using the equipment.
Biomedical Equipment Technician (BMET) = person responsible for 
maintaining the equipment.
Procurement officer = person responsible for procuring the equipment.
Local distributor = local agent of the medical device company.

TABLE 3. Participants’ Characteristics During Each Interview Session

Session 
Number

BMETs During 
Session

Type of 
Hospital# Gender Education Level*

1 1 Public hospital Female Higher level diploma

2 1 Mission hospital Male Diploma

3 1 Private hospital Male Diploma

4 1 Public hospital Male Diploma

5 3 Public hospital All male 1× Diploma

5 3 Public hospital All male 1× Diploma, 1× Higher-level diploma, 1× Certificate

6 7 Public hospital 1× female, 6×male 3× Diploma, 3× Higher level diploma 

7 3 Public hospital All male All diploma 



Oosting, Wauben, Mwaura, Madete, Groen, Dankelman: Barriers to Availability of Surgical Equipment in Kenya: A 
Surgical Equipment Journey Approach

J Global Clinical Engineering Vol.1 Issue 2:35-42; 2019  38

organize their own tender process, all other public hos-
pitals organize this process via the county government. 
Private and mission hospitals use tenders too, but they 
can also procure directly from the local distributor or the 
medical device company. The bureaucracy within the pro-
curement phase, which makes it a very time-consuming 
process, was mentioned in all 7 interview sessions. The 
procurement committee comes together to analyze the 
bidders and will often award the lowest bidder that meets 
all the specifications. 

‘To get a new electrosurgical unit took up to 4 months. 
We have to make a request, set up specifications, this 
is taken to the supply department who puts it in the 
local newspaper. The bidders get 2 weeks to respond. 
After 2 weeks we sit down for an evaluation, after which 
we write a report to the CEO advising which company 
to award. Then the award letter is made and then we 
have to wait for the supplier. Then the problems around 
importing it into the country start, delays often happen 
at customs.’ Session 7 

‘It is often a challenge to know what the market 
value of equipment is. Sometimes we budgeted for 1000 
dollars, but the good equipment is 2000 dollars, that is 
also why we end up with cheaper inappropriate equip-
ment. The procurement law states that the lowest price 
that suits the specifications wins. European equipment 
is often too expensive to win.’ Session 6

‘We also check what the hospital’s history with a 
company is. If the company did good training and has 
good support they are rated higher during the tender-
ing process.’ Session 7 

‘Some equipment is really cheap, but when it breaks 
it is difficult to repair and then we have to buy new 
ones’ Session 2

Although the system for procurement is in place, a 
lot of surgical equipment is often received by donations. 
Donations can either be organized via the county govern-
ment or are directly sent to the receiving hospital. The 
private hospital visited during this study did not receive 
any donations, whereas one of the mission hospitals 
obtained equipment mostly by donation, often arranged 
by expat surgeons working in the hospital. The public 

hospitals’ equipment was received by both donation and 
procurement. 

Before the new equipment can be used and maintained 
(next phase), training is needed. The difficulty to receive 
appropriate usage and maintenance training by the medi-
cal device company was identified as a large barrier too 
and was mentioned during 4 of the 7 interview sessions. 
One participant stated: 

‘We have received on-site training given by the medi-
cal device company. However, information is often quite 
limited. Often, we cannot open a machine to do trouble-
shooting because they come in with a new machine. We 
would recommend that we can train on models that 
can be opened up and where we can troubleshoot to 
learn what to do in case of an error.’ Session 7

USE AND MAINTENANCE PHASE
Equipment is used by various healthcare workers (e.g., 

surgeons, nurses or medical officers) in the operating 
theatre (OT). Many types of surgical equipment require 
accessories to perform surgery; these can either be con-
sumables (one-time use) or reusable parts. Accessories 
need to be cleaned and sterilized after usage, which is 
most often done by the sterilization department. However, 
participants within this study explained that some parts 
(for example, accessories of the electrosurgical unit) are 
cleaned in the OT complex with heavy chemicals (e.g., 
cidex). Equipment, such as electrosurgical units and 
anesthesia devices are often stored in the OT or in the 
corridors between the OTs. These devices are cleaned by 
the cleaning staff, often also with heavy chemicals. 

Surgical equipment can either be out of service be-
cause of a breakdown or because of planned preventative 
maintenance (PPM). Repairs and PPMs are done by the 
BMET department within all hospitals in this study. Spare 
parts, tools, and manuals are required to keep equipment 
functioning. Spare parts can refer to power boards or dis-
plays that need to be replaced when they are broken, but 
also to filters that need replacement every other month. 
All hospitals reported their repair orders in hardcopy 
books, except for 2 hospitals (1 mission and 1 private) that 
additionally store a digital copy in a software program. 



39 J Global Clinical Engineering Vol.1 Issue 2:35-42; 2019

Oosting, Wauben, Mwaura, Madete, Groen, Dankelman: Barriers to Availability of Surgical Equipment in Kenya: A 
Surgical Equipment Journey Approach

The difficulty to get spare parts in Kenya was men-
tioned during all 7 interview sessions. The 5 hospitals 
that receive donations all have difficulties to obtain both 
consumables and spare parts required for the equipment. 

‘The challenge with donated equipment comes when 
it breaks, the spare parts are often not available. For 
example, for the electrosurgical unit, a different patient 
plate is available within the country than the ones that 
came with the device, so we have to find a way to work 
around this.’ Session 2 

However, also for procured equipment, the supply 
chain of consumables and spare parts remains a challenge. 
This is either due to the long bureaucratic procurement 
process that needs to be followed for each new order, 
the high costs of spare parts and consumables, or delays 
because parts have to come from outside Kenya or the 
African continent. Only a small portion of the equipment 
available in the hospitals is supported by a maintenance 
service contract, which means that maintenance, spare 
parts, and consumables are provided by the medical 
device company. 

‘If we have imported a machine from overseas, we 
also have to import the spare parts. Getting the spare 
parts becomes tricky and takes a lot of time.’ Session 3

One participant mentioned that they do not always get 
permission to order a spare part required for PPM, that 
has the potential to increase the lifespan of the equipment.

‘Sometimes BMETs only get permission to fix when 
it the equipment is broken. When it is still functioning 
but needs to be serviced to keep functioning, this is 
not understood. At the moment it is obsolete, everyone 
starts looking for a spare part’. Session 1

Participants in 2 hospitals also mentioned the break-
down of equipment due to the challenging environment 
in which equipment is used. Modern sensitive equipment 
is often not designed to withstand power interruptions, 
unstable electricity networks, dust, and high tempera-
tures. Additionally, participants working in 2 hospitals 
described how the use of heavy chemicals for cleaning 
shortens the lifespan of the equipment. 

‘Power in Kenya is different, also temperatures, al-
titudes, pressure, and the users are trained differently 

than in Europe and Asia where equipment comes from’. 
Session 4

DISPOSAL PHASE 
When equipment is obsolete, it needs to be disposed of 

either by the hospital or via the government. All participants 
were involved in the disposal process, but approval often 
has to be obtained from the disposal committee or from 
the procurement department. This is a time-consuming 
procedure and often results in piles of unused equipment 
on the hospital grounds, as one of the participants from 
session 5 described:

‘You find we even get used machines and they are 
most of the time obsolete. Then we only have to worry 
about the disposal, and that means extra work for us.’ 
Session 5

DISCUSSION 
Surgical equipment is not always available in LMICs, 

which results in delays of surgeries that are urgently 
needed by the population.. Other studies have identified 
synergies in the barriers to medical equipment between 
different LMICs.10–13 This study offers insights from front-
line BMETs providing maintenance on a daily basis on why 
these barriers exist, by identifying the journey during the 
life span of surgical equipment. Participants worked in 6 
different hospitals in Kenya. In other to ensure theoreti-
cal saturation 5 additional hospitals (1 private hospital, 
3 public hospitals, and 1 mission hospital) were visited. 

The identified surgical equipment journey within this 
study revealed that equipment undergoes 3 different 
phases during its lifespan: procurement, use and main-
tenance, and disposal. Within the procurement phase, 
a difference between public and private hospitals was 
found that results in a different procurement route: pub-
lic hospitals are obliged to procure via tenders, whereas 
mission and private hospitals can also buy directly from 
the medical device company. Procurement of equipment 
was identified as a timely process by all the participants. 
Besides the tender process being very time-consuming, 
it does not always result in the most appropriate type of 
equipment when the lowest bidder wins. Diaconu et al. 



Oosting, Wauben, Mwaura, Madete, Groen, Dankelman: Barriers to Availability of Surgical Equipment in Kenya: A 
Surgical Equipment Journey Approach

J Global Clinical Engineering Vol.1 Issue 2:35-42; 2019  40

identified that equipment costs are often leading in pro-
curement planning in many LMICs, underestimating the 
true costs of maintenance, servicing and user training.15 
Public hospitals can only buy equipment from respondents 
to the tender, and those respondents need to provide 
equipmentthat fits the specifications of the tender. Ac-
cording to the participants in the public hospitals, this 
means they can often not buy from large international 
brands, because they do not respond to the tenders, or 
are out of scope because of the budgets that are set in the 
tender specifications. However, training opportunities 
and companies’ track records on spare part delivery and 
support are becoming more and more important during 
the tender awarding process according to some of the 
participants in this study. Diaconu et al. also identified that 
careful consideration of the context of use results in the 
most successful uptake of medical technology in LMICs.15 

Procurement of appropriate equipment is the first 
step in a good functioning surgical equipment journey, 
secondly, the use phase should be properly organized. 
This starts with providing training for both the user 
and the BMETs.15 The participants in this study have 
experience with on-site training and overseas factory 
training at the medical device companies. Participants 
indicated that some of the on-site training is very short 
and superficial, especially when the training is done with 
functioning equipment without the possibility to open up 
or troubleshoot. By the time maintenance is required, the 
company has to be consulted for advice again, because it 
was not covered during the training. Maintenance is now 
often recorded offline in repair books, which is difficult to 
consult during the procurement of new devices. Computer 
software for inventory, repair, and maintenance record 
could increase the amount of information about previous 
procured or donated equipment and their lifespan within 
the hospital, which can be helpful information during the 
procurement process.15 

Previous studies mentioned the lack of consumables 
and spare parts as a barrier to the availability of surgical 
equipment in LMICs.11,16 Our study confirmed these barriers 
within the surgical equipment journey. However, within 
this study, we also have researched the underlying process 
to these barriers. We identified that the procurement of 

consumables and spare parts can be a timely and costly 
process. Firstly, spare parts can become very expensive 
when they have to be imported from overseas. Secondly, 
parts for donated equipment are often not manufactured 
anymore which leads to disposal of equipment. Lastly, 
participants indicated that they do not always get permis-
sion to order a spare part for PPMs because the equipment 
is still working. When the delivery of consumables is 
delayed, this results in equipment that is out of use. This 
is one of the reasons why consumables are often reused. 
The costs of consumables are often paid by the patient, 
so reuse of these parts will reduce the costs of surgery 
for the patients. 

Participants within this study indicated that although 
problems arise with donated equipment when mainte-
nance or consumables are required, they still welcome 
donations because a lot of newer technology will other-
wise stay out of their reach due to its high costs. Some 
medical device companies are starting to lease high-end 
equipment to hospitals in Kenya. These hospitals have a 
contract with the medical device company for the con-
sumables and servicing of the equipment. Additionally, 
the Kenyan government has recently equipped 98 public 
national and county hospitals with brand new equipment 
for intensive care units, diagnostic imaging, and surgical 
equipment. Within this program training and servicing 
is provided for at least 7 years.17

Kenya aims to increase the quality of its healthcare system, 
alongside the WHO and the global health community aim 
to increase access to safe surgery worldwide. Availability 
of medical equipment is vital for the realization of these 
goals. The possibility to lease high-end equipment and 
the implementation of high-end equipment by the Kenyan 
government are all attempts to increase the availability of 
equipment in Kenya. However, sustainable interventions 
at multiple organizational levels are required to optimize 
the surgical equipment journey in the future.  

A list of potential interventions to increase availability 
that were identified by participants is provided in Table 2. 

Table footnote: 
BMETs = biomedical equipment technicians.
LMIC = low- and middle-income countries; 
R&D = research and development.



41 J Global Clinical Engineering Vol.1 Issue 2:35-42; 2019

Oosting, Wauben, Mwaura, Madete, Groen, Dankelman: Barriers to Availability of Surgical Equipment in Kenya: A 
Surgical Equipment Journey Approach

This study only included BMETs working in Kenya and 
the quality of the healthcare system in Kenya (number 73 
on the GDP list of the world bank) is expected to be higher 
than in other countries, such as Uganda or Mozambique 
(number 106 and number 132, respectively).18 Kenya has 
6 colleges for BMET training and 2 university programs for 
biomedical engineers which equip BMET departments with 
well-trained BMETs. In contrast, other countries have no 
BMET departments within their hospitals or BMET train-
ing available in the country. They have to hire employees 
with a technical background, but without specific training 
on medical equipment. Barriers identified in this study 
could be even larger in these countries. Commonalities 
and best practices of both medical providers and BMETs 
in other countries may, therefore, provide also other 
root causes to limited availability of surgical equipment 
in LMICs. Despite these limitations, we believe that this 
study can be used as a starting point to design strategies 

to increase the availability of surgical equipment in the 
future either by academia, medical device companies 
or policy makers. It also highlights the importance of 
including local stakeholders’ input in the design and the 
development of plans for the provision of surgical care.

ACKNOWLEDGMENTS
This research was funded by the Delft Global Initiative 

of the Delft University of Technology, Delft, The Nether-
lands (P70357).

CONFLICT OF INTEREST
The authors declare that there is no conflict of interest 

regarding the publication of this paper.

ETHICAL STATEMENT
All procedures performed in studies involving hu-

man participants were in accordance with the ethical 
standards of the institutional and/or national research 
committee and with the 1964 Helsinki declaration and 
its later amendments or comparable ethical standards. 
Ethical approval was obtained from the Human Research 
Ethics committee of the Delft University of Technology.

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TABLE 2. Potential Interventions to Increase Availability of 
Surgical Equipment as Stated by the Participant in this Study

Theme Potential Intervention

Donations - Policies on donations

Procurement
- Procurement of durable equipment, 
including training, access to spare parts and 
consumables

Training

- More university-trained biomedical 
engineers, more on-site training for users and 
BMETs 
- Training by the medical device company on 
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Equipment

- Demonstrations before equipment is 
procured 
- Robust designs and suitable for the context 
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dust, high temperatures, cleaning detergents 
etc.)

Medical 
Device 
Companies 
and 
Manufacturing

- Medical device companies within the 
country/or continent. 
- Users and BMETs in contact with R&D 
departments to give feedback 
- Adapted strategies for LMICs based 
hospitals (placement of equipment or leasing 
equipment) 



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Surgical Equipment Journey Approach

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