Healthcare Technology

Background

Health technology context Health Technology covers a wide range of apparatus, consumables, devices, equipment and instruments that would require many volumes of documents to cover effectively. This document, as part of the broader IUSS Norms and Standards project, aims to look at the key elements of Health Technology and its management as it manifests in healthcare facilities. The document specifically aims at framing the subject of Health Technology within the infrastructure development and operations domain.

The various definitions of Health Technology are listed in the Glossary but it is important to note that this document focuses on durable medical equipment and related consumables used in healthcare facilities. Hospital plant and machinery, normally associated with the building and most often installed as part of the building, are dealt with in various other documents in the IUSS document bouquet, either under the respective hospital engineering disciplines or under the respective clinical service area.

Application of the Guidelines

This document, published under the Health Facility guides, would be useful for practitioners of Health Technology Management both at the level of an individual facility and for groups of facilities (for example, in a district) and at any level of care. It would also be of great value for HTM practitioners and facility managers in general who might lack the first-hand experience of this relatively specialised field. In many cases the guidelines show the way towards developing specific and applicable solutions rather than being prescriptive. This approach is necessary to ensure that they remain sufficiently generic to be applied across a broad spectrum of scenarios. The document would also be of interest to health infrastructure professionals who might need specific insight into the domain of Health Technology and its management, recognising that technology and infrastructure are closely inter-related and will become ever more so in future healthcare systems.

Associated process and related documents

This document should be considered in the context of the solid platform provided by the Health Technology Policy and the Health Facilities Planning Directorates of the National Department of Health. This includes the Framework for Health Technology Policies which outlines the vision of a National Health Technology System; the draft Health Technology Management Policy document which inter alia outlines the organisational and structural requirements at all levels of governance pertaining to such a system; the Health Technology Strategy which outlines specific objectives and activities, with associated timeframes, for establishing a National Health Technology System; the Report of the Interim Steering Committee on Health Technology Assessment, which underlines the importance of having formal processes in place to assess issues of health technology cost-effectiveness, access, service-fit and social impact, amongst other “evaluative dimensions”; and lastly the draft Medical Device Regulations and associated background documents which – in their final form – will be promulgated under the South African Health Products Regulatory Agency (SAHPRA) Act .

Life cycle of Health Technology

Planning

Introduction

Planning and budgeting are often considered jointly since planning – for it to be effective – needs to take place within the context of policy, financial, and other constraints. Box 1 shows the overall process.

BOX 1: The planning and budgeting process (start-up)

Steps	People responsible	Actions
Plan and budget within the framework of guidance and direction from the national level.	Health service managers at national level in consultation with managers at other levels.	Framework requirements follow regulations and standards set by government; develop a Healthcare Technology Policy including decisions on standardisation, maintenance provision, finances for HTM activities, and the organisational structure for an HTM service; define the overall “Vision” for healthcare delivery at each level of the health service; develop “Standard Equipment Lists” which define the essential equipment stock for the healthcare to be delivered at each level; use “Generic Equipment cifications” for acquisition ofequipment; develop good policies for purchasing, donations, replacement, and disposal of equipment; and participate in the planning, equipping and operation of health facilities.
Increase the availability of planning skills for equipment at all service levels, by developing planning “tools” through one-off exercises.	HTM working groups and sub-groups. Finance officers.	Knowing where one is starting from establish an Equipment Inventory to keep up-to-date records of the current equipment stock; estimate the equipment stock values; define the usage rates of equipment-related consumable items so that realistic estimates can be made of the finances required for equipment accessories, consumables, and spare parts; and set up budget lines to record and monitor expenditure on all the different equipment activities.
	Health management teams. HTM working groups and sub-groups.	Knowing where one is headed develop a library of literature and resources which will help with equipment planning and budgeting; adapt the vision for healthcare delivery at their service level; adopt good policies for purchasing, donations, replacement, and disposal of equipment; adapt the Standard Equipment List for their service level; develop generic equipment specifications and technical and environmental data; and estimate human resource requirements and associated “acquisition” and capacity building.
Ensure realistic estimates are made for all equipment-related allocations at all service.levels, by using budgeting “tools” to calculate expenditures required.	HTM working groups and sub-groups. HTM managers and their teams.	Capital budget calculations calculate expenditure requirements for replacement items; calculate expenditure requirements for new purchases; calculate expenditure requirements for support activities linked to purchases and donations; calculate expenditure requirements for pre-installation work; and calculate expenditure requirements for major rehabilitation work.
Ensure realistic estimates are made for all equipment-related allocations at all service levels, by using budgeting “tools” to calculate expenditures required.	HTM managers and their teams. Heads of section. HTM working groups and sub-groups.	Recurrent budget calculations calculate recurrent expenditure requirements for maintenance; calculate recurrent expenditure requirements for consumable operating costs; calculate recurrent expenditure requirements for administrative expenses; and calculate recurrent expenditure requirements for ongoing training.
Use the tools to make long-term plans and budgets	HTM working groups and sub-groups.	Long-term planning establish an Equipment Development Plan covering the priorities for equipment needs across their service level over time; establish an Equipment Training Plan to cover the ongoing rolling programme of training required in relation to equipment activities; establish a Core Equipment Expenditure Plan which prioritises equipment spending across the facility over the long term; and establish a Core Equipment Financing Plan indicating possible sources of funds and related options.
Review the plans and budgets annually, and monitor progress in order to improve planning and budgeting.	HTM teams. HTM working groups and sub-groups.	Annual planning update the Equipment Inventory; update the Equipment Development Plan; update the Equipment Training Plan; cost the capital and recurrent requirements for the current year, and update the Core Equipment Expenditure Plan and Core Equipment Financing Plan; and prioritise across their service level to obtain the annual purchase activities, annual rehabilitation activities, annual corrective activities, annual training activities, and thus the annual equipment budget.
Review the plans and budgets annually, and monitor progress in order to improve planning and budgeting.	HTM working groups. Heads of department and HTM managers. Health management teams.	Monitoring progress ensure annual plans are implemented; study the implications arising from planning and budgeting; request help for any deviations from plans such as emergency purchases, maintenance and consumable contingencies; monitor actual expenditure against allocations; seek the funding identified; consider linking allocation of budgets to whether departments achieve their performance targets; monitor progress through establishing planning and budgeting tools and associated indicators; and ensure that the information generated is used to improve stock control, training, procurement, utilisation, etc.

Service and related technology planning

For healthcare technology to be managed effectively, a clear idea of healthcare delivery goals and targets is needed, as well as the context in which the technology is operating. Equipment should not be viewed in isolation – it is there for a purpose, and must be managed according to set objectives. For effective planning, access to a wide range of information and reference materials is needed, as well as a clear vision of the direction in which the health service is headed, plus identification of what equipment is required to help achieve the health service goals.

To inform the technology part of the debate, the HTM working group (at each level) should consider the equipment implications of the healthcare interventions suggested, and then offer technical advice to their health management team. Box 2 and Checklist 1 show some of the issues that the national, province/district- and facility level HTM working groups, respectively, should consider.

BOX 2: Baseline information on medical devices

Medical device situation	Considerations People responsible	ResultPeople responsible
Availability and condition of medical devices (including type, number, location and physical condition). Status of electrical, water, and waste disposal systems related to medical device use.	Medical equipment inventory including status and condition. Current health technology management infrastructure (or lack thereof).	Facility map. Medical equipment inventory (quantitative and qualitative). Outline of health technology management infrastructure.

CHECKLIST 1: Equipment considerations for vision at national level

Issues	Example
What expansion of services is necessary or feasible?	What should be the role of a hospital (central, referral, district) in terms of the interventions and procedures to be carried out? What does this mean in terms of equipment availability? What type of care can be offered by rural, district or town health centres? Can any types of care be transferred over to them? What does this mean in terms of equipment availability? It may be best to locate certain specialised services (such as intensive-care units) only at certain hospitals. Some specialised services, such as radiotherapy, may only ever be offered at national level. With pressures to reduce costs, improve efficiencies, and possibly to reduce staff numbers, can service provision be rationalised? Is expansion based only on needs that can be realistically met?
What are the implications in terms of staff, skills, resources, patient referral networks?	Introducing a new service has knock-on implications for human, material and financial resources. For example, should eye instruments be bought for a facility if there is no eye surgeon, or prospects of one becoming available? Or if the referral system is such that dialysis is only undertaken and supported at a central facility, one should think carefully before placing dialysis machines at other further locations. However, if such expanded “satellite” services are required, then all the resources required to ensure effective service provision should be identified, provided and maintained.
Are desired expansions financially affordable?	Although many hospitals may ideally wish to have fluoroscopy facilities (for example), at a cost of approximately $500 000 per suite, is this a feature each hospital can necessarily invest in?
Do the services suggested fit into the overall health service in the country?	Is it possible to develop a vision which fits in with the other health service provider organisations?

Planning and budgeting when starting out

Box 3 shows the minimum requirements for a scenario for an HTM system in its infancy, where the initial focus is not on long-term forward planning, but concentration on planning and budgeting on a yearly basis. As the system matures, other elements for forward planning can be added.

Box 3: Minimum planning and budgeting requirements

Planning and budgeting element

If just starting out

1. Equipment inventory 2. Stock value estimates 3. Budget lines for equipment expenditures. 4. Usage rates for equipment-related consumable items. 5. Reference materials. 6. Developing the vision of service delivery for each facility type. 7. Standard Equipment Lists. 8. Purchasing, donations, replacement, and disposal policies. 9. Generic equipment specifications and technical data. 10. Capital budget calculations. 11. Recurrent budget calculations. 12. Equipment development plan. 13. Equipment training plan. 14. Core equipment expenditure plan. 15. Core equipment financing plan. 16. Annual equipment planning and budgeting. 17. Monitoring progress.

1. Essential to have. 2. Useful to carry out this exercise later on when rough estimates needed for long-term forward planning. 3. This alteration to budget layout can be done later, but it will help with analysis. 4. Useful to do this exercise as it helps with calculation of specific (annual) estimates. 5. These can be developed over time. 6. Should have an understanding of this, even if full exercise not undertaken. 7. Initially, list of urgent equipment needs drawn up by departments can be used. Later on, Standard Equipment Lists obtained elsewhere can be used. 8. Essential to have. 9. Initially learn from others. Later, develop own. 10. Initially learn how to make specific (annual) estimates; only learn the rough estimation methods when undertaking long-term planning. 11. Initially learn how to make specific (annual) estimates. Only learn the rough estimation methods when undertaking long-term planning. 12.  Use the basic equipment development planning process only, and only apply it to the short term. 13. Develop a straightforward one for the short term 14. Initially only plan annually (see below). 15. Initially only plan annually (see below). 16. Create annual actions plans and an equipment budget showing income and expenditure. 17. Undertake the basic elements only – progress with annual plans and tools, coping with emergencies, providing feedback.

nly plan annually (see below). 15. Initially only plan annually (see below). 16. Create annual actions plans and an equipment budget showing income and expenditure. 17. Undertake the basic elements only – progress with annual plans and tools, coping with emergencies, providing feedback.

  2. Needs assessment 2.1 Standard lists of equipment Once the vision for the direction of health service delivery has been developed, the healthcare interventions and procedures to be offered will be known. Based on this information, the Essential Service Packages can be developed; these will translate the vision into: • human resource requirements, and training needs; • space requirements, and facility and service installation needs; and • equipment requirements.

The tool used in the process of defining what equipment is needed for each healthcare intervention is the Standard Equipment List. This is: • a list of equipment typically required for each healthcare intervention (such as a healthcare function, activity, or procedure). For example, health service providers might list all equipment required for eye-testing, delivering twins, undertaking fluoroscopic examinations, or for testing blood for malaria; • organised by activity space or room (such as reception area or treatment room), and by department; • developed for every different level of healthcare delivery (such as district, province) since the equipment needs will differ depending on the vision for each level; • usually made up of everything including furniture, fittings and fixtures, in order to be useful for planners, architects, engineers and purchasers, and • a tool which allows healthcare managers to establish if the Vision is economically viable.

The Standard Equipment List must reflect the level of technology of the equipment. It should describe only technology that the facility can sustain (in other words, equipment which can be operated and maintained by existing staff, and for which there are adequate resources for its use). For example a department could have: • an electric suction pump or a foot-operated one; • a hydraulic operating table or an electrically controlled one; • a computerised laundry system or electro-mechanical machines; and • disposable syringes or re-usable/sterilisable ones.

It is important that any equipment suggested: • can fit into the rooms and space available. Reference should therefore be made to any building norms defining room sizes, flow patterns, and requirements for water, electricity, light levels and so on; • has the necessary utilities and associated plant (such as the power, water, waste management systems) available for it on each site - if such utilities are not available, it is pointless plannns. Facility level  Takes the third step and assesses: - how they can provide the healthcare interventions; and - what numbers of equipment they require depending on how they organise their work. Organisational decisions influence the quantity of equipment. For example, the timing of clinics can reduce or increase the workload in the laboratory. Before ordering new equipment, its level of use will need to be assessed. 2.2 Equipment development plan Especially for an HTM system that is not mature, it is essential to have important to have an equipment development plan; one suggestion for the development planning process is presented in Flowchart 1 below.

FLOWCHART 1: The basic equipment development planning process Process Activity HTM manager and his/her team: Evaluates the current equipment stock Analyse the up-to-date Equipment Inventory to discover the replacement, major rehabilitation, maintenance, consumable, training, and administrative requirements. Compare the Equipment Inventory with the Standard Equipment List to discover the shortfall of equipment that needs purchasing (If the Standard Equipment List is not available, compare the inventory to the urgent equipment needs drawn up by departments).

Evaluates future requirements Study the Vision for the facility to discover any new services planned.

Compiles the needs List all these requirements. The HTM working group (or its planning sub-group) Prioritises the actions to take, and makes the Equipment Development Plan Decide what to attempt: - as short-term goals (in the coming year or two); and - as long-term goals (for example, within 3-5 years).

Prepares various action plans Creates plans for: - equipment replacement and new purchases, and any associated support activities; - major rehabilitation projects; and - corrective actions (maintenance, consumable needs, training, administrative needs).

Prioritising and appraisal of options It is equally important, in the context of needs assessment, to critically examine the process and its outputs and outcomes. Checklist 2 below poses some key questions for consideration by the appropriate stakeholder/s.

CHECKLIST 2: Key questions for prioritising and appraisal of options Impact • Which changes would have the greatest positive impact in meeting needs? • Do the identified needs relate to a local or a national priority (e.g., maternal and child health, HIV/AIDS, etc.)? • What would be the implications of not addressing the needs? Changeability • Which things can be changed and effectively improved? • What evidence is there of effective interventions? • Can negative impacts be stopped or reduced? • Are there national or local, professional or organisational policies that set out guidelines on what should be done (e.g. national frameworks, national guidance, etc.)? Acceptability • Which of the options for change are likely to be most acceptable to the health service providers, to the target population, and to the managers? • What might be the “knock-on” effects, or unintended consequences, of making a change? Resource feasibility • Which resources are required to implement the proposed changes? • Can existing resources be used differently? • Which resources will be released if ineffective actions are stopped/changed (e.g., proper management of health technology, etc.)? • Are there other resources available which have not been given prior consideration (e.g., income generation of laboratory services, consideration of public-private partnerships, assistance from NGOs, etc.)? • Which of the actions will achieve the greatest impact for the resources used?

2.3 Consumables Consumables are a major contributor to equipment-related cost of ownership, and form a significant portion of recurrent and operational expenditure. It is therefore important to establish the consumables needs so that adequate provision is made and service delivery is not interrupted. Flowchart 2 below suggests a process to facilitate the needs assessment related to equipment-related consumables.

  FLOWCHART 2: Establishing usage rates and requirements for equipment-related consumable items Process Activity The HTM working group (or its stock sub-group) at facility level: Undertakes an initial one-off exercise to establish usage rates and requirements for equipment-related consumable items. Investigates the actual annual requirements and rates of use across the facility for: • replacement accessories; • equipment consumables; • spare parts; • maintenance materials; • energy supplies; and • equipment cleaning materials.

Identifies: • the actual requirements (i.e. the types of items, makes, sources, and descriptive/identifying part numbers); and • the rates of use for these recurrent items by department (e.g., quantities needed per day, week, or month in order to deliver the required health service to the patients expected). By: • consulting with departments; • talking to equipment operators and maintainers; • referring to departmental statistics and records on patient attendance; • referring to stores records; and • using information from suppliers.

Makes use of the information gathered for planning and budgeting purposes. To: • calculate more realistic annual recurrent funding requirements to cover consumable items; and • supply the Health Management Team with sufficient information to set more realistic budgets.

Provides feedback to the Stores Controller. Supply the Stores Controller with sufficient data to: • enter onto the Stores” Stock Cards (Bin Cards); • calculate correct re-ordering quantities and times; and • make equipment-related consumable items “stockable” items.

Provides feedback to the Specification Writing Group and the Tender Committee. Provide them with information for more appropriate selection of models during procurement.

Updates the information regularly. Undertake an annual review as part of the equipment management activities.

  3. Asset management 3.1 Inventory It is essential that an inventory (asset register) of medical equipment is maintained. However, it is both costly and time-consuming to include each and every medical device in an asset register. For those items in an asset register, the following information should be captured and verified: • Equipment type (an international nomenclature system such as the Universal Medical Device Nomenclature System (UMDNS) should be used so that all institutions use a common name for the same type of device). • Make/manufacturer. • Model. • Serial number. • Date of acquisition. • Price paid (include any costly accessories). • Supplier details (name, address, contact person, contact details). • Location – department or ward where the unit is used.

The responsibilities, activities and role-players relating to equipment inventory are shown in Box 5.

BOX 5: Inventory-related responsibilities, activities and actors Body Responsibility Activity People involved HTM Service Creates and updates the Equipment Inventory. Organises the gathering of inventory data. Either by: • facility staff for their own facility; • district staff for the facilities in their district; • central staff for the health service as a whole; and • using specialist help. Inventory team Carries out the Equipment Inventory at each facility. Visits each department in the health facility, and: • looks in all rooms, cupboards, etc.; • physically checks all equipment for the details required; and • fills in the Equipment Inventory Record Sheets. If existing records are available: • modifies or expands the information as necessary to cover new items; • fills in any gaps; • corrects entries; and • updates data in order to make the Equipment Inventory as accurate as possible. Due to the workload and knowledge required, it is useful for the team to be made up of: • two maintenance staff (from the relevant HTM team); • a senior equipment user from the facility; and • a member of staff from the department being assessed (who changes as team moves from department to department).

HTM teams Compile the Equipment Inventory. Make hard copies. • Enter the data gathered, either onto an inventory card or a computer screen, for each individual device. • Create summaries, prepare and print out hard copies. • Provide a copy of the Equipment Inventory.to the Stores Controller for inclusion in the General Inventory held by stores. Make use of trained technical staff and secretarial/computing support to assist with data entry. Central-level HTM team Develops the Equipment Inventory as an active (regularly updated) resource. Analyses the Equipment Inventory for planning purposes. • Uses computer-based tools required for this purpose (for example, word-processing spreadsheets or specific commercial inventory products which staff have been trained on. Makes use of support from staff trained in keeping computerised records.

3.2 Asset management system Proper asset management requires an appropriate information system which can be used to maintain data on those items that have been included in the asset register.

Equipment audits provide a snapshot of equipment status in a facility or groups of facilities, and can be aggregated to reveal the situation at national level. Audit data also serves to inform decision making related to needs assessment, asset management, maintenance strategies, replacement planning, and so on.

Also, once an inventory system is up and running, it will be necessary to periodically obtain estimates of total equipment stock values – this is used, for example, in benchmarking the total expenditure on maintenance. Flowchart 3 below shows the process for obtain such estimates. Asset management software It is essential to adopt and standardise on an appropriate asset management information system. There are a number of such systems available; serious consideration should be given to open-source solutions and/or or solutions which are cost-effective and sustainable, requiring minimal support.

  FLOWCHART 3: How to estimate total equipment stock values Process Activity The HTM working group (or its pricing sub-group) at facility, district, state or national level: Gathers data on current equipment prices. Use purchase contracts, supplier information, data from service contracts, manufacturers’ websites, etc.

Compiles a Reference Equipment Price List. List typical prices for different equipment types.

Makes a stock value estimate for the health facility, or each facility type. Use one of the following three calculations for the facility:

To obtain a rough estimate of the “new” stock value: Estimate the major expensive equipment categories (for medical equipment, plant, furniture, etc.) for the health facility. Then multiply their approximate numbers by the reference prices.

To obtain a more exact estimate: Cost the Equipment Inventory, using the reference prices.

To obtain an estimate for the future: Cost the Standard Equipment List for the facility, using the reference prices.

When making estimates for more than one facility: Take the stock value for a facility type and multiply it by the number of facilities of that type in district, province or organisation.

Improves planning and budgeting. Ensure the correct stock value is always used for planning and budgeting purposes.

Ensures the information is kept up to date. Revise the prices regularly in order to provide a database of current equipment prices.

Revise the stock values periodically.

  4. Budgeting & financing 4.1 Estimates of budget lines for equipment expenditure It is essential to have budget lines for health technologies/medical equipment in national, province, district and facility budgets. A process for developing budget lines is shown in Box 6.

BOX 6: Process for developing budget lines for equipment expenditure People responsible Action Finance officers, at all levels of the health service (central, province, district, facility) Establish different budget lines (sub-divisions) as itemised below: a. capital funds to cover equipment replacement (depreciation); b. capital funds to cover additional new equipment requirements; c. capital funds to cover support activities which ensure equipment purchases can be used (installation, commissioning, and initial training); d. capital funds to cover pre-installation work for equipment purchases; e. capital funds to cover major rehabilitation projects; f. recurrent funds to cover equipment maintenance costs, including spare parts, service contracts, and minor works; g. recurrent funds to cover equipment operational costs, including consumable items and worn out accessories; h. recurrent funds to cover equipment-related administration, including energy requirements; and i. recurrent funds to cover ongoing training requirements. HTM working groups Start using these budget lines to analyse how money is allocated and spent for equipment purposes. Health service providers Ensure that budgets are presented by cost centre so that it is clear what allocations are made between national, provincial, district and facility levels. In this way, it can be seen what money is spent on equipment activities at each level of the health service. Lobby other bodies involved (such as Ministries of Finance, Public Works) to also show equipment expenditures to establish what is allocated by other agencies for equipment activities in the health service.

The high-level budgets thus obtained can then be “unpacked” into more detailed line expenditures, such as shown in Table 1 below, with projections covering 3-5-year budget cycles. 4.2 Estimates of maintenance costs for forward planning An important – and often neglected – expenditure category is that of maintenance, be it for medical equipment or healthcare technologies and infrastructure in general. Box 7 unpacks the maintenance line item to indicate the various categories of maintenance-related expenditure for medical equipment, while Flowchart 4 suggests a process for estimating maintenance costs as part of planning.

TABLE 1: Example of a core equipment expenditure plan Capital expenditure Short term Medium term 2012 2013 2014 2015 Replacement Use calculations for rough estimations (see Note below) New equipment Support activities linked to purchases Pre-installation Rehabilitation Sub-total Recurrent expenditure Equipment maintenance Use calculations for rough estimations (see Note below) Consumables Administration On-going training Sub-total Total expenditure Note: Initially, rough estimates are used for the short- and long-term overview when preparing this Core Equipment Expenditure Plan. During annual planning the estimates are revised, using calculations for specific requirements, to obtain the Annual Equipment Budget. The experience gained from that annual revision process may mean that the long-term estimates in this Core Equipment Expenditure Plan may have to be altered, so that they are more realistic.

BOX 7: Elements of annual maintenance budgets

I. Planned budgets:

These allocate funds for anticipated maintenance costs, which can be derived from the following main areas of expenditure: a) spare parts – which are required regularly, determined from previous experience and any planned remedial work; b) spare parts – which are required according to planned preventive maintenance (PPM) schedules and timetables; c) maintenance materials – which are required regularly, determined by previous experience and any planned remedial work; d) maintenance materials – which are required according to PPM schedules and timetables; e) service contracts – required for any planned remedial work; f) service contracts – for breakdowns which are likely to be required, determined from previous experience; g) service contracts – required for PPM of complex equipment; h) calibration of workshop test equipment; i) replacement of tools at the end of their life; j) office material; and k) any increased maintenance requirements brought about by planned new equipment purchases under the capital expenditure budget. Note: there will be other elements which may fall under other budgets. These could include: • other administrative costs which are included in budgets held by other departments; • major repair works – in some cases the planned rehabilitation of equipment which requires major work with the purchase of substantial amounts of materials or contracts (the large sums of money required for such projects may have to fall under the capital budget); and • pre-installation work (such as site-preparation); this often falls under capital funds as it is linked to specific purchases.

II. Contingency budgets:

In addition to planned budgets, contingency budgets also exist. These allocate funds for unplanned maintenance work, such as emergencies, or sudden breakdowns which could not be predicted.

[See Section 10.2 for further discussion on maintenance-related issues].

  FLOWCHART 4: How to make rough estimates of maintenance costs for forward planning Process Activity HTM working groups and/or HTM managers: Refer to existing documents. Use the up-to-date equipment stock values and equipment reference price lists.

Calculate adequate maintenance budget requirements. Use one of the following methods, depending on the type of financial projections required in the business plan:

To obtain an ideal estimate for a specified type of facility Cost the Standard Equipment List for the specific type of facility. Then calculate: • 5-6% of the ideal stock value for medical equipment, for its maintenance each year; • 1-2% of the ideal construction costs for buildings, for their maintenance each year; and • 3-4% of the ideal purchase and installation costs for service supplies and plant, for their maintenance each year.

To obtain a more realistic estimate based on current stock Cost the existing Equipment Inventory for the health facility. Then calculate: • 5-6% of the realistic stock value for medical equipment, for its maintenance each year; • 1-2% of the realistic construction costs for buildings, for their maintenance each year; and • 3-4% of the realistic purchase and installation costs for service supplies and plant, for their maintenance each year.

To obtain a reduced estimate based on the current stock it is possible to rehabilitate Cost the existing Equipment Inventory. Then calculate: • the percentage which is actually repairable (for example, 20%) to obtain the value of the reduced stock of items which are worth rehabilitating. Then calculate: • 5-6% of the reduced stock value for medical equipment, for its maintenance each year; • 1-2% of the reduced construction costs for buildings, for their maintenance each year; and • 3-4% of the reduced purchase and installation costs for service supplies and plant, for their maintenance each year.

To obtain a more pragmatic/practical estimate for most urgent needs Identify and cost only certain equipment areas to concentrate on, which it is desired to keep functioning over the next few years. Then calculate: • 5-6% of the pragmatic stock value for medical equipment, for its maintenance each year; • 1-2% of the pragmatic construction costs for buildings, for their maintenance each year; and • 3-4% of the pragmatic purchase and installation costs for service supplies and plant, for their maintenance each year.

Feed back the maintenance assumptions made here to the replacement budget calculations. Were reduced or pragmatic maintenance amounts calculated? (See last two methods shown above.) If so, increase the replacement budget so that more of the facility's stock can be returned to a working and repairable condition.