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Fig. 1 In a country without trained emergency medical technicians, ambulance drivers, or a functioning prehospital trauma system, this generously donated ambulance found its greatest use as a delivery truck far from the emergency trauma care for which it was intended.
Courtesy of HVO

AAOS Now

Published 5/1/2010
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Jonathan J. Phillips; R. Richard Coughlin, MD, MSc; Richard A. Gosselin, MD, MPH

Socially responsible orthopaedic donations

By Jonathan J. Phillips; R. Richard Coughlin, MD, MSc; and Richard A. Gosselin, MD, MPH

Good intentions aren’t enough

The device- and hardware-dependent nature of orthopaedic surgery results in many donations targeted to orthopaedists in the developing world where resources are sparse. With the recent devastation in Haiti and a rush among aid groups and charitable donors to offer assistance, the practice of responsible donation is again called into question.

In January 2008, the World Health Organization (WHO) Bulletin published “Beyond good intentions: Lessons on equipment donation from an African hospital.” One of the Gambian healthcare workers interviewed noted, “And you do get the impression some times that the intention is good, but inadequate attention has been paid to the follow-on issues...You tend to find that what you’re getting are the discards, are the rejects.”

This statement reflects the sentiment of recipients toward the donation of un-useful medical equipment (Fig. 1). A short discussion on the pros and cons of charitable donation of medical equipment amongst the orthopaedic community is thus timely and amply relevant.

Technology—here and there
Surgical care in high-income countries (HICs) is dependent on the rapidly evolving availability of innovative device technologies. These technologies contribute greatly to mitigating the otherwise debilitating sequelae of musculoskeletal disease and trauma in orthopaedic care. In contrast, orthopaedic surgeons in developing world countries rely on often rudimentary treatments of limited effectiveness, secondary to the unavailability of hardware and equipment.

The large number of orthopaedic hardware manufacturers in HICs supply most of the modern orthopaedic technologies in the developing world through formal or informal donation programs. Approximately 80 percent of healthcare equipment in the developing world is funded by foreign governments or international donors. These donation programs are fostered by good will on the part of the donors, social responsibility initiatives, tax breaks, and a desire to reduce the cost of storing surplus equipment.

In the 2000 WHO report, “Guidelines for Healthcare Equipment Donations,” documented examples of inappropriate aid, in terms of medical devices and equipment, provided the stimulus to develop international guidelines for future donations. According to the report, “Although donors’ intentions are unquestionable, often their lack of awareness of the local realities of the intended beneficiaries leads to unforeseen consequences of the donation at the recipient end.”

Charity donors
Direct from industry is only one source of orthopaedic donations that are received by developing world governments, hospitals, clinics, and nongovernmental organizations (NGOs). Individual physician and surgeon donors, along with private hospitals and orthopaedic clinics, are regularly looking to offload current and outdated surplus onto the developing world.

Such small scale “garage cleansing” donations are often directed at solitary hospitals, clinics, and healthcare NGOs. The altruistic efforts of charity donors are highly commendable and serve a necessary role, although they must be balanced with an awareness as to the scope of their impact. The costs and benefits of donation must be carefully weighed within the context of each locale.

Both recipients and donors may benefit from charitable donations. As previously mentioned, donors may benefit from good will, tax breaks, and increased storage space. On the recipient end, donations may translate into decreased musculoskeletal burden, with a larger number of patients treated and better functional outcomes. Surgical capacity at district hospitals is enhanced with the ability to treat a wider variety of disease and trauma. Novel devices provide new training opportunities for modern treatment options. In addition, charitable services and material resource donations help foster international relationships.

Unfortunately, seldom is all or most donated materials put to effective use to benefit orthopaedic care. Aid donations may have unintended damaging effects, which often go unrecognized. Misappropriation of donated materials at the level of the local government or hospital often occurs no matter how large or small the gift. Routinely, a series of inflated import duties, customs, and taxes are levied by local officials before donations ever reach the operating room.

Devices that do make their way to the operating room may not be used to benefit the underserved population for whom they were intended. High-priced, complex orthopaedic devices may lie idle and unused in storage if not appropriately targeted to hospitals capable of using them. Low-volume medical technology import businesses within vulnerable micro-economies may be significantly affected by the loss of demand for their products. Effective delivery and monitoring for appropriate use of donated materials in a developing world system can present an imposing logistic hurdle.

Lower and middle income countries often lack equivalent political and health systems and are often ill prepared to receive and manage large-scale donations effectively. Time, effort, and monetary resources are expended by both donor and recipient to move donated goods from the source country to the target site. Carefully devised action plans are necessary to facilitate successful delivery and use of materials.

Good donation practices
As interest in developing-world orthopaedics increases among medical aid groups as well as clinical and industry professionals, the need to raise awareness of socially responsible donations of orthopaedic hardware and technologies also increases. The WHO “Guidelines for Healthcare Equipment Donations” offers guidance for interested donors. Though broad in scope, and nonspecific to orthopaedic surgery, this report should be reviewed by parties interested in making charitable donations of orthopaedic equipment.

Basic considerations—such as the provision of manuals, special parts, and tools when donating equipment that requires maintenance—must not be overlooked. C-arms or autoclaves may go unused unless all factors in their effective use are considered, including compatibility with site country’s voltage, instruction manuals in a language understood by those using the materials, and the availability of lead protection in the facility receiving the donation. Most interlocking nails will be useless without an available c-arm and fracture table.

The following four underlying principles should be considered in each case.

  • Health care equipment donations should benefit the recipient to the maximum extent possible.
  • Donations should be given with due respect for the wishes and authority of the recipient, and in conformity with government policies and administrative arrangements of the recipient country.
  • A double standard in quality is unacceptable. If the quality of an item is unacceptable in the donor country, that item should not be considered for donation.
  • Effective communication between the donor and the recipient is key, with all donations made according to a plan formulated by both parties.

Adherence to these guidelines can result in more appropriate donations that have maximal impact and produce a positive experience for everyone involved.

Jonathan J. Phillips; R. Richard Coughlin MD, MSc; and Richard A. Gosselin MD, MPH, are all associated with the Institute for Global Orthopaedics and Traumatology; Department of Orthopaedic Surgery, San Francisco General Hospital+University of California at San Francisco and Orthopaedics Overseas.

Additional Resources:

WHO Guidelines For Health Care Equipment Donations

“Beyond good intentions: Lessons on equipment donation from an African hospital”