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Clinical engineering updates in the Middle East
Chapter 16
Clinical engineering updates in the Middle East Hashem O. Al-Fadel Temos Assessors Advisory Board, Temos International Healthcare Accreditation, Germany
During the past decade, its estimated that half of medical technology existing was not here before that. This adds more burden on clinical engineering (CE) support and more for continuing education and training. The Middle East depends mostly on imported medical technologies, similar to many developing countries in the world. This in turn creates many challenges to support such technologies that may be different from other countries. CE in Middle Eastern countries mostly emphasizes on maintenance functions and is viewed as such by hospital management and governance bodies. In this chapter, the current status of CE will be briefly reviewed in some countries. The author got experience or knowledge with such as Jordan, Kingdom of Saudi Arabia (KSA), United Arab Emirates (UAE), Egypt, Lebanon, and Turkey. History of CE, present status, challenges, and recommendations will be provided, including some of the main issues in the selected countries.
History of CE in the Middle East The start of CE in the Middle East, particularly in the Arab part, can go back to the late 1970s and early 1980s when high flux of medical equipment and technologies started to come to hospitals in the region. During that period, aids from the developed countries have shed some lights on the education and support of such technologies. For example, the first biomedical education was started at the Cairo University and during that period with the initiation of Biomedical Engineering education. Project “Hope,” based in the United States started to help Egypt to support medical equipment maintenance programs in some hospitals and to assist the support of the biomedical engineering education already existing at that time. In the Gulf countries, since they had abundant of financial resources at that time, hospitals are very well equipped and thus required even more support than the other Middle Eastern countries. Therefore, these countries were able to attract qualified clinical engineers
Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00016-X Copyright © 2020 Elsevier Inc. All rights reserved.
from western countries as well as other countries. In Jordan, Lebanon, Egypt, and Turkey, since they have enough qualified technical staff, they managed the support of their equipment without the need to hire experienced expatriates.
Present status The present status of CE will be described briefly for the selected countries chosen based on the experience of the author in these countries within the past two decades.
Jordan The country is presently in the midst of a troubled region; in the north is Syria and in the east is Iraq as this in turn resulted in a huge influx of refugees to the country. This has added huge pressure on the economy and as such it affected the healthcare services in the country with less acquired technology and a consequent addition of more pressure on the CE support in the country. Currently, there is a shortage of CE professionals in the country as most of the qualified staff will seek work in the Gulf Cooperation Council (GCC) countries and other developed countries due to low salaries and limited resources. Even though the maintenance support of health technology is less demanding compared to a decade ago due to technology and digital advancement, most support is provided by equipment suppliers and is less dependent on in-house support. Regarding the regulatory part, this is done by Jordan FDA, making sure all new technologies meet certain standards as it is required by the exporting countries. This, however, has helped to elevate some of the challenges the country was facing if compared to a decade or two ago. Still there are many challenges facing Jordan for the acquisition and support of medical equipment and devices, which are similar to other Middle Eastern countries and will be explained later in the chapter for the whole region.
111
112 SECTION | 2 Worldwide clinical engineering practice
Kingdom of Saudi Arabia
Lebanon
KSA is the biggest importing country in the region for medical equipment and technologies due to huge demand and availability of resources (Medical devices fact book). This, however, creates huge demand for CE support. The country presently is experiencing shortage of financial resources due to the decline in oil prices and as such there is a national-wide restructuring to adopt to the current situation. KSA had historically depended on foreign trained clinical engineers particularly during the past decades. Presently, the Kingdom has many qualified clinical engineers who studied in western countries as well inside the country and today, it currently depends much less on expatriate clinical engineers. With the start of Saudi FDA in the past 10 years, the regulation of medical devices’ import has helped to reduce many of the challenges facing the proper acquisition of medical technologies. However, there are still many challenges facing CE in KSA similarly to other countries to be addressed later on.
Similar to Jordan, Lebanon is presently in the midst of a troubled region from north, south, and east. This resulted in a huge influx of refugees in the country which has added a huge pressure on the economy, affecting the healthcare services in the country. All this lead to a big reduction on acquisition of medical technologies and again adding more pressure to the CE support in the country. Similar to Jordan currently, there is a shortage of CE professionals in the country, as most of the qualified staff will seek work in the GCC countries and other developed countries, seeking more income and opportunities. On the regulatory part, this is done by ministry of health, making sure all new technologies meet certain standards as required by the exporting countries.
United Arab Emirates UAE could be considered the second largest importing country per capita in Medical Technology in the Middle East after Saudi Arabia (Medical devices fact book). With many similarities to that in KSA for the present status, including pressure on financial resources. It differs that it depends mostly on expatriates’ clinical engineers to support the medical technology. Due to more openness of UAE for trade and investments than other countries, many of the manufacturers and equipment exporters have regional offices in Dubai to support the whole region. This, however, is helping the country to provide more support as compared to other regional countries.
Egypt Even though Egypt is one of the first countries in the Middle East to address the CE support as well to have education and training in this field, it is presently experiencing many challenges in supporting medical technologies and may even more than the countries described here. This is mainly due to the post-Arab spring, the instability of the region, the brain draining of many qualified clinical engineers to work in other countries and with most the recent depreciation of the Egyptian pound and with the severe shortage of hard currencies and financial resources in the country. On the regulatory part, this is done by Drug Policy and Planning Center of Ministry of Health, making sure all new technologies meet certain standards as required by the exporting countries which is a new trend compared to more than a decade ago.
Turkey Turkey is one of the biggest Middle Eastern countries in the region with very big market for healthcare technology. The country heavily emphasizes on medical tourism from European and Arab countries and possesses a good healthcare infrastructure within the region. Since it is within or closer to Europe, the support of medical technology is more matured as compared to the other countries described in this chapter. However, the instability of the region, particularly to the south border with Syria and Iraq, has added pressure on the financial resources for the country and, therefore, the private sector seems to have more support to CE than the public sector due to generation of financial resources from medical tourism. On the regulation side, the Turkish Medicines and Medical Devices Agency affiliated with MOH is the official regulatory agency (Medical devices in Turkey).
Common challenges The challenges facing CE in the region includes the following: 1. Shortage of financial resources and less emphasis on technology support from the time of purchasing. Although this may vary from one country to other, it can be found more in the private sector than public due to the recent economic pressure. 2. Qualified and trained engineers in some countries are limited in numbers due to either brain draining such as in Jordan, Egypt, and Lebanon or less trained local staff in some Gulf countries as compared to expatriates especially with the exodus of many expatriates from some countries in the region. 3. Adequate support from some vendors, or even from manufacturers, is often not provided. For example, a vendor might not be prompt in solving equipment problems or experience long delays in providing the spare parts needed.
Clinical engineering updates in the Middle East Chapter | 16 113
4. Difficulty to find well-qualified engineers. 5. There is no national or regional health technology assessment (HTA) system to standardize equipment acquisition in such a case, you may find many equipment available without use and or many hospitals have similar high-tech equipment that are not fully utilized. 6. Sustainability in governmental CE support in relation to HTA programs is not maintained and consequently there is no long-term policy of support to address equipment advancement and support. 7. Education and training at local universities for CE do not address the local needs in many of the current programs. Many of the old problems and concerns raised in the past have been reduced as compared to early 2000 due to digitization and maturity of information technology (Alfadel, 2004).
Societies, accreditations, and education 1. BME Society in Egypt started in 1989 and was available and active in the late 20th century; currently it lacks sustainability. 2. BME Club (society) in KSA started in 1992 and currently there are more chapters in a number of exiting associations. 3. BME Society in Jordan started in 2005. 4. KSA, Jordan, Egypt, and Lebanon have local accreditation programs. 5. Support from the WHO, World Bank, and USAID can be found from one agency or more in some middle eastern countries such as Jordan, Lebanon, Egypt, and Turkey. 6. Mandatory International hospital accreditation in UAE. 7. All these mentioned countries have programs for biomedical engineering education in local universities.
Recommendations The following are some recommendations for CE status in the region: 1. To work on forming a network of cooperation at high level for HTA for medical devices with cooperation with HTA international agencies.
2. To strengthen and activate the currently available biomedical associations or societies with collaboration between them across different countries as possible. 3. Due to shortage of financial resources, the associations or societies need to prepare strategic plans and to prioritize the requirements due to financial limitations. 4. Regulatory associations in KSA FDA, Jordan FDA as well as associations from other countries can collaborate and to include chapters for CE and possibly implement certificate of needs. 5. To emphasize on CE certification or accreditations and possibly to form a regional certification independent organization. 6. To continue holding regional CE conferences and workshops and to look for solution to the most pressing problems in the CE field for the region. Though this has started to take place, but concept papers and recommendations that could come out need to be distributed to all stakeholders for follow-up and implementation. 7. More integration of CE and information technology would help greatly to automate the operation and increase the productivity (Institute of Medicine).
References Alfadel, H., 2004. Clinical engineering in the Middle East. In: Clinical Engineering Handbook, pp. 97–98.
Further reading Alfadel, H, Health Technology Assessment, Perspective of Medical devices for Arab Countries, Hospital Built. Institute of Medicine, 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. IOM. Magazine Issue 2, 2009. Medical Devices Fact Book, https://store.bmiresearch.com/worldwidemedical-devices-market-factbook-2016.html. Medical Devices Regulation Turkey, http://titck.gov.tr/TibbiCihaz.
Clinical engineering updates in the Middle East Hashem O. Al-Fadel Temos Assessors Advisory Board, Temos International Healthcare Accreditation, Germany
During the past decade, its estimated that half of medical technology existing was not here before that. This adds more burden on clinical engineering (CE) support and more for continuing education and training. The Middle East depends mostly on imported medical technologies, similar to many developing countries in the world. This in turn creates many challenges to support such technologies that may be different from other countries. CE in Middle Eastern countries mostly emphasizes on maintenance functions and is viewed as such by hospital management and governance bodies. In this chapter, the current status of CE will be briefly reviewed in some countries. The author got experience or knowledge with such as Jordan, Kingdom of Saudi Arabia (KSA), United Arab Emirates (UAE), Egypt, Lebanon, and Turkey. History of CE, present status, challenges, and recommendations will be provided, including some of the main issues in the selected countries.
History of CE in the Middle East The start of CE in the Middle East, particularly in the Arab part, can go back to the late 1970s and early 1980s when high flux of medical equipment and technologies started to come to hospitals in the region. During that period, aids from the developed countries have shed some lights on the education and support of such technologies. For example, the first biomedical education was started at the Cairo University and during that period with the initiation of Biomedical Engineering education. Project “Hope,” based in the United States started to help Egypt to support medical equipment maintenance programs in some hospitals and to assist the support of the biomedical engineering education already existing at that time. In the Gulf countries, since they had abundant of financial resources at that time, hospitals are very well equipped and thus required even more support than the other Middle Eastern countries. Therefore, these countries were able to attract qualified clinical engineers
Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00016-X Copyright © 2020 Elsevier Inc. All rights reserved.
from western countries as well as other countries. In Jordan, Lebanon, Egypt, and Turkey, since they have enough qualified technical staff, they managed the support of their equipment without the need to hire experienced expatriates.
Present status The present status of CE will be described briefly for the selected countries chosen based on the experience of the author in these countries within the past two decades.
Jordan The country is presently in the midst of a troubled region; in the north is Syria and in the east is Iraq as this in turn resulted in a huge influx of refugees to the country. This has added huge pressure on the economy and as such it affected the healthcare services in the country with less acquired technology and a consequent addition of more pressure on the CE support in the country. Currently, there is a shortage of CE professionals in the country as most of the qualified staff will seek work in the Gulf Cooperation Council (GCC) countries and other developed countries due to low salaries and limited resources. Even though the maintenance support of health technology is less demanding compared to a decade ago due to technology and digital advancement, most support is provided by equipment suppliers and is less dependent on in-house support. Regarding the regulatory part, this is done by Jordan FDA, making sure all new technologies meet certain standards as it is required by the exporting countries. This, however, has helped to elevate some of the challenges the country was facing if compared to a decade or two ago. Still there are many challenges facing Jordan for the acquisition and support of medical equipment and devices, which are similar to other Middle Eastern countries and will be explained later in the chapter for the whole region.
111
112 SECTION | 2 Worldwide clinical engineering practice
Kingdom of Saudi Arabia
Lebanon
KSA is the biggest importing country in the region for medical equipment and technologies due to huge demand and availability of resources (Medical devices fact book). This, however, creates huge demand for CE support. The country presently is experiencing shortage of financial resources due to the decline in oil prices and as such there is a national-wide restructuring to adopt to the current situation. KSA had historically depended on foreign trained clinical engineers particularly during the past decades. Presently, the Kingdom has many qualified clinical engineers who studied in western countries as well inside the country and today, it currently depends much less on expatriate clinical engineers. With the start of Saudi FDA in the past 10 years, the regulation of medical devices’ import has helped to reduce many of the challenges facing the proper acquisition of medical technologies. However, there are still many challenges facing CE in KSA similarly to other countries to be addressed later on.
Similar to Jordan, Lebanon is presently in the midst of a troubled region from north, south, and east. This resulted in a huge influx of refugees in the country which has added a huge pressure on the economy, affecting the healthcare services in the country. All this lead to a big reduction on acquisition of medical technologies and again adding more pressure to the CE support in the country. Similar to Jordan currently, there is a shortage of CE professionals in the country, as most of the qualified staff will seek work in the GCC countries and other developed countries, seeking more income and opportunities. On the regulatory part, this is done by ministry of health, making sure all new technologies meet certain standards as required by the exporting countries.
United Arab Emirates UAE could be considered the second largest importing country per capita in Medical Technology in the Middle East after Saudi Arabia (Medical devices fact book). With many similarities to that in KSA for the present status, including pressure on financial resources. It differs that it depends mostly on expatriates’ clinical engineers to support the medical technology. Due to more openness of UAE for trade and investments than other countries, many of the manufacturers and equipment exporters have regional offices in Dubai to support the whole region. This, however, is helping the country to provide more support as compared to other regional countries.
Egypt Even though Egypt is one of the first countries in the Middle East to address the CE support as well to have education and training in this field, it is presently experiencing many challenges in supporting medical technologies and may even more than the countries described here. This is mainly due to the post-Arab spring, the instability of the region, the brain draining of many qualified clinical engineers to work in other countries and with most the recent depreciation of the Egyptian pound and with the severe shortage of hard currencies and financial resources in the country. On the regulatory part, this is done by Drug Policy and Planning Center of Ministry of Health, making sure all new technologies meet certain standards as required by the exporting countries which is a new trend compared to more than a decade ago.
Turkey Turkey is one of the biggest Middle Eastern countries in the region with very big market for healthcare technology. The country heavily emphasizes on medical tourism from European and Arab countries and possesses a good healthcare infrastructure within the region. Since it is within or closer to Europe, the support of medical technology is more matured as compared to the other countries described in this chapter. However, the instability of the region, particularly to the south border with Syria and Iraq, has added pressure on the financial resources for the country and, therefore, the private sector seems to have more support to CE than the public sector due to generation of financial resources from medical tourism. On the regulation side, the Turkish Medicines and Medical Devices Agency affiliated with MOH is the official regulatory agency (Medical devices in Turkey).
Common challenges The challenges facing CE in the region includes the following: 1. Shortage of financial resources and less emphasis on technology support from the time of purchasing. Although this may vary from one country to other, it can be found more in the private sector than public due to the recent economic pressure. 2. Qualified and trained engineers in some countries are limited in numbers due to either brain draining such as in Jordan, Egypt, and Lebanon or less trained local staff in some Gulf countries as compared to expatriates especially with the exodus of many expatriates from some countries in the region. 3. Adequate support from some vendors, or even from manufacturers, is often not provided. For example, a vendor might not be prompt in solving equipment problems or experience long delays in providing the spare parts needed.
Clinical engineering updates in the Middle East Chapter | 16 113
4. Difficulty to find well-qualified engineers. 5. There is no national or regional health technology assessment (HTA) system to standardize equipment acquisition in such a case, you may find many equipment available without use and or many hospitals have similar high-tech equipment that are not fully utilized. 6. Sustainability in governmental CE support in relation to HTA programs is not maintained and consequently there is no long-term policy of support to address equipment advancement and support. 7. Education and training at local universities for CE do not address the local needs in many of the current programs. Many of the old problems and concerns raised in the past have been reduced as compared to early 2000 due to digitization and maturity of information technology (Alfadel, 2004).
Societies, accreditations, and education 1. BME Society in Egypt started in 1989 and was available and active in the late 20th century; currently it lacks sustainability. 2. BME Club (society) in KSA started in 1992 and currently there are more chapters in a number of exiting associations. 3. BME Society in Jordan started in 2005. 4. KSA, Jordan, Egypt, and Lebanon have local accreditation programs. 5. Support from the WHO, World Bank, and USAID can be found from one agency or more in some middle eastern countries such as Jordan, Lebanon, Egypt, and Turkey. 6. Mandatory International hospital accreditation in UAE. 7. All these mentioned countries have programs for biomedical engineering education in local universities.
Recommendations The following are some recommendations for CE status in the region: 1. To work on forming a network of cooperation at high level for HTA for medical devices with cooperation with HTA international agencies.
2. To strengthen and activate the currently available biomedical associations or societies with collaboration between them across different countries as possible. 3. Due to shortage of financial resources, the associations or societies need to prepare strategic plans and to prioritize the requirements due to financial limitations. 4. Regulatory associations in KSA FDA, Jordan FDA as well as associations from other countries can collaborate and to include chapters for CE and possibly implement certificate of needs. 5. To emphasize on CE certification or accreditations and possibly to form a regional certification independent organization. 6. To continue holding regional CE conferences and workshops and to look for solution to the most pressing problems in the CE field for the region. Though this has started to take place, but concept papers and recommendations that could come out need to be distributed to all stakeholders for follow-up and implementation. 7. More integration of CE and information technology would help greatly to automate the operation and increase the productivity (Institute of Medicine).
References Alfadel, H., 2004. Clinical engineering in the Middle East. In: Clinical Engineering Handbook, pp. 97–98.
Further reading Alfadel, H, Health Technology Assessment, Perspective of Medical devices for Arab Countries, Hospital Built. Institute of Medicine, 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. IOM. Magazine Issue 2, 2009. Medical Devices Fact Book, https://store.bmiresearch.com/worldwidemedical-devices-market-factbook-2016.html. Medical Devices Regulation Turkey, http://titck.gov.tr/TibbiCihaz.