Sustainability challenges in medical equipment donations to low- and middle-income countries (original) (raw)

1. Introduction

The World Health Organization (WHO) classifies medical devices and equipment as an essential component of a health care system. A medical device is an instrument used to prevent, diagnose, or treat an illness. Medical equipment (ME) requires various activities such as maintenance, repair, and calibration to be maintained by clinical engineers [1]. The Sixtieth World Health Assembly recognized ME as pivotal to achieving Sustainable Development Goal 3 (SDG3) of Good Health and Well-Being [2]. Healthcare facilities in low- and middle-income countries (LMICs) have limited access to ME. The high cost of importing ME constitute a significant barrier to accessing medical technology. Therefore, the healthcare systems in LMICs rely heavily on donations of ME to meet the goal of universal health coverage. Studies have shown that about 70–80% of the ME in LMICs has been donated by high-resource settings [3, 4]. In addition, surveys conducted in sub-Saharan Africa reveal that only about 10–30% of such donated ME becomes functional [5]. Various reasons, such as lack of expertise, knowledge, and spare parts, have been associated with poor integration of ME into the healthcare infrastructure of developing countries [6]. Donations have the potential to dramatically improve access to healthcare in resource-poor settings, especially in the case of global crises. The Mectizan Donation Program, an attempt to eliminate river blindness, provides good evidence for the merits of careful healthcare donations [7]. However, irresponsible donation exacerbates the situation by burdening the recipient countries with disposal costs. For every dollar donated to ME donation programs, about 62.5–87.54 cents are wasted [8]. The WHO established official guidelines for appropriate ME donation in 1996. The version has since been revised, and the most recent related documents were released in 2011. There is no evidence of how well the donors and recipients of ME donations comply with these guidelines since no regulation exists.

This study aims to investigate the critical barriers to successful ME donation, evaluate the adherence of such donations with WHO-established guidelines, compare the donation process of new and used ME, and make recommendations for sustainable ME donation. All ME donation ecosystem stakeholders must be considered to capture the complete picture. The recipient experience has been given scant attention in contemporary literature. This study attempts to understand the experience of recipients of new and old ME donations in various capacities. Most ME donations are not made directly. Often, they involve third-party organizations on both sides, helping with the donations. This study focuses on the experience of the new equipment procuring international agency in Pakistan (PK), the United Nations Office for Project Services (UNOPS), an end user (hospital) of used donated ME in PK and intermediary recipient (IR) and distributor (third-party organizations) in Sierra Leone (SL). It explores the analysis of recipients (procuring agencies), IRs (non-governmental organizations (NGOs)), and end users (hospitals) in the international ME donation ecosystem. It further compares the ME donation process adopted by international procurement organizations and NGOs as well as the experience of end users receiving used and new ME in PK and SL to understand the challenges in the donation supply chain.

2. Research context

2.1. Barriers to sustainable donation

The sustainability of ME donations needs to be achieved on multiple levels. Various kinds of research have established that sustained access to medical devices in low-resource settings contains the following elements: sustainable functionality of the donated medical devices that strengthen the capacity of health systems in LMICs; sustainable and supportive relationships between the various stakeholders in ME donations to ensure long-term accessibility to consumables, spare parts, and knowledge; sustainable disposal of out-of-service ME; and sustainable ME training of technical staff for maintenance and reparative service. There is often a mismatch between the needs of the recipient hospital and the received equipment. It may be that the quality of the received equipment is not suitable for the recipient country’s environment. Other times, it is a quantity mismatch where the recipient may receive more equipment than it can accommodate. Both situations may result in unsuccessful donation programs. A thorough analysis of the literature reveals common barriers to successful donation. Emmerling et al. [9] identified challenges in successful donations in Honduras, Rwanda, and Cambodia. Other studies assessing ME donations to various LMICs reveal multiple barriers due to quality mismatch.

Various instances have been reported where the use of donated equipment was completely inhibited due to frequency and voltage differences between the equipment and recipient facilities [10]. A similar case was observed in Haiti when the operating temperature, voltage, and frequency were not assessed before the donation and installation of the equipment. The host hospital had purchased transformers to tackle this, but the equipment still failed to function as it operated outside its required temperature range at the wrong power supply frequency [11]. To tackle this, equipment testing is required to verify whether the equipment suits the host environment. Such testing is often done by procuring or intermediary agencies for ME donations. A survey by Gentles et al. [12] revealed that only 43% of 30 responding donor organizations had volunteer technical staff to test the equipment before it was shipped out. Thus, a lack of standardized quality testing of the equipment is a significant challenge in sustainable donation. Another common element in the mismatch scenario is the technical limitation of the staff expected to maintain and repair the donated equipment. With no prior knowledge of the new equipment, technicians consider their lack of knowledge a major obstacle in keeping the donated ME functional. The lack of authority of technicians to repair the equipment due to service contracts and poor communication between the end user and technicians further emphasize the importance of training the human resource. Furthermore, with just one year of training given for technical staff in Rwanda, the amount of out-of-service equipment was reduced by 43% [13]. Lack of effort to ensure that the needs of the host facility align with the items and training provided by the donor is a prevailing challenge in the way of sustainable ME donations. Healthcare infrastructure in LMICs relies heavily on donated ME, but there are recorded cases where the donations proved unnecessary and excessive. Large donations in quick successions severely overwhelm the recipient countries’ healthcare facilities, resulting in expiring medicines [10, 14] and components failing to be absorbed into the infrastructure. Kamba et al. [15] highlighted the environmental threats caused by the improper disposal of donations in the healthcare sector. Although the WHO guidelines mention that quality and quantity should be discussed between the donor and recipient for the donation to fulfill its purpose, research shows a lack of compliance with these guidelines. The long-term effects of the donation on the recipient hospital’s budget needed to be assessed before accepting a donation. In the case of used ME donation, the operating costs of a device may increase over its lifetime, as it requires additional maintenance and repair. Additional overheads must be considered before accepting donations of new and used ME. Costs of replacing a part, acquiring consumables, and training operators and technicians on the new equipment are a few of the reasons why the operating costs might exceed a hospital’s budget. Manufacturers of consumables and spare parts might also take advantage of the opportunity to sell at a higher price. Williams et al. [10] discussed instances in Ghana where transnational funders initially provided the recipients with chemical reagents required to run the chemistry analyzers. This donation, however, was limited to addressing a specific health-related initiative, after which the funds to acquire the reagents were suspended. As a result, the host hospitals were left with equipment they could no longer use unless they were responsible for purchasing their reagents. Distributors of such chemicals might require the hospitals to agree to exclusive purchasing agreements, which might not be a viable option for such recipient hospitals in the long run. For instance, Becton Dickinson (BD) is an active ME donor to low-resource settings and a member of the Partnership for Quality Medical Donations (PQMD). BD conducts a thorough needs assessment before making donations, and their service agreements usually require the donation of necessary materials such as reagents for a year [16]. Another long-term cost is the preventative and reparative maintenance of the donated equipment. If the maintenance is not covered as a part of the service agreement and relevant training is not provided to the technical staff of the host hospital, the hospitals must invest in hiring biomedical engineers to maintain the quality of the equipment.

Furthermore, outside of challenges posed by quality and quantity mismatch of ME, there is a more significant hurdle in executing successful donation programs. Being at the receiving end, the recipient has little control over the donation programs. The donor-recipient power imbalance has been prevalent throughout studies across LMICs. Marks et al. [5] described this as an “anything is better than nothing” attitude from the recipients, as they may feel embarrassed to voice their concerns or decline a donation in fear of losing future donations. The donor should maintain communication lines and empower the recipient to share their feedback. Compton and Thatcher [17] discussed the efforts of intermediary organizations called medical surplus recovery organizations (MSROs) to deal with the challenges of surplus donations. Such organizations collect the surplus ME, inventory it, and distribute it to LMICs. The research found that six out of ten pieces of equipment donated by the hospitals were broken. Due to obsolete and non-functional donations, “ME graveyards” are commonly seen in such host hospitals [18]. Hence, while donations are sometimes falsely used to make host countries the dumping ground for ME, organizations use them to meet their corporate responsibility targets. In such cases, the donated ME is unfunctional or breaks down soon after arrival. The WHO guidelines recommend that the donated equipment be functional for at least two years after the donation. Cases were reported in healthcare facilities in Uganda where an anesthesia machine worked just once before it broke down, and out of 20 donated incubators, only 13 were functional [19]. Infant warmers were donated without the necessary patient probes required to use them. Ugandan Ministry of Health policy requires donors to ensure that the donated equipment meets the country’s voltage requirements; this was still not considered when the donations were made. Such a situation puts a question mark on the proper motivation and intention behind the donations. Eze et al. [20] discussed how some donations might be motivated by indirect monetary gain. Research done in Canada revealed that hospitals often receive financial incentives from ME manufacturers to make donations [21]. In such a case, the hospitals might take advantage of the opportunity to dispose of old non-functional equipment in return for incentives. Moreover, to escape the rigorous legal requirements related to medical donations, donors and recipients seek non-profit organizations and charities for the trans-border movement of the equipment. Consequently, some donations have become merely a means for donors to greenwash their organizations to build a good reputation.

2.2. Existing guidelines for ME donations

Compared to LMICs, medical devices are highly regulated in higher-resource settings. The regulations exist as minimum requirements for medical devices to meet international standards. Such standards help harmonize medical device design and production for safety concerns, making it viable for exported or imported products. The requirement to comply with these standards varies even in high-resource settings. For instance, while it is a law in Italy, it is treated as a strong recommendation in the United Kingdom [22]. The case with regulations regarding ME donation is similar since national policies vary worldwide, and no universal legislation governs donations. Considering the recurring barriers to donations, a few existing guidelines are already available to stakeholders. Various checklists and frameworks have been developed to standardize ME donation and procurement. Some of the prominent guidelines include those suggested by the WHO [23], Tropical Health Education Trust [24], and PQMD. The main focus of the guidelines includes informing donors on the best methods to overcome challenges in the way successful donation is and empowering recipients in the decision-making process of the donations. However, WHO has tried to address this lack of structure by publishing official guidelines on ME donation. Most recent editions were published in 2011. McDonald et al. [25] analyzed 88 reports with information about 53 different donations. The results revealed that most of the donations reported do not provide adequate information to assess their compliance with WHO guidelines. Those who managed to record the donations in writing still failed to comply with the guidelines. Generally, the minimum requirements contain structural, organizational, and technological requirements for specific kinds of equipment. A major deciding factor in the success of a donation program is how well the needs assessment has been conducted. The guidelines contain instructions on how to conduct a thorough needs assessment. It can be used to form a donation acceptance criterion for the recipient. If there is one, the criterion must reflect the recipient country’s national policy. ME manufacturer Medtronic requires prospective recipients to complete an eligibility form along with providing a compliance certificate [26]. To further aid the donation process, Medtronic partners with non-profit organizations such as Medshare to distribute ME globally. General Electric Foundation under General Electric is another ME manufacturer promoting sustainable ME donations. The foundation has supported low-resource settings through capacity building and training biomedical equipment technicians through the Association for the Advancement of Medical Instrumentation (AAMI), focusing on developing an evidence-based curriculum for ME technicians in low-income countries like Ethiopia, Rwanda, and Ghana [27].

An excellent example of compliance with ME donation guidelines was observed in the Democratic Republic of Congo’s Takaya Health Centre in 2012 [28]. The needs assessment for the donation was done based on consultation with physicians with first-hand experience and knowledge of the challenges and the limited resources available. Complying with the technology-appropriate clauses of the guidelines, low-cost and durable devices were donated to the facility. Post-donation quarterly reviews were carried out to test the functionality of the equipment. Auxiliary devices were sufficient for six months after the donation, and the recipient could purchase most of the depleting supplies locally. A small portion of the donated ME could not be made functional due to a lack of training and familiarity with the equipment. The study continued for a year after the donation to determine the usage and durability of donated equipment for each patient encounter. The results would help future donations to determine the technology appropriateness for the country. Two-way donor-recipient communication to identify needs prior to the donation has been identified as a strong indicator in determining the success of the donation. Poor communication between the stakeholders results in unsuitable donations [12]; however, selected 28 health facilities across Ghana receive ME donations from Canada. Recipient perspectives were gathered to assess the significance of donor-recipient communication. The study revealed that 96% of the respondents agreed that there was communication between the donor and recipient. About 86% stated that the donor asked the recipients what their greatest needs were in advance. The donors either conducted surveys or asked recipients to submit a wish list. In a few cases, the donor visited the hospital to collect first-hand information. Such communication allowed recipients to make additional requests. Although such requests were not always met, only 11% of the responders reported receiving complete “surprise packages”. This survey was part of a more extended research study that included a long-term assessment of the Canadian donation programs in Ghana. The same study by Gentles et al. [12] revealed that some Canadian donors conducted needs and impact assessments every three months. A big part of official guidelines on ME donation encourages donors and recipients to determine metrics to evaluate the success of donations over time. Assessing the impact of previous donations allows all stakeholders to identify best practices and challenges. Such an evaluation would lead to improving the appropriateness of the future. A method of evaluation suggested by Compton et al. [16] includes receiving feedback from recipients about whether the donated equipment fulfilled its intended purpose or failed to do so. They have also identified the challenge in such an evaluation where the recipient might hesitate to provide honest feedback for fear of harming the relationship with the donor. To achieve valuable and honest feedback, the donor must empower recipients by including them in decision-making. It is also recommended that the donors evaluate the efficiency of the guidelines against their donation model before its implementation. Project metrics help assess the effectiveness of the intervention, in this case, the donations. Webber et al. [29] recommended evaluating metrics before project implementation. For a practical evaluation, metrics should reflect the retrospective and the prospective data. Common metrics in ME donation include the number of personnel trained, the financial outcome of the project, the number of maintenance requests received for the equipment after the donation, etc. If there is insufficient historical evidence to base the metric, all the stakeholders should work with local partners to develop an accurate metric. It is essential to pick a metric that gathers the necessary data but does not burden the partners. Metrics should encourage periodic updates to lead to an evidence-based model. Measuring progress can be resource-intensive, but it is necessary for future donations.

3. Methodology

3.1. Research approach and strategy

One of this study’s objectives is understanding recipients’ perceptions of ME donation practices. To this end, primary data were collected through questionnaires and interviews to validate the literature review results. Gentles et al. [12] conducted similar interviews to develop an understanding of donor and recipient perspectives on ME donations made by several Canadian charitable organizations. The literature review and WHO guidelines provided the research strategy framework. This contributed to informed decision-making in drafting the best questionnaire and interview questions for this study. The quantitative and qualitative data from the questionnaire and in-depth semi-structured interviews with the recipients and users were combined for analysis. As preliminary work, relevant organizations were identified in PK and SL. Semi-structured interviews were conducted in three organizations across PK and SL to gain insight into recipients’ experience of donated ME. The organization in SL is a non-profit organization that acts as an IR of used donated ME. For this study, the organization will remain anonymous and referred to as the IR in SL. In PK, the interviews were conducted with employees of a UN project implementing arm called UNOPS. UNOPS acts as a procurement agency by receiving funds for transnational donations of new equipment. UNOPS will either be referred to as UNOPS or Recipient in PK for this study. The third participant organization is a hospital in PK that uses ME donated by multiple donors. The hospital will be referred to as an end user in Pakistan (PKE) for this analysis. The participants work as clinicians, technical, administration, and support/procuring staff. The initials of their occupation will be used to differentiate between the responses from different departments. Some initials like T as Technical, A as Administrative, S as Support, and C as Clinical are presented for easy analysis. The initials will be followed by a number to count the responses from each department. For instance, T1 and T2 represent responses from participants 1 and 2, respectively, of the technical department.

3.2. Data collection

Thirteen sections containing thirty-seven questions inspired by the WHO and other official guidelines [23, 24, 30] were drafted as questionnaires and short interview questions to conduct semi-structured interviews with the participants. The designed questionnaire was a five-point Likert scale ranging from 1 (least significant) to 5 (most significant), where the participants’ perspectives on critical issues were sought. Some of these essential sections include the role of the organization and the participant, needs assessment/recipient’s donation acceptance criteria, donation requirement and criteria/donor’s donation criteria, appropriate technology, and metrics for success. A follow-up evaluation section was also added, which contains open-ended questions to understand the individual perspective of the responder on how they believe that the donation method can be improved. Such a discussion would allow the opportunity to reevaluate the current donation acceptance criteria. The semi-structured interviews were conducted with a total of eleven participants. There were four participants from an IR (SL), five participants from UNOPS (Recipient (PK)), and the two remaining participants were from end users (PKE). A chain referral sampling technique was employed to reach out to the interviewees. Single individuals were reached out to in each organization, who referred others for the interview. All participants had a working knowledge of English and could ask questions if they struggled to understand it. The participants were provided with necessary information about the purpose of the data collection and study. The small sample size and limited geographic sample of this study could be perceived as a limitation, but it is a starting point to explore the sustainability practices in ME donations by considering the common countries of operations. Future research will look into a bigger sample size and geographic location using a quantitative approach to validate this study.

4. Data analysis, discussion, and conclusion

4.1. Case findings

The findings and analysis of the questionnaire and conducted interviews are presented in graphs and tables in this section. The analysis starts with understanding the perspective of staff working in different departments of the recipient organizations on needs for assessment. Figure 1 highlights the participants’ responses, and further inquiries were made via semi-structured interviews to establish more facts on their responses. It can be established that the highest significance levels were for the availability of an appropriate environment (available facilities, such as physical space, electrical and pneumatic power, water supply, heating, ventilation, and air conditioning, to install and operate the requested equipment). However, the availability of material resources and maintenance resources (ancillary/supportive equipment) was considered the least significant of the four factors. The participants were asked about the significance of the availability of spare parts in their current donation acceptance criteria. Currently, apart from UNOPS, the other two organizations do not consider this factor to be of great significance in accepting donations.

Further analysis considered donation requirements and criteria, and, as shown in Table 1, apart from the respondents working in UNOPS, the employees from the other two organizations were unaware of the donors’ compliance rules with the recipient country’s national policy. For the second question, UNOPS was the only one dealing with donors who provided support after the donation. The support is provided for a year, although WHO requires the donor to provide two years of support post-donation. None of the participant organizations’ donors employs a parts-only policy.

Figure 1

Needs assessment.

Table 1

Donation requirement and criteria

According to WHO guidelines, the donor must provide equipment that complies with international standards, and the necessary subsystems and components are to be provided along with the ME. Considering the analysis in Figure 2, among the respondents across the three organizations, those working at UNOPS strongly agree that their donors comply with these regulations.

Similarly, as shown in Figure 3, the recipients in SL and PKEs disagree or strongly disagree that the donated equipment meets standards promulgated by international bodies such as the International Organization for Standardization and the International Electrotechnical Commission.

Figure 2

Availability of accessories and subsystems.

Figure 3

Compliance with international standards.

It should be noted that most equipment is initially manufactured according to international standards. However, once it has outlived its intended lifetime, it no longer meets the previous standards.

Furthermore, in terms of appropriate technology, the WHO has highlighted a list of favorable characteristics in relation to the successful donation of ME in LMICs. The participants rated the significance of these characteristics to ME donations. The analysis of the findings in Figure 4 shows that of the three sets of participants, respondents from UNOPS (PK) recognized each characteristic as significant (rating 4–5), reflecting adherence to WHO guidelines. The number of accessories required and low-energy consumption received a lower rating from SL and PKE. Accepting donations with high-energy consumption would mean higher operating costs for the end users, which might not be an excellent long-term solution. A lack of necessary accessories makes the ME obsolete for the host hospital, increasing the costs required to acquire the parts.

Figure 4

Availability of appropriate technology.

However, based on further information from the semi-structured interview, a recurring challenge in ME donation in LMICs is that the donor does not provide the recipient with the necessary instruction manuals, subsystems, or maintenance support required to operate the donated equipment. In the case of UNOPS (PK), since the donated ME is provided directly from the manufacturer through donated funds, a checklist is made to ensure that all the necessary cables, subsystems, and documentation are available for the recipient. The donors also provide maintenance support by providing training or testing equipment to the biomedical engineers of the recipient organization. As reflected in Table 2, although most respondents from SL agreed that they were provided with installation instructions from the donor, the same support was missing from the donors in other categories, such as providing training to the technical staff. As for the PKEs, the two respondents highlight that no such support was provided by any donor in any form. Another additional question was used to assess whether the recipients were aware of the national policy in their respective countries around ME donation acceptance criteria; most respondents replied that they were unsure if there was a national policy for such donations, confirming their earlier response.

Table 2

Availability of appropriate technology

Regarding donor-recipient communication, the WHO guidelines emphasize effective donor-recipient communication, as it should be used to formulate all plans for ME donations. The level of communication between the two stakeholders can also help understand the power dynamics in the relationship. For UNOPS (PK), the type and number of ME to be donated are discussed between the donors and the recipient. Such a relationship shows that the recipient has some power in the decision-making of the donations. As for IR (SL), while the items are agreed upon, the number of donated items is not agreed upon. In the case of the end user (PKE), the host hospital has no power in the donation quantity of items. Considering the success of the donations, using the right metric to assess donations can help identify challenges in successful donation programs. The participants were asked open-ended questions to determine their current metrics and quality assurance methods. The analysis of their responses was categorized into themes, as shown in Figure 5, and the total number of responses under each theme was calculated. The resulting numbers helped identify the frequency of each response.

Quality is another critical factor to consider in ME donations. The recipient must determine if the received ME meets the essential quality assurance standards. As shown in Figure 6, three common themes emerged from an open-ended question asking the participating organizations to identify the most used quality assurance methods. The analysis shows the Standard Testing Method as the respondent organizations’ most famous quality assurance procedure.

Figure 5

Current metrics used in ME donation success.

Support after the donation is critical; follow-up evaluation is paramount to ensure continuous improvement and sustainable donation practices. The support after the donations was investigated; all the participants across the three organizations stated that the donations were not monitored long term by any stakeholders. However, the investigation of the follow-up evaluation using the efficiency of the current donation acceptance criteria shows that all the UNOPS (PK) participants agreed that they were satisfied with their organizations’ current donation acceptance criteria. In contrast, all the IR (SL) and end-user (PKE) participants responded that they were dissatisfied with the current criteria. To identify possible improvements that can be made in the donation process across the three organizations, the follow-up evaluation process was further investigated, and all the participants were asked open-ended questions. The participants identified seven common themes, as analyzed in Figure 7, where most respondents identified the lack of long-term donation assessment as the key challenge.

Figure 6

Quality assurance methods.

Figure 7

Feedback about the donation process.

4.2. Discussion: synthesis of findings with literature review

This study aims to identify common challenges in sustainable ME donation in LMICs. Considering the findings discussed in the current ME donation process followed by new and used ME recipients, they were compared with official WHO guidelines to evaluate their level of compliance. Using such findings, the model followed by the two organizations (new and used ME recipients) will be evaluated to compare their efficiency. Finally, sustainable practices for ME donations will be analyzed. Compliance with WHO guidelines is an important thing that needs to be considered in ME donations. This study established that UNOPS PK has the highest level of compliance with the guidelines among the three participating organizations as reflected in their current donation programs. In contrast, the donation process employed by the IR in SL and PKE hospital was far from compliant. The findings imply that the nature of an organization is linked to the success of its donations resulting from the organization’s internal policies. Satisfaction with the donation process was highly dependent on adherence to WHO guidelines. The lack of compliance with guidelines widely associated with ME donations is often attributed to poor reporting and communication. The donation programs of new equipment at UNOPS (PK) have the highest satisfaction level among the participants, and the major reason for the success of its donation initiatives is its strict compliance with its own and WHO policies and guidelines. There is a confirmation that the organization’s strong communication lines between the donor and end user ensure that the right quality and quantity of ME is donated to the end user. Other identified emerging themes associated with the challenges in ME donation in LMICs include a lack of trained technical staff, spare parts, consumables, accountability of donors, a proper needs assessment, and lack of established metrics and standardization. Considering this case study’s findings and analysis from other relevant literature, it could be concluded that to address the common recurring challenges in the ME donation ecosystem and for sustainable donations, organizations need to establish and adopt standardized metrics to measure success, sustain long-term relationships with their donors, improve human resource assessment methods, and comply with international guidelines and policies. This will be helpful in the best ME donation practices to hold all stakeholders accountable and empower themselves by maintaining lines of communication with their donors and by conducting comprehensive needs assessments before accepting donations.

4.3. Conclusion and future research

The research methodology helped draw meaningful results to answer the research questions. The challenges identified in sustainable ME donation for the respondent organizations are concurrent with the learnings from the literature review. A lack of availability of spare parts and consumables, less emphasis on technical training, poor communication and power imbalance between the donors and recipients, and lack of accountability and compliance with official guidelines are significant barriers to sustainable ME donation. The international procuring agent UNOPS was the most compliant with WHO guidelines, suggesting that donations of new ME involving such organizations are more sustainable than donations of old ME involving local or intermediary organizations. Considering the challenges and the insight from the interviews, long-term policies, empowered recipients, appropriate training, and sustained access to spare parts and consumables have been identified as viable solutions to ascertain the sustainability of donation programs. There is a considerable gap in the literature regarding ME donation practices in South Asia. A more comprehensive study needs to be conducted in this region to evaluate the percentage of out-of-service donated equipment. The results of this study relied heavily on a literature review focusing on Africa. With adequate historical data on ME donation in South Asia, the recommendations can be better aligned to cater to the region’s needs. The donors need to participate in the discussion of sustainable donations; the recipient alone does not have the power to make informed decisions about donations. Thus, investigating critical challenges in ME donation and the recommendations to make the donations sustainable will allow the stakeholders to make informed decisions about donations.

Funding

The authors declare no financial support for the research, authorship, or publication of this article.

Author contributions

Conceptualization, O.O. and H.W.; methodology, O.O. and H.W.; software, H.W.; validation, O.O. and H.W.; formal analysis, O.O. and H.W.; investigation, H.W.; resources, O.O. and H.W.; data curation, O.O. and H.W.; writing—original draft preparation, H.W.; writing—review and editing, O.O.; visualization, O.O.; supervision, O.O.; project administration, O.O. All authors have read and agreed to the published version of the manuscript.

Conflict of interest

The authors declare no conflict of interest.

Institutional review board statement

This study was approved by the Faculty Research Ethics Committee (FREC) of University of the West of England (May 2022).

Informed consent statement

Not applicable.

Sample availability

The authors declare no physical samples were used in the study.

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