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Right. All right. Hello. Hi. Very good afternoon, everyone. My name is Jan. I am the Gas Se Secretary and I'm an anesthetic in um the UK. And joining us today, we also have G man who is the U KG an represent. And uh so we are going to be uh um uh so understanding are not global needs in social care, which is module two for the Fugal Innovations course today. And then later at four o'clock, we will do module three, which is technology designed for low resource things. So without further ado I'm going to introduce to you our very first and we are very proud to present is Doctor Eg Lambert who is a senior registrar in plastics and reconstructive surgery. He works at the Amadu Belo University Teaching Hospital in Zaria Nigeria. Lambert is also our guest of International surgical rep. So over to you, Lambert. All right. Thank you so much, Jim. Um I'm very grateful to be here to talk to us today about um the challenges and unmet needs um as regards surgery um in low and middle income countries. Um I reside in Nigeria where I also work and um these challenges, um cut across um, West Africa, sub Saharan Africa and also other low um middle-income countries. Um for by way of introduction, I mean, 2015, um, so 9 15, the last set of commission on global surgery, um identified the fact that um, um, surgery have been relegated to the background. Um First of all, sorry, um we'll aim to understand the challenges of um global surgical care. We also, um see how we can appreciate the challenges faced um in low and middle income countries. Then we also attempt to identify some workable solutions to these problems. Um Like I said earlier, um in 2015, the Lancets Commission on Global Surgery um discovered that surgery has been relegated to the background um in the discuss regarding um public health. Um so they met and then they came up with the concept of um global surgery and um global surgery is basically, um has to do with the study and practice of improving access um to timely quality and affordable um surgical care for everyone. Um That's just uh what's global surgery is all about and that's what's um go also helps to propagate. Um I don't know whether my slides are moving. I, since I, since I seem to get to get um some sluggish um reaction over here. Um Sorry about that. Um Global Surgery is essentially like I said, what it aims to do is to ensure that everyone has access to um timely quality and affordable um surgical. I'm K um an estimated 5 billion people globally don't have access to quality and affordable um surgical interventions. Um from statistics that we have gathered. And then because of this, um the committee had to define set criteria um that had to be met um before we can say that um there's access to um surgical um care. Um Let me see if I can turn off my camera. I don't know why my slides are not moving but um sorry about that. Ok. So sorry, my slide seems to be stoke on slide three John is, is it moving at your end? Are my slides moving your mute Jan? I'm sorry, make a mistake. Can you hear me? We can hear you. But how about this? You send your powerpoint to Gene presentation going on and gene can upload it in a moment but you can keep going with what you've got. Ok? But just, just a couple of minutes now for everyone who's listening. So now, but you just send your powerpoint to Gene. Um and then we'll sort it into a PDF and then we'll get onto the main. Let me do that. No problem. Is that all right to you? That's good while we're waiting. Welcome everyone. I see that we've got a lot of people around. We've got people from Kenya, we've got people from Lebanon, Uganda. Um and is um in case you have missed out. We've also got a chat box on the side. Um, the plan is, we've got three very esteemed speakers today. So there will be 15 minutes um, for the first talk, then 15 minutes for a second talk, 15 minutes for the last talk. And at the very end we will do um, the, er, question and answer. I've got my own questions, but obviously the best questions come from the audience. So, um, you're more than welcome um, to ask some questions now. Um, um I'm really sorry that this has been um rescheduled, but hopefully everyone is gonna enjoy today. Um As you can see, Lambert's got some very snazzy slides um for everything else as well. So that's all right. Um Do you have sent them? I don't know if you've received to your email. Yeah. So whilst this is going on Lambert, um I think J's received it. So probably you can go on. So where we left office about the Lancet Commission in 2030 if I'm not wrong. Um And then you can carry on from there. All right. Um So do I need to stop sharing my s my slides change? Yeah. All right. All right. Um So I've, I've stopped sharing my slides. So, can you see this now? Yes, thank you. Thank you. So you on here. All right. Thank you very much. Yeah. So, as I was saying, um, the, um Lancets Commission on Global Surgery, um not noticed the fact that surgery had been to the background um when discussing public health, um they therefore came up with the concept of global surgery, which is basically trying to make um surgery um affordable and accessible to everyone. Um Globally. Um Next slide, please. Yes. Um and in this um aim to achieve global surgery, the low and middle income countries are not left out. And then it was also discovered that an estimated 5 billion people globally lack access to quality and life saving um surgical interventions. Um Next like this. Yeah. So as a result of this, um the committee decided that they will define um six indicators that will be used to monitor access surgery um for everyone. And uh one of them is um access to timely and essential surgery where they look where they um start the fact that um at least uh people should be able to access a facility where the bell that procedures can be carried out within two hours of where they live. Um They also looked at the work force density and they um proposed that um at least um there should be 20 surgical personnel, be surgery anesthetic or, or um physicians per 100,000 population by 2030. And then, um for the surgical volume, um they proposed that um the numbers should be increased to at least 5000 procedures um per 100,000 population by 2030. And also they look to reduce perioperative mortality as much as possible um by 2030. And uh there also aims to protect against impro improv expe expenditure to stop um people from spending so much out of pocket that will leave them um broke and um impoverished at the end. So, these are some of the indicators that were proposed by the committee um to um help achieve um global surgery. So let's look at the challenges um and the unmet needs that will face um low and middle income. One of them is um the social economic challenges and we uh we, we, we see that poverty um rise in most l mis and statistics have it that um at least um about 2040% of people living in Nigeria um live below the poverty and as a as of 2019 and this number has increased um drastically um over time. Um Therefore, people have to pay uh people find it difficult to pay out of pocket um for um their so surgical needs. Um due to um poverty. Another issue there is health insurance, um low and middle income countries find it um find it difficult um covering most um of the population when it comes to insurance. And in Nigeria, just 5% of the population have um health insurance. Hence, you have a large maj majority of the population um how they have to pay out of pocket to access um surgical care. Um because of this they have to resort to poor alternatives like traditional healers, traditional um bone uh setters and traditional beta tenants. Um leaving them with more um Mobi and increasing um the mortality. Next slide, please. Um A second challenge that um we have discovered also is um timeliness of care. Um People are not able to access um timely care because they don't live near this, the facilities that can provide these be order procedures. Um Also, it's called that road networks are quite poor. So um accessing these facilities are really difficult and even where they are decent networks, transport facilities, ambulance facilities are not readily available to move them from their point of emergencies to the point um of care. And also um call center facilities, network services also make it difficult to um call for help when emergencies arise. Next slide, please. Um Another challenge is the workforce density in lower and middle income countries. We describe that there is a job of surgical personnel um in these countries as a result of um immigration for um greener pastures better and better working environment. We also discovered that um younger doctors are not um wanting to choose surgery orthetics as their core specialty. They prefer to do public health and some other um easier specialties because essentially the um pay is the same across board. And also those who have um chosen to work as surgeons um suffer from bone marrow because of the um increased um workload next slide, please. Um We also discovered that um there is lack of political will from leaders in these countries. Um They don't want to invest um in health care and because they find uh probably better alternatives abroad, so the result to health care and where they can meet their um surgical needs and they also don't have a fit in the system to solve their problems. Hence the um seek um care abroad. Next slide, this um another challenge and uh we've discovered is that um most of the surgical instruments we use and the consumer rules are not manufactured in our countries, we have to import them. Um Our also our, our equipment, spare parts, imaging uh materials are also not locally sourced. And since we have to buy these things from um high-income countries, we also grapple, grapple with rising exchange rates. And so um the the more the exchange rate, the more difficult it is um to source um foreign exchange to buy these materials. So these materials are not readily um available um for surgery. Mhm Next slide. This um so these are some of the um challenges that um we have faced and they are workable solutions that um to these challenges that we have identified and one of them is improving um insurance coverage. Um for Nigeria, we we are looking to um see how the National health insurance scheme can cover um much of the population. Let's try those in the rural areas that don't have to pay out of pocket for, um, surgical care on, on that solution is to um upgrade the facilities in rural areas. Um, from primary healthcare centers to even secondary healthcare centers where the Bell, whether procedures can, um, be performed. Um, this has actually started in some states, uh, across the country and also in West Africa. Um, these are being up. Um, we're also looking to incentivize um, surgeons to agree to walk in the rural areas. Um The right areas are not exactly attractive for surgeons um because of poor power supply poor living conditions. But then we can uh make these places conducive and attractive for surgeons to work. Um where I work the hospital where I work, we started it. We usually send um resident surgeons to um do a one month rotation in rural areas to both gain experience and also provide surgical care for the population. Um We also, we could also increase um surgical workforce by um encouraging younger doctors to choose surgery as a specialty because of um the shortage of surgical stuff that we have. Then we can also continue to engage our leaders. It's not a one off thing. We have to keep doing it because the more we do it, um the more likely that they're going to understand that um surgical care um is needed in our countries and eventually they will respond to us and they are not forgetting global interventions uh from organizations that could come in to also um assist in carrying out. Um So, um so to ease the surgical body, for example, um smart chain is um an organization that has come to Nigeria and other um low income countries to um pioneer uh free cleft lip and pilot surgeries and other organizations are also coming in from time to time and this is easing the bur um of this of surgical care in um these countries. Next slide, this um the solutions to these challenges and and unmet needs that we facing. You are middle income countries are not far fetched. And um it is obvious that Gas O is one of the bodies that are the forefront of championing these solutions with um the workshops and the um trainings um that are usually being organized as well as interactions between high um re re um training surgeons in high-income countries and also um in low and middle income countries. And thank you very much for listening. Um Have a, have a good afternoon. Ok. Thank you so much Lambert. Um really enlightening for all of us here and we'll keep the, keep the questions coming guys and we'll tackle all the questions at the end when we have all three speakers online. So next up, I'm just gonna stop presenting, I'm gonna share my next slide. So next up, I'm going to introduce to you, Doctor Fga Ko, who is our guest of international S and G representative and she's also a senior registrar uh at the Amadu University Teaching Hospital in Zaria Nigeria. So just give me sorry. OK. OK. Mhm Yeah, super. Can you hear a speaker? Am I audible? Yes, we are over to you. Good day, everyone. Um I'm actually pleased to be a speaker at this forum to just highlight some of the challenges faced with. Um So care in NM I CS and I'll be coming from an obstetric perspective. OK. Um OK. So next slide, OK. This will be the outline for this presentation. Next slide. OK. So um conditions that are actually amenable to surgical obstetric trauma and anesthesia are quite significant. However, they are a largely underestimated source of um global war of diseases because the focus initially in NM I were based on communicable diseases whereby vaccines where um vaccine coverage was improved in LM I CS, which are seen to drastic reduction in computable disease. However, no computable disease of which most of the conditions amenable to fall on that have actually been underestimated. And then um the largest one me meets for so occur in LM IC where the poor control of the world population received only um 3.5% of the surgical procedures conducted globally. Now, for us to have like a proper, so it requires a synergy between all pillars of the health care system, including infrastructural foundations like um as basic as having um the minimum standard for a structure beats standard structure for theater, for the lab work, um constant running water and electricity. Then human resources is also another important pillar to ensure. So because apart from skilled health workers, there has to be a proportionate distribution of health workers among all regions in order to actually ensure universal coverage. And then equipment is the top pillar because even if you have skilled resources, skilled human resources, you have infrastructure without equipment to work with and there will definitely not be an adequate target. Uh Next slide, please. So um um basically for obstetric care, you know, the hallmark of uh obstetric care is actually to ensure a safe model and a safe baby. And then usually the best indicator to ascertain and the quality of obstetric care is actually maternal morbidity, maternal mortality and then severe maternal morbidity. So that's why the concept of an essential obstetric care actually came about, which is actually the basic minimum that either a primary health center or other secondary facilities should have put in place now to ensure that a positive pregnancy outcome. So the essential obstetric has been better into two. We have the basic emergency obstetric and newborn care in which it's actually focused on primary health centers, which are usually where um which are usually uh centers are usually found in the most remote of places, especially in NCES. And it it ensures that administering antibiotics are include tonic drugs, anticonvulsants and there should be uh skills for manual removal of placenta, removal of routine products of conception after a miscarriage or abortion. And then there should be provision for assisted vaginal deliveries and basic urary cation. Once the facilities, in addition to all these basic emergency of surgical new One care, she should actually be able to perform a surgeries like C section, have a seed, blood transition and provision to for, to care for sick and no be treat uh newborns. Now, these are just the minimum standard that have been put in place to actually ensure that at least people in L mis, especially in the most remote and most rural places in L mis actually have the basic minimum of care not to ensure a positive pregnancy outcome. Next slide, next slide. Ok. So now focusing on barriers to obstetric care in LM I CS. Um well, according to the development goal 31 of the targets is actually to reduce global maternal mortality ratio less than 8500 live words by 2023. However, between 2020 20 the global mortality ratio has declined by 34% which is just about one third of the 6.4%. And how you in debt to actually achieve this uh SD now, most of this uh reduction improvement in maternal mortality ratio has actually been from developing countries while the stagnation even decline has actually been in the developing countries of which LM I and make a large chunk. So now the according to wh O for every maternal debt and for every life threat comp situation, it's actually a story behind and it's our duty to actually understand the lessons from that story so that we can actually avoid such outcome next like next slide. So now this is a map, a map showing um just the burden of maternal mortality ratio, as I said earlier for SZ three, it is expected that by 2030 which have less than 8500 live bird. So you're looking at this map if you can see Africa, right? I think in all these regions in Africa, there's actually no country that has uh maternal m show less than 70 per 100,000 live apart from Egypt. And then you can see countries like Nigeria like actually having more than 566 per 100,000 live birds that just to show you the actual distribution of this burden of this maternal dead burden in the world, which is actually been focused on L mis like in Africa like in Middle East. Next like, OK, so now uh generally when we are talking about barriers et care, we can actually relate it. Like I said earlier, the Hallmark is actually severe maternal Mobi and maternal debts, we can relate it um due to to the faces of maternal delay, I'm sure most of us are familiar with the three phases of the day of maternal debt. We have the first delay which is disease delay in decision to seek care for whichever problem or complication. And then the second delay is actually the delay in identifying and reaching the medical facility. The third delay is actually the delay in receipt of adequate and appropriate treatment. Now, there there are factors that actually directly or indirectly influence each of these. Like we have the sociocultural factors which directly affect decisions, even recognize and seek care for any obstetric problem. And then we have a delay um uh factors affecting accessibility of facilities, which actually has an indirect influence on decision to seek care and a influence on identifying and reaching the medical facility. And then we have the type of quality of care which also has an indirect influence on delay in decision to seek care and also a direct influence on um delay in receipt of adequate and appropriate treatment. Next slide. So now for the social economic and you know, previous slide for the social economic and cultural factors that actually affect uh obstetric care that might lead to maternal morbidity or mortality, we have the high poverty index. Doctor Lambert has already highlighted us about the burden of um how many percentage of people actually live below the poverty index and then it has increasing constantly. So now when we with with very poor people, you know, even if you recognize that you have a problem and then you are not thinking about how am I going to afford this care? It may actually delay you in actually deciding to actually spend seek for help. Now, there's poor health seeking behaviors, which is actually a di correlation to either our social cultural um sociocultural factors, especially in this environment. Now, there are some people that actually don't believe in going to hospital to seek for help, even if they have the money. There are people that actually need permission from their spouses to go and seek for help. There are people that actually don't believe in actually giving birth in the hospital and then they do home deliveries. It's whether in hygienic or unhygienic areas. So this poor health skin behavior actually contribute significantly to this um maternal morbidity. Now on healthy cultural practice, like I said earlier, also a decision not to go to the hospital decision to keep it at home decision. Um practice that you have to take permission from your spouses. The lack of health insurance is actually a very big burden because we all know that medical care is, is actually expensive and just very few people can actually pay out of pocket. Now, when you have about less than 10% of the whole population, actually accessing health insurance, it is going to cause a big problem because even if you have a problem, you know that if you go to the hospital, you can't afford it. There is no health insurance, you might actually think twice before going to the hospital and high levels of unempowered women, like I said, the whole marker of urgent care is just to give us, is to ensure a safe mother and a safe baby. Right? So now when you have unempowered women, women that really don't have many women that need to take permission from spouses or from families to seek for help. Even when they have complications. It's like, um it's actually a very big problem and then it actually the day in either seeking help or even the day in getting into the facility. Now, um va various accessing medical facilities, we have four road network actually for people that are actually in the most remote oral areas in these countries. Right. There are some people that um they are in um wherever they are, there's actually no road network even need to um the closest hospital next to them because that cost cost, there can be several et away and there's actually no road network to actually leave there. So actually have to enter like maybe to actually get to a landed hospital. So it's actually a very big problem in some areas. Now, even if there's a proper road network, transportation is actually a problem because how do you get to see 24 hours transportation in some of these places? Right. And then if you have a problem in the night and then you are not mobile and then there is no uh public transportation to take you to the nearest hospital. So it actually post delay and actually reaching the medical facility. Now, in security, we've been having uh increasing rates of insecurity in our environment and n mis instability here and there. Now, when I was growing up, like uh even in the middle of the night, it's everywhere where you'll see people walking out in the middle of the night because everywhere will sleep. But now of recent times, once it's like nine pm, you see everybody in their arms, nobody really wants to go out at night because of care, fear of um so many things kidnaps I robbers. So now if you have a problem in the middle of the night, even if you decide to go to the hospital, right, you might actually think twice, I might say to actually leave in the middle of the night, which will actually indirectly was at the leg and actually reach that facility. Now, I have this proportionate distribution of health facilities. It's um it has been uh recommended that um according to the wh o that for every 500,000 people, there should be about four facilities that can cater to a group of 500,000 people. But now there are some areas that you get to see more than 500,000 people in, in particular local government. I know, you know, have at the same facility that to them. So that means that and then you might not see some urban areas that have like uh congestion of different cars of health facilities be tertiary, secondary primary health facilities. So there's actually this proportionate distribution of health facilities in some of these areas and then poor coverage which is directly linked to this proportionate tion of health facilities. When you have poor coverage of uh health facilities across the uh across the region across the country and it will actually lead to barriers in accessing medical facilities. Next light, next slide. Ok. So for the quality of care, right, um I'll just portray the point that Doctor Lambert made. Well, there's lack of uh adequate number of well-trained health professionals because of the high turnover immigration here and there, even the uh high turnover among skilled workers even within the country, right? There are some, there are, there are states that um have uh that most health workers would like to work there and then there are some states that have a actually have a high turnover of health workers. So um you might have a well-trained professionals, but then the numbers might actually be very little. So it's the quality of care obviously cannot be compared to areas that actually have a large number of well-trained skilled professionals, discretionary distribution of skilled workers actually pose a problem because most of the skilled workers, we have actually concentrated in the urban areas. Then the rural remote areas where you actually have these problems where these these problems are actually predominant. You might get just one skilled health worker in uh covering a large local government of a large region which is definitely not enough. Now, health financing challenges. Now the health finance is not just for the patient as as to the health insurance also health financing. It's a big problem because when you look at the budget, the health budget of some of these elements and compared to the health budget of some of the developed countries, you can actually see a very marked depend. Now there is no health system that can try without adequate health budget to finance the hospitals and all be it coming from the government, be it coming from the private sectors. So poor health financing to the hospitals actually pose a a problem with this. And then cash resources like doctor mentioned earlier about the equipment to use and it can it was surprised that even in some of the tertiary hospitals, some of the basic equipments that are like routine in some developing countries are actually like very scars even in tertiary hospitals in most LM I CS. Next slide. So I'll just talk about some of my personal experiences. Um Last two weeks, I was in Jigawa State and then um let me talk about infrastructure again, right? So I was in a hospital that is supposed to be a tertiary hospital and then we had night problems for the two weeks that I was there. So we had emergency cases and then you know that you need to actually operate on the. So and then you now have problems like there's no constant life supply and then you need to look for backup and then the backup that is not already available. So now there's actually a skilled personal, they have to do whatever needs to be done for the pressure. But then there's actually an infrastructural problem, right. So now my experiences in K I've worked in so many centers in tertiary secondary hospitals and in each of these places actually have peculiarities while some secondary hospital actually have problems with adequate manpower, adequate skilled personnel, because most of them are concentrated in tertiary hospitals. Some of time to actually they have this killed manpower. Sometimes even the equipment used to work with is actually a problem. So it's just um to portray the point that there there needs to be a signage, there needs to be a harmony in the infrastructure, the human resources and in the equipment match and show adequate obstetric care. Next. So um what are the strategies that have been put in place, actually ensure and um adequate obstetric care? So like I said earlier, the early focus was on infectious diseases. However, just like doctor I said, the Lancet Commission on Global Surgery introduced a framework of uh the National Surgical Et Anesthesia Planning. And then this framework actually offered a systematic approach to strengthen health system. Now, initially, most of this um approach, strength health c attention in we have from primarily volunteer work from like developed countries or from non nongovernmental organizations. But then it's actually not sustainable. So that's why this framework actually came into place now to ensure there is a national framework that will ensure uh strengthening of health systems in LM I CS. Now, this framework actually covered um six domains. However, this framework is still faced with challenges because the the national framework was proposed and then each country is actually supposed to modify it based on their own identified needs. But then we still have challenges of developing framework of implementing the framework. And then even after implementation com com commitment to the framework itself and then there's also problems of indicator collections also financing the framework and then regionalization amongst other problems identified next slide. OK. So now these are the six these are the six domains for the framework, infrastructure, workforce service delivery, financing, information management, and governance. So each country is actually supposed to work towards developing their own framework, identify their own challenges and putting things in place. So the focus on on one part of the framework for a country might not be where another country might actually focus on depending on their own identified deficit. But however, it's important that all of these domains are put into place, are being considered not to ensure um global and surgical or surgical anesthesia. OK. OK. Next slide. So this is a map showing some of the countries few countries that have actually developed and implemented their framework like uh Ethiopia, Nigeria, Senegal, Tanzania Zambia, one that they actually um personalized the framework and actually have implemented their framework. However, we still have challenges of commitment to this framework while countries like Pakistan are still in the process of developing their own framework. So next slide. So now um apart from that, like I said earlier, the idea of that framework was just to move from a place of voluntary or mission based. Um um so a to like a a national framework for so a however, we cannot, you know, the rule that key players and Ns have played, I have played in actually improving et care in. We have like the Clinton health access in my part, find have government organization like UNICEF and F pa wh O which have actually um actually championed campaigns that many targeted and that is targeted to improve human resources and also to ensure adequate equipment also in these uh regions. And then these NGO S and organizations do not actually work in them. They actually collaborate with ministries of health, with healthcare agencies and other governmental organizations not to ensure that um they actually put things in place. Now, um each country has their own peculiarity. So depending on the identified challenge from the country, these these players actually come into play and collaborate with the ministries to not actually tackle their challenges. So personally, like in Nigeria, I know that some of these are actually championed uh programs like training on essential tri care, training on essential newborn care. See abortion, immediate postpartum contraception, and even based distribution of family planning. Now another strategy one that I actually love personally because in as much as you want to like help people, you actually have to ensure that every person can actually afford medical care. That's a home coverage, right? So now the National um Health Insurance Act of the uh National Nigeria National Health Insurance Act that was just signed actually has in one of its domain actually has a rule. It actually considered indigent people vary. People like under five unemployed people, very elderly people, very poor people. So that in as much as they cannot afford to, to get an insurance scheme, the federal government is actually supposed to like um sponsor, like paying something into their own insurance. You will not be able to cater for the needs of these indigent people. And then the beautiful part about this National Health Insurance Act now that has been signed, is that for defaulters also, be it the practitioners or be it hospital actually penalties for defaulters just in order to ensure that this National Health Insurance Act actually, uh actually, um it's a actually successful. So uh hopefully, it has not yet said it has not yet been implemented, but hopefully, in Nigeria, it should be implemented. And then I think um we should be able to see at least an improvement in a, in how people access obstruction care and medical care generally. So, um, generally, um I have just highlighted some of the challenges and barriers that we've identified um towards the assessment of surgery care in LM I CS. And then it's important that causes like this. It's important that uh we are aware of these challenges. It's important that we are aware of the strategies that have been put in place. And it's important that we actually bring some on solutions naturally to help. And these LM I actually catch up with developing countries and ensuring and general global obstetric care. So, thank you. Next slide. These are my references. Thank you. Thank you so much. Thank you so much so far. Yes. So we have uh three speakers for, for this second. And unfortunately, our first speaker, uh Doctor Maria is truly struggling to log in. So we might just move on to uh question and answer session uh uh for our two speakers. So for a favor and uh I stop that you can see us for favor and uh l if you can just pop your came and the micro phone on again, maybe we can see um well, all our audience joining us from all over the world, uh We're really excited to hear from you. Please let us know if you have any questions? Uh ok. I might just take if you guys don't mind. Um, a very thorough. Um Thank you very much everyone. Um So my first question is a bit of an imaginary question. So if time, um what would be your first priority? You as yourself as doctor, er, Doctor Lambert, what would be your first priority you wanted to come all the effort into? Did you get that question? Ok. Um Yes, II had I had the last couple of the question but the first part I didn't really get. Can you come in in time? Power, money, resources weren't a problem. Let's say we have an imaginary funder that's gonna come. Um and say because you're in the front line, I will trust you and put all my efforts into one thing. So where would, where would you want to meet? Um where would you want to sort that? A? Ok. Um Thank you very much John. Um I think human, human resources is um human resources a real big priority because no matter how much money you have, no matter how much equipment you have, no matter how much instruments you have, if you don't have the manpower to get things done, all those resources, all those equipments will just be a waste. One of the major um problems we are facing now, like I said, is workforce. Um currently um we, we are, when I started residency, we are about 20 registrars in the department of surgery. Currently, there are just four registrants, the department of surgery. So people are migrating in their numbers and it's not just here, it's a cross board. So human resource is very, very important. Thank you. Ok. Um, so thank you John for the question. Um First man, I think, I don't think there's a right or wrong answer for your question because it kind of depends on where you're coming from. Like I said, each region actually have their own peculiarities. Right. Yeah, we, I actually work in the same center and even in my own department, we actually have that challenge. We have more of senior residents now compared to junior residents, right? Because they have not been like employment for a couple of years to actually augment um junior residents that have moved to senior resident. But then there are some regions that you cannot be talking about workforce when you don't actually even have like an infrastructure. Like I said, there are some regions I have to travel from. So I think the aim if you, if you actually have a lot of money to come on in you, I will not just come and tell you that, ok, this is where you start from, that actually have to do a grassroot analysis because the problem that you might have in right is different for employer that you might have in maybe government because you don't even have hospitals or you might not have adequate hospitals even so, even if you do human resources. So where would those people be? So, I think differently, just with your own challenges and that is why that framework was actually do that are supposed to personalize it, find out your own peculiarity at that point in time and then know where to channel your energy you start from. That's great. Every, every place has their own unique situation, even within a big, big country that I think it resonates with all of us in all different places. Um There are a couple of questions here. I'm not sure I'm getting the right hand on the, but I will try. Um First one, I just wanna go with your last one, that amazing presentation. However, the whole healthcare structure in *** needs needs to be changed as well as active engagement with government for doctor retention and utility insurance. I think that's what do you think about that? Um That comment. Um They say there, there needs to be active engagement with the government for doctor retention and utility of insurance incentive or your thoughts about that? That um that idea. Uh Yes. Um Thank you very much. You are absolutely right. Um The these structures, when the foundation of this structure has a problem, the entire structure is bound to be 40 or we eventually collapse. Um So we have to really dig deep into the roots of this matter and begin to take health care seriously. Um the truth of the matter is that our leaders have not really taken healthcare seriously. Um That's why you have uh them traveling to seek healthcare abroad and things, you, they find that these things are the good to look for outside can be done here. And um like I said, the engagement will not just happen once we are doing it, we are working on it as resident doctors, the medical associations, we keep going to them, we keep engaging them using both the cars and the stick approach. And at some point they listen to us, they make, they do some interventions some point they don't, but then the party is definitely not gonna one in the day and we'll continue with the engagement on the issue of insurance. Um I think we've come a long way actually as 10 years ago or 15 years ago, almost nobody was insured, health wise, everybody was paying out of pocket. But now um once you're a civil servant, you are entitled to health insurance, at least to a certain extent. And then even for those who are not civil servants, those who are not government workers, there is a particular arrangement for them where they can pay um little contributions and then they are also captured um in the health insurance scheme and education also plays a role because some people don't really know about the availability of these insurance packages. So they are just there believing that um nothing is there for them. So it also um fall on us as p to reach out to these people and tell them, ok, there are package like available for you. Um You can PTT as a community into a particular fund and then when there's a health crisis, there's a s surgical crisis or obstetric problem um from that fund, it can be used to take care of you and you don't need to pay out of pocket. Thank you so much Lambert for highlighting um uh the positive changes that have already been happening and we hope will continue to happen and improve. Um I just had one quick question for favor and II picked up on your presentation about um sort of cultural beliefs and uh sort of uh certain cultural practices that might not be healthy that might prevent women from seeking um health care, uh you know, in, in labor or, or in Antenatal period. I just wonder if you're aware of any say, innovative ways in which maybe the community has, uh maybe the secondary care components have sort of reached out into the community because that's where, you know, a, a lot of things that affect outcomes in secondary care actually start from the community. So, are you aware of any innovative ways that maybe we can or maybe that is already going on and sort of reaching out to the community to kind of change or challenge these um cultural beliefs? OK. Um Thank you Jane for that uh question. Yeah. Um So I think I totally missed it in my presentation. So, um, you know, like I said, some people actually don't believe in going to the hospital. Some people actually have to take permission to go to the hospital. So one of the ways in which the government has actually tried to, that is actually to drink um traditional bread attender because there are people that are not skilled, they are not well trained, they actually go to this that in their communities actually take the deliveries and then do all sorts. And then by the time the patient is actually coming to the hospital, they have like severe complications, right? So one of the ways they did that was actually to train traditional attender, they have been campaign driving workshop to train them just for them to actually have the basic minimum skills to actually be able to conduct a not delivery and then to actually be able to detect any complications that they will know that. Ok. Now, right now, there's actually a problem. So because you need to identify a problem before you can even know what to do. So they've been trained in order to identify the problem and then Apple pre referral systems, right? And then, and that's where one of the, I think that's one of the things that brought up about the popularity of mi in our environment that everybody even in the and the use of environment because like that was one of the quickest orto that um these attendance could actually use to prevent post he, which is a major um killer of um pregnant in the environment. Right. So they've been trained on that, which had the very least you taking a delivery because most of these women that actually deliver in those remote areas are actually, those are very high priority. So they are prone to it, they are prone to postpartum hemorrhage. So they've been trained to actually admin is and then even when they are inside the right and now that, ok, there's still an issue or they still see signs do not know how to refer them. And they've actually, and they've actually been linked to like hospitals close by to them. Now, another way this, I was actually involved in this training. That was a couple of years back in which we actually trained a community based because there's some uh uh some in some settings, there, there's aversion use of contraception, right? So, but you know, when you're coming as a health worker, you're just trying to like preach the gospel of contraception in order to space family and then prevent conditions that comes with too frequent childbirths, right? They might not actually listen to you. But then when you're not hearing this from like people in their community, you know, they might tend to get a listening here. So a couple of years back, I think it was championed by Clinton Health Access Initiative, community distributors for country were actually trained, at least for the basic like barrier methods of contraception and all and even the natural methods of contraception so that it will go door to door, like talk to these women enlighten them. Tell them about the importance of contraception that it's not like I'm telling you not to give birth, but at this to your Children, right? So these are some of the ways that they try to like reach out to reach out to women in those remote areas. Thank you. We have just one more question. Should we just do one more? Yeah, I'm trying to suss out questions but you know, feel free to jump in if I'm interpreting it wrong. Um So which we have met in Uganda is a came. So she was talking about, what about, I suppose in the place of an unmet need discussion. What about the place of law responsibility when there's a death? So I think it's talking about medical negligence, the infrastructure of malpractice and error and how and its effect on your met need. So I suppose um whether it has a place um first and if so what, what we gonna do about it and how often we make it um to suit your Met need and that's what I can try about out. So I suppose that's a question to the speakers. So, um what are your thoughts about that. All right. Um Thank you, Leon now um for, for negligence and malpractice. Um Yes, it happens. We're not going to deny that it doesn't happen, it happens. Um But for, for where we are currently in Nigeria, we have the Medical and Dental Council um that has recently launched um a campaign against them negligence and errors. Um In the past, um patients didn't know their rights. Patients didn't understand that they had the right to certain things. They had the right to be um treated, they had the right to refuse treatments. They had the rights to um whoever they wanted um to treat them. Um But then with the passage of the um Patients Rights Acts um by the National Assembly, um patients have begun, begun to understand that yes, um they have the right to uh appropriate and timely um treatment. So, in the event of event of negligence, um there are bodies that uh this can be reported to and addressed and eventually the case will be taken to the Medical and Dental Council of Nigeria where the case will be reviewed and um the offending practitioner um adequately um reprimanded and we've had a lot of cases like that. Um licenses withdrawn, um license is suspended. And um the like, so yes, um we've worked on that tremendously and um negligence has drastically reduced. I hope that answers the question. And if I may just add some things about the negative, I think um you know, for you to even know that there's some as a patient coming from a patient perspective, for a patient to actually even know that um something went wrong, you have to be self-aware, right? So like when you have patients that are ignorant, when you have patients that like have low education, like it's actually going to be difficult for that patient to even know that I should, I actually deserve a better care competitive. So I think that's one of the things that actually brings about the like the low like most people just in this environment actually let talk from that perspective. So you have a a woman that actually or a family that actually suffered maternal deaths, right? And they just accept like coaching his job, the will of God, it just mean to happen right now in most cases, the problem is not actually from the hospital or medical negligence, right? But there are some instances that he has the hospital or the health workers should have done better, especially in setting in this hospital quote, because there are so many buildings that are hospitals that are actually in the hospitals, right? So actually in those settings. So they just accept it like that. But I think with continuous education, the first thing that the patient need to know they are right? They need to know that it's there better, right? And then we as health workers actually need to do better. And I think with that it's actually going to be quite difficult actually. Um I really don't know how to put it right? Or because in as much as you want to help a patient yet, you know that this patient deserves better, right? Or you are handicapped because probably I need this patient to access ICU K. And then at this point in time, the center that I'm in, there's no ICU K. So when you call it negligence kind of, but that it's not on me because I can only do, I can only provide care to the extent that I can provide. So how do you actually defend this? So I really don't, there's like a disparity and then there are like blurry lines, you know that in which you can actually see outrightly, this is neglige or this is no negligent. But most of the, most of the cases I've actually seen about medical legal issues actually in like well-established hospitals. I know that it is because yes, we have well established hospitals that almost have all standard facilities or actually private facilities. So those are the places that I know that. And as you see like a couple of cases and then obviously patients that patronize those cases actually have the funds actually well done and are actually exposed to the new di right? And I know this is something they actually voice that and actually seek for help for justice. Thank you. Thank you so much and thank you to Lamber as well. Thank you to the both of you for giving us your time today and for highlighting your unmet needs and hopefully, uh you know, throughout the rest of the course, uh we'll, we'll, we'll come up with more ideas, strategies to, to, to deal with these problems and move forward in a real positive manner. Uh I'm going to move straight on to module three, which is about technology designed for low resource settings. And we're very, very pleased to have with us. Uh Professor Pete Comma and June Te, who's joining us from Kenya, I believe uh to talk to us uh about um uh this topic. So without further ado, I'm going to introduce Pro Pete Comma first who is a professor of Health Engineering, leading the healthcare Meats Research Group at the University of Leeds. His research concerns the development of sensing and automation technology with application to address global health challenges with a particular focus on underrepresented groups and conditions. So, um I'm going to uh hand over to Pete first and put your slides on right now. Oh, perfect. Thank you very much Jean. Excellent. Can I advance them myself? G or do I need to ask you? You have to ask? No problem, no problem at all. Thank you for this. Well, thank you very much for the invitation to speak to you today and I'm really pleased to be joined by June Um Hopefully between the two of us, we'll get some nice kind of complimentary messages out to everyone. So, yeah, thank you very much for the invitation. Um Just as a brief background, my background's in mechatronics, a subject which looks at the integration of electronic computing and mechanical engineering. And during my P HDI was involved in applying that to healthcare. So first of all, looking at rehabilitation and then I was interested in surgery and more and more, I've kind of grown into the idea of applying these skills to look at the inequity and provision of surgery and surgical technology across the world. So that's the kind of the angle that I'm coming from my presentation today. I will next slide please jean, I will share with you three lessons I've learned and just draw on a couple well, three case studies, hopefully to highlight the points that I'd like to make. And then I'd be very interested to kind of hear from you about any questions. So here I've got this idealized representation of innovation that can be applied particularly in the healthcare domain. So you start off with a particular challenge and you move through these two phases where you develop ideas, you refine them according to kind of user requirements. So this might be your clinical or health care team. Uh You clearly define the problem, you test it and then suddenly you find yourself with a solution. So we often see diagrams like this, which kind of represent and portray this, this innovation process that we'd like to go through. Um I guess the message that I'm gonna sort of talk to you today is that that process is rarely as straightforward as we see here. Um And there's kind of lots of ups and downs. Um And it's important to understand where the challenges might layer next slide, please. So, um the first case study is actually some a project where I started off in surgery and surgical technologies and this involves the development of a device we call the IAP the intraabdominal platform. So, the concept came from a surgeon that we work with. And the idea was to um provide a structure that could be used in keyhole surgery, in particular laparoscopic surgery where you inflate the abdominal cavity with gas and then you use instruments that are inserted through incisions in the abdominal wall to perform surgical operations, particularly on things like the liver or the kidneys which lie in the abdominal cavity. So the idea was we could provide a structure with which the surgeons could use to retract tissues to. So that enables them to kind of expose underlying tissues and to conduct their operations. The idea was that it would help um reduce the dependence on numbers of assistants who would typically kind of have to do this manually um and give more flexibility to the to the lead surgeon. So we thought it was a wonderful idea. And we set off on our, on our way to develop um a a solution and engineer something. Uh next slide, please. And we assembled a good team. Um and we went through a whole range of prototypes. So we understood kind of the size, we kind of looked at things like the anatomy and the typical size of the abdominal cavity, the kind of loads we might be having to lift. So how heavy is a liver, how we're going to retract tissues, how we're going to hook them and pin them on this device? And we went through lots of different iterations that you can see there, the design slowly changing over time. And we went all the way from a system that was designed to be reusable to something that was single use and we got various bits of funding along the way. So we were very pleased with how the project was progressing. We had some good investment and then we started to have sort of commercial interest in the project, which ultimately is what we'd like as engineers. We'd like to design things that can go into the real world and actually have an impact. Um So next slide please, we were asked to kind of illustrate the system and how it would be used in real life. So we at leeds have access to a really good anatomy department and we could do cadaveric simulation. So using cadavers in particular ones that have what we call like a soft fix. You can simulate a, a surgical procedure. So that's what you can see here. Some images and stills from videos where we use the device to retract tissues. So we were increasingly pleased with the way it was panning out. We thought. Right. We have a system, we've designed it, we think we have some IP here, some intellectual property and we have commercial interest. So it all seems to be going very nicely. And then next slide, please, we produced this final system. Um and you can see here, I've kind of represented um what they sometimes call kind of the the hype cycle. So as you go through this period of innovation, you come up with concepts, you rapidly develop kind of prototypes, you test them. And then we found ourselves with sort of view of feedback redesign. So we went through this iterative process, produced a final design and then at the point where we thought it was all done, actually, the companies that were involved asked lots more feedback and they asked in particular from a range of surgeons. So we had our key surgeon that had been informing the design. But as we got a broader set of opinions coming through, we found that there was a real diversity in surgical opinion. So we designed a system that very well met the needs of perhaps one or two surgeons. But actually, if you looked at, if you took a step back and took that more holistic view. We found that the surgeons in this area tended to do things quite differently in style and a lot of them didn't really see the same need for a device like this as perhaps our lead champion surgeon, our advocate. So we were left in an awkward position where we designed a system that we were very pleased with it worked. But actually, we should have taken this step right at the start to get this broad kind of consensus, a greater understanding of what the clinical need was. We thought we understood it and we had a good viewpoint, but that was limited and it was very focused on one of to individuals. So my lesson here is that it is very important not to design a solution that doesn't have a real clinical need. And it's an easy thing to do for us as engineers. If we think we have a particular understanding of a clinical viewpoint, we're not trained as medics, we're not trained as surgeons. So we may think we understand it and go off and do our thing. Um But is it very important for us to kind of keep working closely with clinical experts to guide the process and not to rely on just one or two individuals, but to try and get a broad view of the clinical case. So that's my first lesson to make sure that you work with a broad range of people and you really understand the clinical need. Ok. Um The sec er, sorry, the next slide um brings up the second case study. Um So the, the last one you'll notice is essentially a failure. Um I guess we have to accept our failures and, and, you know, learn from them and that's absolutely what I did in that project. It was a really good learning opportunity despite the fact that it didn't come to an outcome that we might have anticipated at the start. This is a slightly different narrative. Um a situation that we nobody in the world wanted to find themselves in. But with the advent of COVID, um we were faced with shortages of respiratory equipment all around the world. So in the UK, there was a real need for oxygen efficient respiratory support devices. We were running out of oxygen in hospitals, in particular, when they described it as those waves, the capacity just wasn't within our hospital infrastructure to supply the numbers of patients that we anticipated. So we worked with the teaching hospitals locally at Leeds and they were particularly interested in looking at um provisions for, for patients who weren't critically ill but could become. So if they didn't receive some um some support earlier on. And in particular, they were looking at a form of um respiratory support called CPAP. So continuous positive airway pressure. So systems which can not act like a ventilator but just provide enough positive pressure to open the lungs and then supplementary oxygen is introduced to help that person's health. Next slide, please. So we were interested in developing a system um working closely with the teaching hospitals during the COVID pandemic. Um they had identified that there was this um a sleep apnea machine which could produce, could be used as a CPAP device and it was fairly low cost. So we were looking to see what we could do, what we could engineer. And you can see a mapping there where we've kind of worked with the healthcare professionals at our teaching hospitals to understand the range of different solutions that are out there. We've mapped how efficient they are in terms of their use of oxygen and how complex they are. And we saw that there was a real gap there. So the sleep apnea machines that you can see one's called the N the NP three plus um are relatively um oxygen efficient, but they are fairly complex. They have a lot of extraneous functionality that they don't really need. So if we needed to produce them quickly or at volume, they weren't particularly useful. So what we were trying to address is that bottom quadrant there that you can see the resource light section. So again, this is a real case in point that we had to work very, very closely with a range of disciplines. So healthcare professionals, but also a range of technical staff from our teaching hospitals. And we rapidly kind of came to the conclusion that what we could do is develop a system specifically to deliver CPAP and to remove a lot of the unnecessary functionality that was in something like the NIPI three, the CPAP sleep apnea machines. And in doing so, we could make this efficient and also low cost. So we could hopefully uh react quickly and deliver these system was where they needed to be. Uh next slide, please. And we were really pleased, we kind of produced this system. Um We were, I guess just behind the curve in the UK because it turns out that the anticipated kind of peak demand never quite hit the peak that we anticipated. So there wasn't a need for these systems in the UK. But we demonstrated in safety tests and working with our clinical partners that these systems could produce equivalent care, uh an equivalent performance to CPAP machines like the NPI that I showed you in the previous slide, but at a fraction of the cost and they were very, very easy to use. Um So this could have been the end of the story, but actually, we felt that there was really kind of virtue here and we didn't want to just look inwardly. We like to kind of look globally and think, well, how else can this be of use? We can't be the only people who have kind of the need for this kind of system. Um And through some of the links we have at the teaching hospitals, we were introduced to a fantastic group of researchers and clinicians at Mengo Hospital in Uganda. Next slide please. And they happened to be interested in looking at respiratory support and testing new systems. And we had a long discussion with them about what we could do and how we could collaborate together. And the interesting thing here is that we were able to run a safety study at Mengo Hospital. So Mengo worked with us and they ran a study with healthy volunteers at Mengo Hospital and they were interested to see how this technology might work in their context. Obviously, the context of the environment is very different from the UK. The set of resources they have are different even things like the physical environment. So they reported lots of ingress of fine dust that we wouldn't really get in the UK. It's far too dump here. Um But they would often get kind of dust, things that would be pulled into the fans. So we work with them and their biomedical engineers as well as their clinical teams to understand how this technology might be of use in their context. And then the COVID wave hit the Ugandan sort of nation and it went across and we were in this position where actually the team at MO had a range of these CPA devices that we call LA and they were forced to use them in emergency use cases with real patients. So it was a really strange position to be in. But the wonderful thing here is that their biomedical engineering team um innovated themselves and used these systems. You can see some of them there. So Rachel was one of the lead engineers or biomedical engineers who really helped to kind of innovate, took the unit system that we had the leve system and hooked it up in such a way with, with their infrastructure, they could actually support and care for people with COVID and they, they did so successfully throughout their kind of their peak wave until things stabilized again. And this was something that we could never have foreseen. So my message here is that firstly, that understanding the local clinical needs are very important. There's no way that we could have had any idea about those local clinical needs unless we'd work with Mengo. And they were the experts in their particular area in their particular context. So they were able to take a piece of technology and use it in a way that we hadn't anticipated um because they were flexible and they could react to local conditions and their local kind of challenges. So it shows you that sometimes you have to be kind of, you have to show ingenuity, but having that understanding of the local environment is absolutely crucial in doing so. So that's why we need to work not just across disciplines, but across national borders as well. Because as an engineer from the UK, there's no way I could appreciate the kind of demands and the challenges that they were facing in Uganda. So, working across those borders is absolutely fundamental. OK. Um Next slide please. And my last case study. So this looks at a system we've been developing for gas insufflation, less laparoscopic surgery, which is a bit of a mouthful. So gills is the shortening there. And basically, uh gills is a technique that's used to allow the use of laparoscopic surgery. So again, this idea of using keyhole surgery techniques in the abdominal cavity. So where you lift the abdominal abdominal wall up to expose the underlying organs, um and this kind of surgery has a lot of benefits or brings a lot of benefits. Um in general for patients, in contrast to open surgery, which is the alternative, you remove the need for this large incision that would go all the way across the abdominal wall. And a large incision like that means that you kind of, your recovery time is quite long because you've got to wait for this large incision to heal. You risk hernia, you risk infections as well. So using a laparoscopic technique with just small incisions, means that the patient can recover much more quickly. You reduce the risk of them having an infection and you enable them to get back out of the hospital and into their kind of daily life much more quickly. So that's very relevant for low resource settings, particularly when people need to get home. Maybe they have caring responsibilities for their family, maybe they're earning money and they need to support their family. So they don't want to be laid up in a hospital for a long time. It can also reduce the expense associated with having to stay in hospital for a long time. So there's a number of advantages to the laparoscopic technique in general. Unfortunately, it's quite difficult in terms of the level of resources it requires to deliver in low resource settings. So one of the things it uses is carbon dioxide gas to lift the abdominal cavity. Now, that can be difficult to um to either obtain or to ensure that you have a regular supply of that in these low resource settings. It also demands the need for general anesthesia and anesthetist team to administer that. Again, these are difficult to obtain in some low resource settings or rural areas which are remote from say big hospital centers. So the Gasless approach innovates by um changing a couple of those scenarios. Instead of using gas to lift the abdominal wall, we use a small, um I suppose it's like a ring that's inserted through the umbilicus and that mechanically lifts the abdominal wall. So you can imagine it's sort of a ring that's inserted through, it's like a spiral through a small incision in the umbilicus and then it mechanically lifts the abdominal wall. So because it mechanically lifts it, we don't need the gas. So there's no resource requirement for gas. And because of this, it also enables you to use a spinal block rather than general anesthesia. So you don't need the, you don't have the cost and the complexity of the general anesthesia. You have the relatively far more simple spinal blocker, which can be administered by a lead surgeon. So as a whole, it's a technique which lends itself to low resource or rural environments, very, very well. So our involvement came uh next slide, please. In that the equipment used to perform this surgery, we need a lift device. So essentially um a bit like a a retractor so it can hold this um this disc, this coil that's inserted through the umbilicus, er and then it can be anchored onto the surgical bed and then used to physically lift the abdominal wall. The challenge was that um the existing equipment used to deliver that had a number of limitations. It evolved over time so it could do its job, but it was very heavy. It was difficult to clean and sterilize to modern standards and it was quite complex to keep it, it was very vulnerable in case of any damage it was difficult to maintain. So we stepped in here working with a team of product designers, engineers, surgeons from the UK and from Northeast India, identifying the need for a kind of a modern fit for purpose piece of equipment that met modern standards and we went away and we went to engineer a new device for gasless surgery. Um, and so the first part you can see here is that we took a long time, given the lessons I've explained before to really get a deep understanding of the need and the context. Um, so really understanding the process of gasless surgery, the context in which it's used. So what kind of hospital environments would this be deployed in? And what were the needs of the surgeons and the patients er in these type of scenarios? Next slide, please? So that took quite a long time, but it was really, really valuable and what we gained from that was a close group of surgeons and not just one surgeon as I've explained before, but actually a team of surgeons who we work with and we went through this innovation process, we often sort of say it's quite an iterative process. So um formally, we might call this participatory design, but basically, we worked closely together with those expert surgeons, not just at the start, but actually all the way through that process. So we produced a series of prototypes which got increasingly more complex, increasingly more realistic until we got to the point where as you can see in the top right, we produced a system that could be used in Cadaveric studies and we did that in India. So we rapidly went through this process. We used a process called frugal innovation. So we tried to keep the system as simple as possible, removing this sort of complexity that might kind of make it more complex, sorry, more expensive or more challenging to design or to commercialize. We kept things simple as they could be once we had that understanding. Um but the participatory design aspect meant that those surgeons kept us on track when we tried to make things too simple or missed this of the right functionality. They brought us back on track and that was a really important part of the process. Next slide, please, you can see there that we went through a series of iterations, um five main kind of loops, five main iterations until we got to the point where we had a really nice candidate system. And at that point, we had to work with another set of partners. So we've had sort of designers and engineers, we've had clinicians and surgeons and healthcare practitioners. And now it's really important to work with industry experts because we felt we had a system that could be commercialized. So we work with a manufacturing partner called XL O based in India. They make orthopedics orthopedic equipment and they have lots of expertise in this sort of domain in terms of commercializing equipment. So we worked really closely with them to get from the prototype that we had to a commercial version which had regulatory support next slide please. And that enabled us to produce a system in a commercial way, which could be used by surgeons. So we could only produce a single prototype somewhere like the University of Leeds. And we couldn't produce that in a way that would be possible for surgeons to use. We wouldn't be able to get the regulatory approval. A commercial company has all the right standards and can go through the regulatory process and is able to do that. So it's that bridge that's really important in making our work more accessible and lots of expertise fed into that process. So there was clinical and surgical know how as well as the engineering kind of testing that goes into that. So all of those aspects kind of combined and we tested this and then the surgeons went and you can see a number of snapshots here of them using it in rural parts of India, in the northeast of India. And from that point, I'm just conscious of time. Next slide, please, we've been working with that same team to translate the work and translate the use of the system from parts of India to Sub Saharan Africa. And through some of our network through our contacts, we've heard increasingly that Sub Saharan Africa, in particular Uganda and Kenya, there was real opportunity for this kind of surgical approach and a need for this kind of technology to support advances in the provision of surgery. In actual fact, the map that you can see there is color coded is shaded according to the um provision of surgery around the world. So lighter pink is higher levels of provision, darker areas of darker reds are where there is less provision or less access to surgery. So you can see it's really kind of fundamental and important to work in these areas. Next slide please. So the nice message here is that we then have been working with those same surgeons are kind of clinical champions if you like. And they've run workshops in different parts of the world in Kenya. And you can see shots here from Uganda in Kali. So it's in the south west of Uganda. They've been running workshops to showcase the technology and the approach of gasless surgery um to people from different hospitals and to kind of highlight how innovation can then be translated to these different regions. Next slide, please. So I think the important message here is that it's really important to work together. And the virtues of doing that are that you build a team which enables you to kind of go through this long journey. And there's lots of kind of challenges along the way, but you need these different skill sets and those same people that have helped us understand the problem. Initially, you can see in the top left, there's Dr Biju who practices in Northeast India. Um He has now gone on to be an advocate for training in gasless surgery and helped people from different parts of the world to gain those skills and to gain the benefits of that innovation. So, working with those communities, you actually build skills and expertise that translate as well as the actual technical operators itself. So I can't, I can't emphasize enough the importance of that kind of collegiate collaborative working together. Um And I think that's probably just brings me to the last slide um a series of kind of thoughts there just in conclusion, but those three lessons to kind of underline that we need to work together, that initiatives like this. Actually, the fact that you're here listening to this is fantastic because we need to work across disciplines as teams and we need to work internationally as well. So not just within one country, but we want to see innovation across different international borders because that's the only way we can kind of really fully understand the challenges of the healthcare challenges and address them in ways which are appropriate to the local context. I think it also empowers people as you've seen there, people working in healthcare can and should get involved in innovation because their knowledge is absolutely fundamental to doing so. Uh So I won't er go on too long. Um Just to say many, many thanks and I look forward to your questions. Thank you so much, Pete. And that was a really, really inspiring talk and thank you so much. Also for sharing uh with so much honesty about the learning points that you've gained from. Really all, all, all, all the many projects that you've taken on and we'll have questions for you uh later. But I'm gonna jump straight into uh introduce in June now. So we have June made with us. June is an and dynamic engineer researcher and senior lecturer with over 16 years of experience in biomedical engineering uh training and research. Doctor Madetes specialty is in biomechanics and she's the current coordinator of biomedical engineering at the School of Engineering and Technology in Kenya University. So over to you uh Ju I'm gonna bring your slides up in to Ks. Thank you so much Jen. Um Are they on? Um So as you've introduced, I'm June Ma. I am a biomedical engineering uh engineer who is very enthusiastic. I'm trying to see my slides. I think I'm still on a different view. Uh Perfect. Um And um I'm very passionate about combining engineering and health sciences just as uh Peter just said because as a g we noticed and yes, I started with biomechanics and biomechanics. It's looking at the body as a machine and you can't do that without involving the people who treat the body and the people who can fix the body. So it's very key. So um ii, we have several case studies that I wanted to look at, but I thought a new people will come with all his innovations. So I thought I had to do context uh based in Kenya. Uh I'll, I'll, I'll highlight some innovations next slide. So biomedical engineering is very new in the Kenyan context. We started it as a de as a degree course in 2013. Uh So far, we, there are two or three universities in the whole of Kenya who offer it. And we are, as we go on, we are learning and I would like to just give you uh a path we took. We developed a ventilator during the COVID-19 period. Instead of me talking about the ventilator, I want to tell you about the lessons we learned because we reiterated so many times because we do not understand our own context when it comes to medical devices. So I'm going to give you a snippet of the lessons we learned and some of the examples from the lessons we learned and says how to overcome some of the challenges next slide, please. So we cannot talk about design without sta sta starting on the regulations and standards. If you want to describe that context, if we want to understand how to develop sustainable technologies, we have to understand how it is. So in the beginning of 2020 most of the systems in the area sub Saharan Africa were using the A EU process because it was already established, did not require any specification for ventilators, we did not have any. So we had to develop them. For our context, we had to understand what the the uh device was to do. For example, for the ventilator, we we drew upon the medical device directive uh which is in the eu but there are things that they had specifically, for example, they were not specific about power and some of our ventilators sometimes can't work with the with our power fluctuations. So Kenya developed specifications for our contexts, how it can be classified, how it can be applied so that it can uh with withstand the dust and the power uh fluctuations and for the market and different manufacturers in the area. Do we have manufacturers in the region at that time we were not importing. So how are we going to uh uh regulate how a manufacturing center for medical device looks like? Uh next slide, this sorry, I'm looking at two S um E aspect. It must de uh demonstrate to operate effectively and safely. It has a checklist that has to be fulfilled with all medical devices, but our checklist could not be the same as other contexts. The responsibility must be determined. Is it the manufacturer or is it the user or is it the designer? We have to think about uh the how this device is going to be reviewed. And remember we've never actually had a medical device that has gone to market in the country, designed, made, manufactured in country. So we are learning this compliance had to be in important from the time the product specification is done to the time it goes to market next slide. So yes, we did use standards. We we are not going to reinvent the will. Of course, we had iso standards that we looked at to think about the quality of the systems, risk management and other various guidelines for clinical investigations. We also thought about uh the electrical components, the sterility of the components and of course, the it was a device that is going to be important in the body. So we were like, ok, it's not only one, the the uh the standard, we're not only going to look at what the Kenya context is, we're going to look at how safe it is for the body. So we were learning as engineers, as I said, we came, we made a ventilator in less than a week, but we did not look at standards, we did not look at regulated bodies and we do not look at the user which is very, very key. So we had to start the process again cause we had uh Ka Bur standard. Next slide, please. Yeah, coming for certification. They started asking us the question that the iso standards want. So they were like, where are the oh, is the conformity metrics? So like, oh, we have to do that. We went back to the drain book or where the risk management plan we were like, oh, we didn't think of that we had to go back to the drain. So we had all these doses that we had not thought about. And it was important for us to do it in the beginning. And this also uh informed the Bureau of Standards how they can uh address when a medical device goes to market next slide, please. So as I informed, we used uh the common international standard iso when it comes to medical devices And it was um interesting to start and dig into that rather than just teach it. But actually use it on a device that we have designed. Next slide, please. We had specifications that I, as I said, the Ky our Kenya Bureau of Standards used all the information they learned from our findings to come up with a critical care uh specification which we advised and they also learned from us, which was actually quite uh brilliant because it brought about quality specialists, it brought about standard and regulated bodies. It brought about all the engineers, all the users, the anesthesiologist come together in a room and actually start discussion of how we can get a medical device to market in our region. Next slide please. This is just showing that we have a another board which is called the pharmacy and Poisons board and it has guidelines on conducting critical uh clinical trials, but they have only conducted trials on drugs, never on devices. So this was also new. We in we helped inform as academia, what are the steps that need to be taken? For example, for drugs, they have to have a placebo for a device, you cannot have a placebo or a ventilator. For example, how do you advise that? And how do you go ahead, how do you enter different phases because they have strict guidelines on different phases. So we have to inform that we are different visits. I want to go into detail with this to the next slide and all the visits were informed by different aspects that they've seen in other devices, but never for medical devices. So we were learning together. For example, as I said, we had to use uh standards for the sterilization. We had to have manuals in place, we had to have protocols in place. We had to have good manufacturing in place. Next slide, we have to look at the electrical safety and this was one of the toughest stages because as I said, we just invented and we thought we just go to market, but we tried to pass certain safety guidelines and this was informed by the standards as well. Next slide please. And finally, this ventilator had to be operational. We had to look at calibration, we had to look at different conformations that it had to go through, not each other because we are thinking about the safety of this patient. We have to think about labeling different interfaces that are going to be used and this really informed us as academia, as a nation, as a country and all the all the regulation and standard bodies on how we can approach the the learnings of a medical device development. Next slide, this is just fating the different um the device to see if we needed, we needed technical features like the drawing and the composition. We need the risk management, we needed bench testing, we needed to get clinical data. So it was not just about making uh something in the lab and taking it to market had to go through different processes. Next slide piece, as I said, we have to look at clinical trial. This is going to be an invasive device. What is needed for this protocol to be discovered. We needed to do the protocol and learn how a protocol for a device is conducted. We need to submit this to an ethical review committee. We need to submit this to the poison uh pharmacy and poisons board in the country for a review and we need to get clar uh clarification for that and to the hospital to approve. So we learned through this process and by the time we got to this process, we had so many reiterations. We wish we started this from the beginning. So this is the journey we took as Kenya to understand the medical device landscape. And we got to a point where we had um an idea of what steps we can take and we developed um different uh groups, different multidisciplinary groups. So we can, we knew how to do the documentation from the beginning. We knew how to understand what standards to purchase or to access from the beginning. So from this information, when we started any device development, we knew what steps to follow. So I can give you an example of some of the devices that we've gone through next slide, please. So uh we have the uh a uh an a need that was provided to us. We need an an affordable alternative to the whole laparoscopy procedure. Peter has shown you how you can have gasless procedure. So we were asked, ok, can we do we have to have the whole light system that is very expensive to be used? Can we simplify it, use the gasless uh kit and also use the a simple one. So we had this discussion with the users from the beginning. We put a team together from the beginning. What is needed. We started documentation from the beginning even when we still had the drawings. So the components that were chosen were specific for medical devices. The imaging that was received was what we needed. So it did not take as long for us to actually go to the point of having uh a prototype that is working next slide, please. So I won't, I won't go through all this, but we developed a device that can actually be showcased and um you know, given to the users not exactly used on the patient, but we had a device that can actually present it and demonstrate it and we, we get iteration from them. So that process people saying where you OK, they'll tell you to add this, remove this, you change the iteration to fit what the user needs. Next slide, please. So that's just uh my team working in the lab. Uh It's not a medical device, certified lab, but it's a start. Next slide, please. You can go to the next innovation and nothing time. Um Next. Yes. So we have another device that I can. I'm very proud of. It's a phototherapy box. It's not surgical, but it's used in the newborn unit next slide. So we had a team from the um from the lab put together a design that OK, the problem they are solving is we have very big phototherapy units that are made abroad. And when they come here, we have uh very many babies that need to use and most of the hospitals can only afford one or two and maybe you have 60 babies. So he came up with a design where you have the same the the um phototherapy like that occupies the same space but can take up to three babies without passing infection across each other. So this is a problem that was found by the user. The user said we have this problem. I don't want all my babies to be in one unit. But I have to, should I ignore one baby and put the other one? How do I choose? So this was a design that actually came from the user next slide. So we managed to prototype it and we, we took it to the user and they were, they said it's something that can work because actually the light was not coming from above, it was from, from the side. So each component, each uh uh each of the three was getting enough lights that are needed. So our next step is to see how we can get this done. And all the out out outputs that we use the properties of the material, all the frequency that needed the wavelength of the light that is needed was was able to be achieved. Next slide, please. So another one is a suction machine next slide. So one of the uh students went to the hospital as well and they discovered that most suction machines in the lab are not, are uh have a backlog backlash. So when the suction happens that the the the liquid goes back and spoils the mechanics within the machine. And there was not affordable unit that was in the market. So they developed a device, it's still in early stages. So this is just showing one that has been put together in the lab. So the the simulation was done, this was put in the lab and it was able to stop the process. If there's fluid passing through a, a certain place, then it stops the process and the fluid does not go back to there uh um circuitry and uh damage the machine. So this is another thing that the user came to us and said we have this issue. How can we mend it? Next slide, almost done. Another one is the medical gasses monitor with the remote alerts. Again, the student went to the hospital and found that uh some of this, the gas is finished before uh the the information which is what whatever it is, the gasses are normally placed outside sometimes a distance from where they're being used and there's manifolds that go through the whole hospital. So how can we know that the cylinder is almost halfway or almost done or damaged? So he came up with an I OT based um app and device that is attached to the manifold that can be able to drill time, monitor how much gas is in the the cylinders when it's time to change. And if there's any fluctuation in pressure, which is a problem that was discovered. Again, we got this problem from the users and we return it to the user and we're trying to retreat it to fit what they suggested. So next slide, we can skip this one. Same time. I want to emphasize on the challenges and limitations. So next slide, please. Thank you. Uh for us, we found that calibration equipment was very hard to get and sometimes very expensive. And that is something that would be nice if it was easier to get because we are doing the testing before it goes to the market. Um Sometimes getting parts in country to complete a prototype was quite difficult. And sometimes the manufacturers are, you know, if you, they don't want, you can't buy one piece, they want you to buy 30 pieces. And sometimes for a medical device prototyping, that's not possible approvals for regulatory bodies sometimes are in inside and they take too long because there's a learning process, especially when it comes to devices, it was important to have a dedicated team to test and go through the process. And sometimes you either get to the team starting the beginning and they drop out because the process takes too long or sometimes the you get a new team member coming in and changes the whole process. So it takes you back. So it's very important to have that from the beginning. It's good to have space and capacity to prototype. And of course, this means funding next slide you can go to next uh next slide. Yeah. Again, redating what pe says, multidisciplinary team is very key um documentation from the beginning is very key. Sometimes it may take you back and approvals, take a long time to be patient and not quick to go to market. Also uh uh saying what you said. Uh you, you don't think you're going to go on the whole thing. And that enabling space is very important. Uh Sorry, it was the end. I've gone first. But I think my most important key message is the context, the challenges we have and how we've come to overcome them and learn some of the lessons. And I would love to co collaborate with anyone to get insights from the uh from uh everyone out there and to understand how we can improve or even how we can add to what we have. Thank you so much. Don't go to the final today. It has my contact details. Thank you. Thank you so much. Thank you. Thank you June and thank you for really inspiring uh talks on tech technology in biomedical engineering and how it really affects our um clinical work. Uh So to our audience, keep the questions coming. I'm just gonna uh start off our clinic. I have a question really to peace and do uh you talked a lot about um uh sort of collaborations working across a multidisciplinary team and really p you've even highlighted some multinational teams working together. I just wondered if uh you had any challenges or any uh insight that you, you uh any problems that you experience with, with so sustaining these relationships because oftentimes, you know, clinical demands can get in the way of things and you know, affect these of partnerships. What, what's your experience with that. Um I can go quickly June and then pass to you if you. Um So maybe one interesting point here is the last project I mentioned with the Gasless surgery. We were fortunate to be able to travel in person to India and to meet a group of surgeons. There was some funding that enabled us to do that. And so we all got together and met face to face and I think where possible, there is nothing better because you just, you start to understand people, you know, you make those kind of personal connections. And that meant that subsequently, when we had to do things remotely, actually, the pandemic meant that we did a lot of the development work during some of the lockdown periods. But because we established that sort of good rapport, that good working relationship previously, that really helped. So we kind of had that good working relationship to build on and, and to use, I guess that's not, that's not always possible. And actually the project we did in Mengo in Uganda with Mengo Hospital. I've never been and we as a team couldn't travel because of COVID and that just relied on being flexible. And I think there is perhaps one of the things that I've taken from this, that as an academic, I'm often sat at my computer, typing away marking reports or whatever. And that's not the reality for a lot of people, particularly working in healthcare where they might be very busy day to day. So email might not be the best communication or setting up multiple teams meetings might not be best. And actually some of the the most useful communication we've had there is via say whatsapp or sort of much more agile communication platform. So I think it's kind of responding to the needs of the overall team and being reactive to that. So you can't impose, this is the way we do it. You have to sort of work as a team to find methods that work for you. Uh So that that would be some of my kind of um yeah, where possible meet in person but otherwise be flexible and be reactive. Uh um Thank you Jean for me. I think Peter has mentioned most things. Um And for me, I think one thing that I found is you need champions, uh champions that are actually passionate about what you're doing and sometimes those champions come from uh in person meetings or even just responding to an email or inviting them to a seminar, they feel like they are part of the journey, part of the, the process. And um yeah, communication is also very key. Um I think if 11 person communicates and the other one doesn't and vice versa. So you have to find a way that you can both communicate um and not only uh stick in your lane, but uh try and find out how best to communicate with them and that moves things along. And also just to bring people up that, uh, you know, are students or they're interested in research and um are interested in innovation and, you know, just trying to get them to, um, uh stay in your dream or uh focus on your dream and then they'll bring more people on and they also have friends in other different discipline in other different countries. And that also helps some of us are stuck in our ways, but they come with a, with a nice picture. Thank you. Um That's a great talk for both of you. Thank you so much. Um I was just monitoring the chat box. Um, all around. Very good at um, at now me and June were both were all at the next door to us when we were seeing what was happening in the girls work shop and we had some joy in playing and hearing from Nana. So it's, it's really to see how things are are going. So thank you so much. Uh Emmanuel, um, made a comment and I think it was directed to June and um all round compliments again is saying the first steps are always the hardest. Thank you for breaking the ground and setting the pace in Sub Saharan Africa. We seldom think about our uh innovation of our own technologies but have been overly dependent on developed countries so well done for setting the pace and setting the ground and that's wonderful. And I must say um having seen what you guys have been doing, I don't know where you find your tenacity and your passion for your job, but I was just like all hats off to you all in pursuing and pushing and, and keep sending those envelopes out and that's, that's all around humbling experience. Um Any other questions on the audience or one minute left, um can be really sorry, go on there. Oh, I was about to be cheeky as well because um um any peeks about what your current projects are and how we can help is basically um my, my question um because we have got quite an international multi discs audience and that was the strength of so um anything, any, well, anything you're working on that, you meet someone, what was the term again, participatory engagement? Um And we're more than happy to give you uh what, whatever we think about things. So, yeah, any s of what's happening um interestingly. Um so we, I met June recently and we went to the uh is a conference in, in Kenya. Um And that was really fantastic to get some good discussions going. Um One of the areas that I think a few people have been working on is around the area of surgery, visualization, light sources. So camera systems for laparoscopy, I guess, not limited to laparoscopy, but typically they're kind of expensive and difficult to maintain. So I know June, some of her students presented some fantastic work at the conference and a group from Delph that we've worked with are also interested in this area. And we have also had interest in this area because it kind of it's quite complementary to the Lyft device. So we had some I think sort of broad discussions between us all that it would be nice to collaborate. So hopefully looking ahead, we can all kind of get together. Um I guess the space is kind of there for us to uh hopefully work together and, and see what we can do in this area. Mm Yes. Um The la one is something that's key for me. And um because uh the thing is we got uh students who are interested mixed with stuff mixed with like it wasn't a project that the student will abandon. So it's something that will go on. They met with Pete, they met with um the team from Delt and they met a team from India who's also trying to do the same thing. So this whole surgical area, I think it's something that can definitely collaborate. Um As I, as I showed you, we have different student projects where we can definitely collaborate. Um We have students who just do projects, abandon them because they have graduated. So they don't need to make money or anything. So that collaboration would, would be very key like I try and um get them to present their work, try to see if I can get some funds. OK. Let's go for a conference. So they feel like they are, they, someone is listening to their work and um something like that, a collaboration even just, you know, a publishing or even um a shout out on Twitter that always works. Um And yes, so just ideas on getting our students motivated cause they, they are very smart but they, they're all silence. I don't know why. Um To move that along would be amazing, great thing you're giving them the less. So hopefully we do more and more of them. Um That's wonderful. Uh j your cheeky questions. Oh I'm just squeezing one more question. I've given the opportunity to the audience. I get my question. Um It's a question uh to really about the guest Laparoscopy. Um I think we have a lot to learn, you know, in terms of building uh low cost uh equipment and, and, and uh sort of in the context of conservation. I just wonder, you know, um in, in, in the UK context, what, what is the take up of laparoscopy? Is, it is a really interesting point. And I think um here often it's seen as maybe a bridge. Um So I think if, if fuller gas laparoscopy could be offered, um people probably wouldn't adopt gas lists because although it can produce kind of comparable surgical views in a single quadrant, um If you want to do sort of more complex procedures. Um, then I think there are some challenges so it's particularly suited to, I suppose, more routine procedures like removing the gallbladder, so laps and things like diagnostic laparoscopy as well. So it's very good for those kind of core procedures. Um, I think there is sort of more broadly something to learn though about that kind of, it shows that you can kind of take something which is a um a routine procedure in say the UK, a gas laparoscopic operation and the resource use is huge. Um We did a green surgery challenge and looked at all of the the resources that are used and often now we use single use instruments in the UK and it's incredibly wasteful. So from an environmental and a cost perspective, moving away from that and looking critically at the kind of the equipment that we use, I think is really important. So there's lots of initiatives, I think there's lots of overlap here to think about global health or better provision of surgical instrumentation worldwide and also environmental sustainability because the two kind of go hand in hand if you're designing responsible reusable equipment, ah it should also be inherently environmentally sustainable as well. So I think there is some good lessons and ways that we can maybe harness some of the obviously the trend certainly in the UK is to fund lots of areas of sustainability. So if we can kind of piggyback off that, hopefully we might be able to benefit for the global community. So I don't know if I really answered your question. Actually, I think I went off on a tangent, but no, you answered it. I think there's so much bidirectional learning really and things that we can pick up in terms of reducing wastage, you know, keeping an eye out on environmental sustainability because we're not, we're not just looking after the patients in front of us, we are looking after the patients in the future as well. Yes, absolutely. Thank you so much. Is there anything else you would like to add during this before we close this session? I'm just uh thankful that I've come, I've got to meet you. I feel like I know you, but um I'm happy that uh this has happened and I, I'm waiting for more collaborations and uh contacts from anyone that is interested. I'm available. Thank you. Yeah, just to echo that. I think it's a great message as a um it's a really good gas, so is great and that's the place where ideas and new innovations come from. So engineers can undo things if we understand new challenges. So, yeah, keep the ideas and communication open. Thank you so much to June and thank you so much for your precious time and giving us uh very great talk. Um So to close this session, I just like to uh thank you everyone again and thank you speakers. L eg uh And hopefully you'll see Maria in a catch up content uh that we'll record later on. Uh I just like to remind uh all our audience that a certificate of attendance, you can fill out our feedback and you'll be able to get a certificate of attendance. And all of these uh talk that we've done today will be recorded and again, uploaded as catch up. And I hope you all enjoyed this uh very inspiring two hours. Uh Hopefully lots of new ideas to come in the coming to your innovations course. And of course, if you have any questions, please get in touch uh and we can put you in touch with our. So thank you, everyone again, say goodbye now we'll see you at our next event. Thank you. Bye.