Hospital-based transfusion practices still widespread due to centralised blood collection and preparation being too expensive

Decreased availability of blood products

Dependence on family donors or higher-risk paid donors

Substandard laboratory support for blood product refrigeration and virus/parasite screening79

Increased risk of transmission of bloodborne infection to patient80

Consistent quality local hospital-based rapid serological testing until centralisation becomes more affordable81

Poor hand-washing facilities

Substandard sterilisation and disinfection practices

Increased Healthcare-Acquired Infection with increased reliance upon antibiotics causing increased antibiotic resistance

Targetted by WHO Global Patient Safety Challlenge: Clean Care is Safer Care

Alcohol-based hand sanitisers or other novel disinfection products

Building designs to combat airborne infection spread are not available

Ignorance of isolation methods in wards

Increased spread of contagious diseases (eg, multidrug-resistant strains of tuberculosis)

Modular or locally appropriate building designs

Inadequate staff training for specific machines

Old anaesthetic machines and equipment, unreliable oxygen and power supplies

For example, only 6% of anaesthetists in Uganda have adequate facilities to provide safe anaesthesia for caesarean sections82 83

Distance learning and interactive electronic tutorials

Seminars and clinical teaching from external tutors

Preoperative surgical checklists56

Unreliable supply of medical-grade oxygen cylinders

Electric-powered oxygen extraction and concentration has been a success84

Solar-powered oxygen generators

Ongoing user education is deficient

Users are sometimes low/non-literate

Power source/batteries cause majority of failures85—even laryngoscope battery failure is a significant problem

Planned Inspection and Preventive Maintenance programmes are often not strictly implemented

Simple technologies with basic or graphical instructions made obvious on device

Ageing refrigeration equipment, interrupted power supply and poor maintenance86

Major issues for vaccines, blood supplies and other temperature-sensitive medications at risk of spoilage

New refrigeration technologies taking advantage of new photo-electric, insulation, cooling and energy storage technologies

Many patients are unable to return to clinic for results

Many tests are inaccurate or expensive

Incorrect or delayed diagnoses cause individual morbidity and epidemics

Rapid, affordable, point of care immuno- and molecular diagnostics87 (eg, for HIV, TB, malaria88 and STIs)

Delays around referral—centres are often a considerable distance—80% of African women live more than 5 km from even a primary health centre and have very poor transport options

Unwillingness and inability to give birth in hospital/institution

Preference for traditional birth attendants and decreased presence of skilled birth attendants at delivery (eg, only 40% in Africa)89

Increased maternal and fetal complications

Inadequate provision of timely caesarian section, control of labour pains, induction and ability to deal with complications

Low-birthweight/sick neonates not readily identified

Community-based transport options

Mobile phone networks

Readily available oxytocin and antishock garment for postpartum haemorrhage prevention and treatment

Inadequate fetal heart rate monitoring with often only a Pinard stethoscope available—requires skill90

Worse detection of and response to perinatal distress/asphyxia

Simplified, portable, rugged oximeters91 and heart-rate monitors