I spent two weeks working in two hospitals in the south-eastern part of of Malawi in August/September 2008.

We were fortunate to be able to stay in a guest house at the Mission Hospital. It being the end of the dry season no running water was available and all water was collected from nearby boreholes. The government hospital was at the District administrative centre about 8km away (half dirt track, half tarmac road). I spent alternate days at the two hospitals

The weather in Mulanje was hotter than we expected, and the ground very dry. Each wind brought a coating of red dust.

Mulanje Mission Hospital (MMH)

The hospital was set up by Scottish Presbyterian missionaries in the late 1800s.

X-ray staff

There are two trained radiographic technicians and a darkroom assistant, who is studying in the afternoons to obtain the qualification he will need to train as a technician. The two trained radiographers were not often on duty together while I was there. They take turns in being ‘on call’ out of hours.

I was made welcome by the X-ray and other staff, and was invited to attend the daily morning hospital handover meeting where reports were made on the previous 24 hours’ happenings.

Patient pathway

Patients are referred to the radiographic technicians for x-ray or ultrasound by the Clinical Officers. Each patient carries their own little notebook (half a school exercise book) with some historical clinical information and the X-ray request. There is not often a separate request form.
On an average day there are fewer than 15 patients for X-ray and perhaps 10 for ultrasound. Though maternity care is free other patients have to pay for their care.

Patients wait outside the X-ray room until a radiographer is free, and their details entered into a ledger: name, age, examination requested, exposure factors, film size and fee paid. (In this mission hospital, an adult chest X-ray costs 700 kwatchas. [c. 290 Malawian kwatcha = Ł1]) When the examination is complete the patients take their films back to the referrer, who, there being no radiologist, has to interpret the films. The films should be returned to the department for filing, but filing was not a strong feature in this department.

Within the department there is one X-ray room, with a small changing cubicle in one corner. A second examination room was being set up for the ultrasound machine, although whilst I was there this was still in a different building.

Equipment and layout

The X-ray machine is a Universal Unimatic 325. It is in dire need of a service; the locks don’t work and the collimation is inaccurate. There is an LBD, and I was able to bring two lamps of the required power to replace the one there which was too powerful. No one could tell me when the last service was done; even then it would not have been by an engineer trained on that particular machine. The unit does not function with the generator supply.

The control panel is behind one lead screen, only about 3ft wide. It is possible to vary the mA, kV and time through a considerable range, though it is not clear how accurate the exposures are.

The chest stand held a moveable grid; I had been asked to bring a replacement grid (not knowing what it was intended to be used for) but I persuaded the staff to X-ray chests without the grid so that the exposures could be reduced accordingly. The 30x40 grid which I brought would not have much use; a 24x30 might have been more useful for skulls.

The table bucky has no AEC, and the system is off-centre.

There is no means of measuring the dose to the patient and no exposure chart, although exposures are recorded in the ledger.

There is no means of marking the patient’s name on the film prior to processing; it is marked on with a felt-tip after processing.

No QA could be performed as there is no output meter, but I suspect the machine may suffer from fluctuating voltage - the images are very variable in quality and many are rejected. My suggestion is to keep rejected films and record the reasons, so as to build up a picture of where the problem lies.