Strengthening biomedical engineering systems in sub-Saharan Africa: a repeated cross-sectional assessment of workshop readiness and medical device maintenance in NEST360-supported hospitals

Background: Biomedical engineering technician (BMET) workshops are essential for maintaining medical devices, yet their service readiness in low-resource settings remains insufficiently described. This study assesses BMET workshop readiness and associated maintenance systems across Newborn Essential Solutions & Technologies 360-supported hospitals in four sub-Saharan African countries. Methods: We conducted repeated cross-sectional health facility assessments of BMET workshops in 2020-2021 (n = 53 hospitals) and 2023 (n = 63 hospitals) across Kenya, Malawi, Nigeria, and Tanzania. We assessed BMET workshop readiness using 186 indicators across six domains: tools and test equipment, spare parts, storage and organisation, systems and processes, human resources, and maintenance and repair capacity. We scored indicators as 1 (available), 0.5 (partially available), or 0 (not available), and aggregated as percentages at hospital level. We summarised domain and overall readiness using medians (Mdn) and interquartile ranges (IQRs). We assessed differences between samples using Wilcoxon rank-sum tests, and explored associations between readiness, planned preventive maintenance (PPM), and device functionality. Results: Overall BMET workshop readiness increased from a median of 28.0% (IQR = 20.9-35.8) to 50.0% (IQR = 36.5-56.5) in 2023 (Wilcoxon rank-sum P < 0.001). We observed improvements across all domains, with the largest gains in tools and test equipment and maintenance and repair capacity, while human resources showed minimal change. Spare parts availability remained low despite improvement, increasing from 4.0% to 14.8%. PPM system presence increased from 68.5% to 90.6%, although implementation varied. Associations between BMET readiness and device functionality were present at baseline but not in 2023. Conclusions: BMET workshop readiness improved across participating hospitals between baseline and 2023, particularly in tools and maintenance systems. However, persistent gaps remain in human resources, spare parts availability, and maintenance system implementation. These findings highlight the need for sustained investment in biomedical engineering workforce capacity, supply chain integration, and system strengthening to support durable improvements in medical device functionality.