Diagnostics in developing countriesBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7111.760 (Published 27 September 1997) Cite this as: BMJ 1997;315:760
Time for an essential diagnostics programme
- a International Health Division, Liverpool School of Tropical Medicine, Liverpool L3 5QA
- b Association for Rational Use of Medication in Pakistan, Islamabad, Pakistan
- c Health Systems Research Institute, Bangkok, Thailand
Diagnostics are big business in developing countries. In Lahore private clinics advertise magnetic resonance imaging on public billboards, diagnostic clinics abound, and ultrasound examination on demand costs $2.50 to $10. In Bangkok there is one computed tomographic scanner for every 62 000 people, and 90% of private hospitals with more than 50 beds own one.1 While some of these changes might be anticipated as government policies shift towards enabling provision of private care,2 there is some evidence that governments themselves are spending public money to expand diagnostic services. For example, one provincial government in Pakistan borrowed $8m to upgrade basic healthcare facilities by providing medical equipment—mainly x ray machines, ultrasound scanners, and microscopes3; in Lesotho plans to upgrade basic health centres included the purchase of x ray facilities and laboratories4; and similar large expenditures are being considered by donors or governments in countries from Peru to Palestine. The investment is sometimes large: in Pakistan, for example, the Network for the Rational Use of Medication estimated that in 1995 the value of the market for medical equipment in Pakistan was $0.25bn, while the pharmaceutical market in the same year was $0.91bn.
The trend towards providing better diagnostic equipment is partly driven by the desire to make diagnostic tests more accessible—something that the World Health Organisation has promoted.5 However, there are other pressures at work. Gleaming equipment and laboratories provide a professional veneer that is attractive to both doctors and patients. Some private practitioners own their own laboratories, and commercial laboratories in some countries pay doctors for patients referred. In some instances, unscrupulous equipment manufacturers encourage purchase of equipment through incentives for the administrators who sign the requisitions forms. Sometimes overseas aid programmes use funds to stimulate their own industrial base, including the manufacture of medical equipment. Yet it is expensive to install, staff, maintain, and buy consumables for any diagnostic equipment, particularly x ray and ultrasound machines, microscopes, spectrophotometers, and kit assays. Therefore, ministries need to be sure the investment is likely to benefit patients, and good science and technical support should help here.
Technical advice from the WHO and other aid and donor agencies generally focuses on efficient delivery of medical tests by ensuring that equipment is regularly serviced, gives accurate measurements, and is supplied with consumable materials.6 This is clearly a prerequisite if a test is to have any potential impact. But we need to step back a little. Providing x ray machines and basic laboratory equipment for a 100 bed district hospital seems sensible, but will such investigations mean better primary care at smaller, less sophisticated, walk-in clinics?
This can be answered by addressing three questions. Firstly, will the tests actually result in altered decision making, change the timing or type of treatment, and thus result in a better outcome?7 To answer these questions, we would need to evaluate the skills of the clinical staff at these facilities and the case mix of the patients. Secondly, given the additional information provided by the test and its potential to improve outcomes, can the healthcare system as a whole provide the care that will result in these better outcomes? Thirdly, “Is this location the most cost effective for this test?” Economies of scale mean that low throughput results in high unit costs, so that an x ray unit at an urban primary health facility seeing 25 general outpatients a day is unlikely to be a sensible use of scarce resources.
These are difficult questions. In the face of specialist clinical demand and strong commercial pressures, healthcare planners need support and information. We propose an essential diagnostics programme that promotes the rational and effective use of diagnostic tests in the developing world. Such a programme could refine a series of basic tests linked to symptom complexes in standard treatment regimens. Methods for doctors and managers to audit diagnostic practice should be developed and disseminated, and the effectiveness of tests should be debated in the public arena, along the lines of the WHO's excellent essential drugs programme. In the meantime, ministries and donors aiming to improve the quality of primary health care should examine carefully whether buying medical equipment for primary care centres is an efficient or effective use of scarce resources.
This collaborative work is part of the Effectiveness of Health Care in Developing Countries Project, supported by the Department for International Development (UK) and the European Union. However, these organisations can accept no responsibility for any information provided or views expressed.