E-DRUG: Essential diagnostics program
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The following editorial in the British Medical Journal "propose
an essential diagnostics programme that promotes the rational
and effective use of diagnostic tests in the developing world."
Thought this may be of interest to many E-druggers. It would
be interesing to know what E-druggers feel about this issue. If
there is sufficient interest perhaps someone can draft a letter
to the editor responding to this editorial and post it to E-Drug
for input from interested individuals. Any volunteer?
Syed Rizwanuddin Ahmad
Email: srahmad@essential.org
PS: For references of the editorial, please go to BMJ's website
(http://www.bmj.com) or write to me.
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BMJ No 7111 Volume 315
Editorial Saturday 27 September 1997
Diagnostics in developing countries
Time for an essential diagnostics programme
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 microscopes(3); in
Lesotho plans to upgrade basic health centres included the
purchase of x ray facilities and laboratories(4); 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.
Paul Garner
Head, International Health Division,
Liverpool School of Tropical Medicine,
Liverpool L3 5QA
Ayyaz Kiani
Project coordinator
Association for Rational Use of Medication in Pakistan,
Islamabad, Pakistan
Anuwat Supachutikul
Senior research fellow
Health Systems Research Institute,
Bangkok, Thailand
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