Analysis of licensed South African diagnostic imaging equipment

Analysis of licensed South African diagnostic imaging equipment

Joseph Mwamba Kabongo^1,&, Susan Nel², Richard Denys Pitcher¹

¹Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa, ²Department of Health Directorate, Radiation control, Bellville, South Africa

^&Corresponding author
Joseph Mwamba Kabongo, Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa

Globally, governments are experiencing increasing pressure to fund essential public-sector services [1]. This is particularly true for healthcare, where worldwide expenditure currently exceeds $4 trillion, representing 9 per cent of the global Gross Domestic Product (GDP) [2]. However, there is wide discrepancy in international healthcare spending, with amounts ranging from less than $3 per person annually in some low-income African countries, to $6,250 per person (18% of GDP) in the United States of America. In more than 30 countries, the annual per capita healthcare expenditure is less than $20 [1]. Thus, while many low-income countries have a high burden of disease, they lack healthcare infrastructure [2]. This is particularly true in sub-Saharan Africa (SSA), which is home to 11 per cent of the world's population and bears 24 per cent of the global disease burden, but has only 3 per cent of the world's health workers and accounts for less than one per cent of global healthcare spending [2]. Like other SSA countries, South Africa (SA) faces substantial healthcare challenges, including dual HIV and PTB pandemics, a high infant mortality rate, and an increasing burden of non-communicable diseases and trauma [3,4]. SA has a population of almost 53 million people and currently spends approximately 8.5 per cent of GDP on healthcare, which is in line with levels observed in Organisation for Economic Co-operation and Development (OECD) countries. Approximately 17 per cent of the SA population (9 million people) has access to private healthcare; the remaining 83% (44 million people) is dependent on public-sector resources. However, the private sector accounts for approximately half of all SA healthcare expenditure (5.1% of GDP) and employs 70% of healthcare specialists, thereby providing a well-developed private-sector infrastructure; conversely, the public sector is relatively under-resourced [5]. It has been shown that public-private partnerships can enhance the quality of existing secondary and tertiary services while extending the provision of primary care [1]. Many governments are thus turning to the private sector in an attempt to address public healthcare needs. It is in this context that the SA Government will be introducing National Health Insurance (NHI) [6]. There is a burgeoning global demand for diagnostic imaging [7- 9] and over the past three decades, basic radiological services have increasingly been viewed as an essential component of healthcare [10-12]. Furthermore, although radiological equipment is expensive and imaging constitutes a significant proportion of healthcare expenditure [13], the value added by radiological services to both the individual patient and the sustainability of healthcare systems has been increasingly acknowledged [14]. Ensuring equitable access to radiological services is thus pivotal to the successful implementation of any healthcare system. South Africa's National Health Insurance system will be no different. Accurate knowledge of SA's diagnostic imaging capacity is therefore important. Although the Radiation Control Board maintains an accurate database of licensed diagnostic imaging equipment in SA, to the best of our knowledge, there has been no unifying analysis of these data, to assess South Africa's overall per capita imaging capacity by diagnostic modality. Furthermore, to the best our knowledge, there has been no comprehensive analysis of the diagnostic imaging capacity of any country in sub-Saharan Africa. The aim of this study is to: i. Conduct an analysis of all registered diagnostic radiology equipment in South Africa ii. Assess the number of equipment units per capita by imaging modality, iii. Compare SA figures with available published international data.

The database of the SA Radiation Control Board; which includes an inventory of all licensed SA diagnostic radiology units including general or conventional radiography (GR), fluoroscopy (FL), mammography (MM), digital subtraction angiography (DSA), computerized tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT) equipment, was captured on an MS Excel spread sheet and analysed by modality, province and healthcare sector. All general purpose, fixed radiology installations were included. Mobile, industrial and mass screening units were excluded. Amongst radioisotope equipment, only positron emission tomography/computer tomography (PET/CT) was considered. For each imaging modality, access to radiological services in the public, private and combined sectors was reflected as the number of units per million population, based on the 2013 South African mid-year population estimates [15]. The public sector refers to government medical institutions and the private sector to any other medical facility with registered diagnostic radiology equipment (private radiologist, other medical specialist, general practitioner, chiropractor, private radiographer, mining company and private medical institution). It was assumed that 17% of the SA population has access to private medical services. The number of SA units per million population for each imaging modality was then compared with available published OECD data, thereby providing a comparative assessment of South Africa's capacity to deliver a national diagnostic imaging service. Although the WHO has published estimated data on the diagnostic imaging capacity of all countries, figures are based on national surveys and interviews, rather than national equipment databases and therefore were excluded from comparison.

South Africa's diagnostic imaging equipment resources are reflected in Table 1. Only three of SA’s eleven provinces (Gauteng, Western Cape Province and Kwazulu-Natal) have the full spectrum of diagnostic imaging modalities in both the public and private sectors. Overall, Gauteng has the best provincial resources and Mpumalanga the least. General radiography is the most accessible modality, with 34.8 units per million population. Geographically, this is also the most equitably distributed modality, with overall the smallest discrepancy in units per million between the least and best-resourced provinces (1:2.3), and between the public and private sectors (1: 5.3). Although the country's overall number of units per million population is similar for fluoroscopy (6.6), mammography (4.96) and CT (5.0), these modalities show an average 11-fold discrepancy between the least and best resourced provinces and an average 13-fold discrepancy between the public and private sectors. Currently, the Northern Cape has no public sector mammography service. The 2.9 MRI units per million population largely reflect private sector capacity, with a 46-fold overall discrepancy in MRI resources between the public and private sectors. Mpumalanga and the North West Province have no public sector MRI service. Table 2 compares South Africa's diagnostic imaging capacity with published international data [16,17]. Of note, there are no OECD data for general radiography or fluoroscopy. Furthermore, there are currently no comprehensive comparative data on imaging capacity in other African countries. For every modality, South Africa's overall imaging capacity is lower than any OECD country. While SA resources most closely approximate those of the United Kingdom (UK), they are nonetheless substantially lower than the UK (Figure 1).

This study is the first comprehensive analysis of the diagnostic imaging capacity of an African country and as such adds important new insights into the provision of healthcare on the African continent. Furthermore, our analysis has revealed that SA's overall diagnostic imaging capacity most closely approximates that of the United Kingdom, while being substantially less than the UK. This is a cardinal observation, since the UK has an existing National Health Service (NHS) and also has published national imaging protocols, as promulgated by the Royal College of Radiologists (RCR) [18].The imaging model of the United Kingdom could thus potentially serve as a model for development of imaging capacity, and the evolution of referral patterns, in a unified South African healthcare system. During the course of this research project, and prior to the publication of our audit findings, the Radiological Society of South Africa (RSSA) fortuitously adopted the RCR referral guidelines, with minor modifications, with a view to implementation in South Africa, in both the private and public health sectors [19]. This serendipitous development makes our analysis particularly relevant to healthcare in South Africa. Based on our findings, cautious implementation of the RCR guidelines would certainly appear to be appropriate in the South African context. Reference to Table 2 reveals that the diagnostic imaging capacity within the SA private sector is superior to that in the UK for all modalities. This suggests that the RCR referral guidelines can be relatively easily accommodated within the South African private sector. However, resources in the SA public sector are substantially lower than those in the UK.The impact of the RCR referral protocols on the SA public sector will have to be carefully monitored, and guidelines will have to be modified as required, to ensure that the proposed referral patterns are sustainable within the public sector. This is particularly true if one considers the countries' respective disease profiles (Table 3). South Africa has a substantially higher burden of HIV, TB and trauma, while the United Kingdom, has a significantly larger aging population. In addition, a major SA challenge will be to address the geographical discrepancies in distribution of imaging equipment identified in this study. If SA is to achieve equitable access to diagnostic imaging, the least-resourced provinces will have to be afforded priority when allocating future equipment resources. A constraint to achieving OECD-level imaging capacity in SA is the discrepancy in GDP between the average OECD country and SA. The OECD average total expenditure on health is approximately 9.4% of GDP, which represents $3701 per capita, while SA's 8.5% of GDP spent on healthcare represents just $645. Unifying the private and public sector imaging platforms under the proposed NHI, would appear to be an important first step in achieving more equitable access to imaging for the South African population. However, to ensure long-term viability, referral protocols would have to be constantly monitored and refined to yield customized imaging protocols appropriate to a resource-limited environment. This research has defined the SA access to radiological equipment.Clinical radiology is at the centre of modern medicine and is critical to the strategic ambitions of the UK National Health System. Does South Africa have enough radiologists for efficient clinical services delivery in the proposed NHI? This question will be an object of another research paper.

This analysis demonstrates a non-homogenous provincial distribution of radiological equipment with a wide discrepancy between the two existing health sectors, heavy loaded private to the detriment of the public, and the access to radiological services is lower than any OECD country.

The authors declare that they have no financial or personal relationships that might have inappropriately influenced them in writing this article.

J.M.K and S.N :Acquisition and collation of data. J.M.K Data analysis and drafting of the manuscript:R.D.P Revision of the manuscript critically for important intellectual content:Accountable for all aspects of the work in ensuring that question related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. J.M.K and R.D.P participated in the conception and design of the research, interpretation of data, and final approval of this version to be published.

The authors acknowledge the South Africa National Department of Health, Directorate: Radiation Control as main source of data used in the analysis and technical support from Mr Leon du Toit and the IT direction for data organisation.

Table 1: South Africa diagnostic radiology resources by modality per million population

Table 2: published international diagnostic imaging equipment resources by modality per million population - OECD/Africa

Table 3: comparative data of South Africa-United Kingdom-OECD average

Figure 1: comparative data of United Kingdom: UK/South Africa: SA

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