Diagnostics are an integral part of the healthcare system and can serve as the cornerstone of precision medicine. The current COVID-19 pandemic has put the importance of diagnostics in the spotlight, re-asserting its place in the global political agenda. However, it remains one of the weakest links in the cascade of care for many common conditions, including Non-Communicable Diseases (NCDs), such as diabetes and hypertension, that continue to afflict low- and middle-income countries (LMICs). Expensive, inaccessible diagnostics are one of the major reasons why residents, especially in rural populations, delay seeking a healthcare professional which often leads to terrible health crises.
Four out of five people with an NCD live in LMICs, but diagnostic services that should facilitate timely diagnosis and treatment remain inaccessible. To design delivery models that work for these countries, we must first understand the needs of the people and communities, identifying the gaps and barriers that limit them from accessing essential diagnostics.
Based on our practical work on the ground and latest research, these are key challenges in accessing diagnostics for NCDs across the rural patient journey in LMICs, and how public and private sector partners must collaborate to address them.
Challenges
At this stage of the journey, patients become aware of their conditions or at least start to experience symptoms that trigger getting care. The pain points patients typically experience revolve around low level of knowledge on conditions, lack of accessible health information, under skilled and ill-equipped Community Health Workers (CHWs), and lack of financial protection. The CHWs that are most accessible to them (i.e., those that are stationed in the villages) also lack the skills, tools, and equipment to provide proper education and risk-assessment to encourage people to get tested. Patients are also anxious to go to doctors mainly due to the fear of being required to undergo laboratory tests and prescribed with medicines, all of which have no part in their household’s budget. As a result, some of them end up going to a local quack to get a herbal remedy and others just do nothing. These residents also typically do not have any sort of financial protection – for these low-income families who earn an average of $5 a day, health insurance is a luxury.
Potential solutions
In this stage of the patient journey, channels for health education must be made accessible to the communities to equip them with the right knowledge about relevant conditions. Digital channels and platforms that use gamification in providing education in a fun and engaging format, have great potential to promote life-saving preventative practices. Health Games, for example, is a mobile quiz app that uses gaming to enable and extend the reach of accurate healthy lifestyle information to young people and healthcare professionals across Kenya.
In terms of providing initial screening, chatbots using instant messaging apps (on low or zero data platforms) can also be utilized to provide an avenue for risk-assessment or pre-screening that is accessible and convenient for rural residents. CHWs from the local health system must also be engaged, better rewarded, and equipped with the tools and supplies to carry out screening or risk-assessment services in harder to reach communities. Public-private partnerships are key to addressing the chronic shortages of CHWs in low- and middle-income countries currently. For example, reach52 has collaborated with public and private sector partners to equip +4,000 Barangay Health Workers in the Philippines with our reach52 access offline-mobile app and diagnostic toolkits to provide screening for NCDs, infectious diseases, and Maternal Health in rural populations.
Challenges
The only time residents start to feel the need to get tested is when their symptoms persist and disrupt their everyday routine. However, they know that the local public health center typically does not offer diagnostic tests and is far from home. If they overcome the distance barrier and end up going to the health centre, they would almost always be told to go to a private laboratory or hospital for further tests that they pay out-of-pocket (OOP). For families in rural communities, these OOP expenses for diagnostics are a huge burden. A comprehensive diabetes test panel for example costs approximately $50 in a private hospital or outpatient diagnostic center in rural Philippines, 10 times more than the average daily earning of a resident. Thus, it becomes inevitable for some of these patients to choose not to get these tests, brush off their symptoms, and allocate their money on food instead.
Local health centers want to intensify screening for NCDs and make it more accessible to community residents, but are being hindered by the lack of resources, i.e., equipment and supplies and local CHWs having limited skills to carry out screening services. The number of public health doctors and staff in these health centers are also severely disproportionate to the population that they are serving. In one of the communities where we operate in the Philippines, there is only one public doctor for nearly 80,000 people. According to the World Health Organization (WHO), fewer than 2.3 skilled health workers per 1,000 population would be insufficient to achieve coverage of primary healthcare needs.
Potential solutions
Clearly increased investment is part of the potential solution – systemic lack of investment in testing means basic diagnostic capacity is available in only 1% of primary-care clinics in many low- and middle-income countries. This needs to be supported by increased regulation and price capping to make essential tests more affordable to health system payers in LMICs, and by greater innovation in the diagnostics. There is too much dependency on a select few high-income countries for diagnostic test manufacturing, so this requires diversification. Similarly, new models of care involving multi-sectoral partners can catalyze change. In 2020, reach52 collaborated with Medtronic LABS to implement a new model of care for hypertension and diabetes in rural Philippines. Patients were diagnosed through community-based screening and enrolled in a ‘patient pay’ monthly subscription service, through which they received blood pressure and blood glucose bi-weekly checks, affordable medicines via the reach52 access e-commerce service, and coaching from trained public health nurses. The service was developed in partnership with the municipality’s rural health unit (RHU) and private diagnostic centers that provided services for confirmatory diagnostics after the initial screening.
Challenges
Patients feel anxious when they enter the treatment stage, especially for those diagnosed with NCDs that were prescribed with maintenance medications. They mostly worry about not being able to sustain their medications primarily due to financial limitations. Free maintenance medicines for diabetes and hypertension are almost always out of stock in rural health centers, so patients can often end up buying them from local pharmacies in town, spending up to $24 a month on average. For insulin-dependent diabetic patients, monthly treatment costs could reach up to $90. In Cambodia, only three out of the 10 essential NCD medicines are “generally available” in primary care facilities.
Apart from budget constraints, compliance is hampered by distances from health facilities and pharmacies. For example, diabetic patients who need to regularly check their blood glucose levels, but do not have their own glucometers and strips, need to travel back to the health center in town for a basic blood glucose measurement. The time and monetary costs of travelling back-and-forth to the health center becomes a reason to not get tested, which then results in poor monitoring and management of their condition.
Potential solutions
In this stage of their journey, patients need accessible means to keep their conditions regularly monitored and under control, stopping disease progression and complications. However, cost of diagnostics in LMICs remains high and needs innovations for lower-priced solutions in which digital technologies can play a significant role. It’s encouraging to see increased activity in this space at the moment.
Roche’s Accu-Check Sugar View for example tests and monitors blood glucose levels using a smart phone without the need for glucometer, potentially offering significant benefits to lower income patients. HelpAround, a mobile patient concierge, also allows diabetes patients of all walks of life to find someone in their vicinity with a glucose tablet, meter, or dose of insulin to share. For hypertensive patients, MX Labs’ Heart Monitor can check blood pressure through facial analysis via a mobile phone.
Health systems don’t work effectively without accessible and affordable diagnostics for the patient populations they serve. The limited availability of essential tests at the primary care level is therefore one of the biggest problems there is in global health. It is solvable but only if all ecosystem stakeholders collaborate, innovate, and invest now to put accessible diagnostics within reach of every community.