Analysis of licensed South African diagnostic imaging equipment

Introduction: Objective To conduct an analysis of all registered South Africa (SA) diagnostic radiology equipment, assess the number of equipment units per capita by imaging modality, and compare SA figures with published international data, in preparation for the introduction of national health insurance (NHI) in SA. Methods The SA Radiation Control Board's database of registered diagnostic radiology equipment was analysed by modality, province and healthcare sector. Access to services was reflected as number of units/million population, and compared with published international data. Results General X-ray units are the most equitably distributed and accessible resource (34.8/million). For fluoroscopy (6.6/million), mammography (4.96/million), computed tomography (5.0/million) and magnetic resonance imaging (2.9/million), there are at least 10-fold discrepancies between the least and best resourced provinces. Although SA's overall imaging capacity is well above that of other countries in sub-Saharan Africa, it is lower than that of all Organisation for Economic Co-operation and Development (OECD). While SA's radiological resources most closely approximate those of the United Kingdom, they are substantially lower than the UK. Conclusion SA access to radiological services is lower than that of any OECD country. For the NHI to achieve equitable access to diagnostic imaging for all citizens, SA will need a more homogeneous distribution of specialised radiological resources and customized imaging guidelines.


Introduction
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 (USA). 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][8][9] and over the past three decades, basic radiological services have increasingly been viewed as an essential component of healthcare [10][11][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.

Results
South Africa's diagnostic imaging equipment resources are reflected in Table 1  (UK), they are nonetheless substantially lower than the UK (Figure   1).

Discussion
This study is the first comprehensive analysis of the diagnostic

Conclusion
This analysis demonstrates an inhomogenous provincial distribution of radiological equipment, with a wide discrepancy between the public and private health sectors, and lower overall access to radiological services than any OECD country.

Competing interests
The authors declare that they have no financial or personal relationships that might have inappropriately influenced them in writing this article.  Tables and figure   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: A comparison of SA and UK data by imaging units per million population