Survey of magnetic resonance imaging availability in West Africa

Introduction The availability and utilization of MRI units across sub-Saharan Africa countries remain poor and its distribution is largely unknown. A cross-sectional survey was conducted to determine the distribution and utilization of MRI facilities across the West African sub-region. Methods An interview and online search survey was conducted from September 2015 to September 2016, to determine the MRI facilities (Government/Public and Private) available in the West African sub-region. In Nigeria and Ghana, face-to-face interviews were conducted while for other West African countries, telephone interviews with radiologists and other health professionals as well as a Google online search were conducted to ascertain the distribution of the MRI facilities in the region. The number of MRI units in West Africa per million population was calculated and compared with other parts of the world from available published data. Results Eighty-four MRI units serve a combined population of 372,551,411 in the West African sub-region at the time of this report. Nigeria accounted for more than two-thirds (58 (69%)) of the available units. Of these, 45 (77.6%) of the units were low-field strength systems. Ghana's 14 MRI units were fairly equally distributed between the private (57%) and the public sectors (43%). Ghana with 0.48 units/million population had the highest number of MRI units/ million population followed by Nigeria with 0.30 units/million population. Conclusion Though there is an increase in the number of available MRI units in the West African sub region in the last decade, the numbers remain appallingly small for the population. Infrastructural and maintenance limitations constitute a major impediment to the use of high filed systems in the region. There may be need for greater cooperation between public and private enterprises for future improvement of MRI utilization in the region.


Introduction
Despite the emergence of Magnetic Resonance Imaging (MRI) over four decades ago in 1974, developing countries in Africa still have limited access to this clinically beneficial and revolutionary imaging modality. Its utilization in West Africa (comprising 16 countries from Nigeria in the east to Senegal in the west, with an estimated population of more than 350 million people) remains low compared to developed nations of the world [1]. MRI remains one of the most wildly used imaging modalities in developed countries, growing exponentially in improvements yearly with the use of higher field strength magnets. In most developing countries, the utilization of MRI is limited due to enormous acquisition costs, lack of infrastructure and the expertise required for maintaining and running the systems [2][3][4]. The limited personnel with knowledge of MRI physics and clinical applications remain a major predicament of the developing nations. In recent years, many developing countries have undergone economic transformation with higher living standards, growth of the ageing population, increased healthcare awareness and access to advanced health services although the health indices remain poor [5,6]. The changing healthcare landscape provides a market potential for MRI in West Africa, if the challenges of infrastructure, health service reform and lack of properly trained personnel are addressed [5,6]. There is a critical need for the development of training programs and deployment of more resources, for MRI facilities to become more affordable in the developing world. This is because, it would be improper, to charge patients for MRI examination at the same cost, as in developed countries. Creating improved access to advanced medical imaging with MRI in the developing world, would be crucial to the improvement its healthcare provision systems. Therefore, a good understanding of the current state of facilities may provide the basis for planning and development of strategies that would address the challenges and tap into the opportunities that may become available in the near future. A cross-sectional survey of the MRI facilities in West Africa was conducted to determine the distribution and utilization of MRI facilities across the sub-region.

Results
As at September 2016 there were 84 MRI units in the West African sub-region with Nigeria having 58 (69%) accounting for more than two-thirds of the available functional units in the region ( Table 1).
The number of MRI units in Nigeria was fairly well distributed across all its geo-political zones. However, all the units were found to be

Discussion
The present survey is the first comprehensive analysis of MRI capacity and utilization in the West African sub-region and provides new insight to the degree of availability of advanced health care facilities in the sub-region using MRI as a diagnostic tool. Generally, many countries on the African continent and other low and middleincome countries (LMIC) have relatively minimal contribution of MRI to their diagnostic armamentarium. A number of the West African countries have no MRI machine or not more than 1 MRI unit per million of their population. On the basis of regional assessment of MRI utilization in Africa, countries in the Northern sub-region of Africa appear to have a relatively good MRI availability and presence, and show better MRI utilization per million compared to other parts of the continent [1,5,[9][10][11]. MRI utilization in Africa is quite low when compared to the leading industrial nations in the world e.g Japan, United States, France and Spain. This may be attributed to a better economic status and financial standing in these more technologically advanced countries. In addition, the existence of first grade health care policies that support the partnership between government and private institutions, in the provision of healthcare and health insurance services, may play a role [12,13]. Participation of the private sector in health investment in Africa, appears to be improving with sub-Saharan African countries, recording a steady pattern of economic growth in recent years. The African continent has become one of the most attractive investment destinations in the world. Foreign direct investment (FDI) in the region has increased fivefold compared to its 2000 level [14] (Table 3). In recent times, there has been a perceptible increase of investment in private health care provision, as well as standalone diagnostic facilities across the West African sub-region.
Although this has had some positive impact on the value of advanced imaging with MRI in the health sector, services still remain fragmented, poorly regulated with great variability in delivery of quality outcomes [12,13,[15][16][17]. This pattern is clearly observable in the Nigerian healthcare environment, where the greatest impact of MRI utilization, is found in the private sector and predominantly in the urban centers. These facilities serve only a limited population of users who are able to afford the services, as access is only by out of pocket payments, with little or no health insurance coverage for use of such services.
It appears that the general economic potential of a nation, to a large extent, has an effect on the distribution of MRI facilities.
Countries with a relatively good GDP per capita and a commendable Amongst these is the predicament, prompted by inequities in workforce distribution and "brain drain" of skilled and educated workforce, out of the sub-region for "greener pastures" in other continents of the world. Thus, the expected availability of human resources in most African nations for effective public health interventions is lacking, particularly in remote rural areas [18]. Most of the rural towns in West African countries do not have good hospital infrastructure that could accommodate an MRI unit, as part of its health management facility or investigative tool. Therefore, there is the tendency for seekers of quality healthcare to look elsewhere and may have to travel to the urban cities, to get access to these investigative health facilities. Additionally, the cost of an

Competing interests
The authors declare no competing interests.

Acknowledgments
We gratefully acknowledge all those across the sub-region who provided the data and gave useful information. We would like to thank Motori Tambou, our staff who assisted with the internet search, clerical edits and web information.