An audit of licensed Zimbabwean radiology equipment resources as a measure of healthcare access and equity

Introduction Approximately two-thirds of the world's population has no access to diagnostic imaging. Basic radiological services should be integral to universal health coverage. The World Health Organization postulates that one basic X-ray and ultrasound unit for every 50000 people will meet 90% of global imaging needs. However, there are limited country-level data on radiological resources, and little appreciation of how such data reflect access and equity within a healthcare system. The aim of this study was a detailed analysis of licensed Zimbabwean radiological equipment resources. Methods The equipment database of the Radiation Protection Authority of Zimbabwe was interrogated. Resources were quantified as units/million people and compared by imaging modality, geographical region and healthcare sector. Zimbabwean resources were compared with published South African and Tanzanian data. Results Public-sector access to X-ray units (11/106 people) is approximately half the WHO recommendation (20/106 people), and there exists a 5-fold disparity between the least- and best-resourced regions. Private-sector exceeds public-sector access by 16-fold. More than half Zimbabwe's radiology equipment (215/380 units, 57%) is in two cities, serving one-fifth of the population. Almost two-thirds of all units (243/380, 64%) are in the private sector, routinely accessible by approximately 10% of the population. Southern African country-level public-sector imaging resources broadly reflect national per capita healthcare expenditure. Conclusion There exists an overall shortfall in basic radiological equipment resources in Zimbabwe, and inequitable distribution of existing resources. The national radiology equipment register can reflect access and equity in a healthcare system, while providing medium-term radiological planning data.


Introduction
The United Nations 2030 Agenda for Sustainable Development, with 17 Sustainable Development Goals (SGDs), is a clarion call for unified global action to address our planet's stark inequalities. Health is addressed in the third SDG. Universal health coverage (the provision of quality, essential health services for all) is a key target [1,2].
Inequalities in global access to healthcare exist between and within nations. Between-country disparities are principally influenced by national wealth, which may be broadly stratified by World Bank income groupings. Low-and middle-income countries (LMICs) by World Bank criteria are home to more than 84% of the world's population, have 90% of the global burden of disease, but account for only 12% of global health spending [3]. The overwhelming majority of global deaths attributed to poverty and/or poor healthcare infrastructure occur in LMICs [4]. In-country health-care inequalities are largely attributable to disparities in resource distribution, with service provision to rural populations constituting a particular challenge [5,6]. Additionally, although private healthcare is playing an increasing role in service provision in all countries, differential access to private facilities contributes to in-country disparities, particularly in LMICs [7]. Healthcare technology, including diagnostic imaging, is acknowledged as an essential component of any healthcare system [5,[8][9][10]. Basic radiological services, such as plain X-rays and ultrasound, are required for effective primary care [5,[11][12]. Access to basic diagnostic imaging services should thus be seen as integral to achieving universal health coverage. The World Health Organization (WHO) recommends one X-ray and ultrasound unit for every 50000 people, or 20 units per million people, and postulates that this will meet ninety percent of global imaging needs [12,13]. This can serve as a yardstick to evaluate access to basic imaging services at country-level. Robust country-level data are thus required to assess the extent to which countries meet this target.
However, there is a striking paucity of imaging resource data at country level. Although the WHO has published national estimates of high-end radiology equipment resources based on questionnaire surveys of member countries, these data do not include basic equipment such as general radiography and ultrasound units [14,15]. It is estimated that two-thirds of the world's population has no access to basic imaging services [16]. In May 2007, the 60 th UN World Health Assembly adopted Resolution 60.29, urging member states to "collect, verify, update and exchange information on health technologies, in particular medical devices, as an aid to their prioritization of needs and allocation of resources" [17].
Notwithstanding this, there has been very little detailed work on incountry imaging resources, globally. The drivers and determinants of these resources remain poorly understood and the relationship between national healthcare expenditure, national health indicators and in-country access to diagnostic imaging has not been assessed.
Additionally, there appears to be scant recognition of the potential role of registered diagnostic imaging equipment in reflecting healthcare access and equity within and between countries. Radiology equipment that emits ionizing radiation is generally licensed for use in a specific location that has been found to meet the infrastructural specifications for safe operation, such as adequate radiation shielding and appropriate electrical supply. Relocation of equipment typically requires re-licensing. Additionally, diagnostic imaging equipment may only be operated by registered radiation workers. An inventory of licensed equipment thus provides robust data on the number and distribution of units, as well as broader insights into the so-called "imaging enterprise" [16].
It is in this context that the Division of Radiodiagnosis in the Department of Medical Imaging and Clinical Oncology at Stellenbosch University embarked on an evaluation of the registered diagnostic radiology resources of Southern African countries. The current text focuses on Zimbabwe, and represents the third country-level study in the series. The first two studies reported data from South Africa (SA) and Tanzania, respectively [6,18]. Zimbabwe, is a land-locked, lowincome country in sub-Saharan Africa. It has a predominantly rural population of approximately 13 million people, an area of 390757 square kilometres, and an overall population density of 33 people per square kilometre (Table 1). Administratively, the country has 8 provinces and 2 cities with provincial status (Harare and Bulawayo).
The 2017 gross domestic product (GDP) was 17.8 billion US dollars (USD). Approximately 6% of GDP is spent on healthcare [19,20]. A Approximately 10% of the Zimbabwean population has private medical insurance. There are urban private hospitals operated for profit, as well as rural hospitals run by large mining/farming companies for the benefit of their staff and their dependents. Since independence in 1980, private healthcare has grown at all levels. In particular, private practitioners have proliferated in the urban areas and in informal peri-urban settlements [19][20][21][22][23][24]. In the first 15 years after political independence, Zimbabwe developed one of the strongest economies and health systems in Southern Africa. However, from the mid-1990s public healthcare funding and infrastructure has declined, as a result of economic challenges, with steady erosion of previously achieved positive health indicators [23,24]. Zimbabwe has no formal, national policy on health technologies. Nonetheless, the Radiation Protection Authority of Zimbabwe (RPAZ) is the national statutory body responsible for registration of all healthcare equipment [25]. The aim of this study was a comprehensive analysis  However, there is no access to fluoroscopy and mammography outside the major cities. In four of the ten provinces, with a combined population of approximately 3.9 million people (30% of the total population), plain radiography is the only public sector imaging modality. The overall geographic distribution of private sector resources is similar to that of the public sector, with the proviso that in six of the ten provinces, plain radiography is the only available imaging modality ( Table 2,Table 3).

Comparison of radiological equipment resources for
Tanzania, Zimbabwe and SA: although Tanzania has the lowest quantum of national public sector resources, it has the most equitable distribution of basic equipment, and the lowest overall discrepancy in access between the public and private sectors ( Table 4).

Comparison of demographic, economic and health indicator
data for Tanzania, Zimbabwe, and SA: national public sector imaging resources broadly reflect per capita healthcare expenditure, such that the lower the national expenditure, the lower the resources.
However, the relationship is not linear. Additionally, despite having more imaging resources than Tanzania, Zimbabwe has inferior healthcare indicators (Table 5).

Discussion
This study provides useful medium-term planning data for the of whom invested in their own basic imaging equipment [19,28].
While this is testimony to the pivotal role of basic imaging in primary care, it also reflects a potential regulatory vacuum in this domain.
Similar trends are evident in private-sector CT access in Harare, where the unit concentration (51/10 6 people) is almost four-times the Organization for Economic Co-operation and Development (OECD) average (13.3/10 6 ), more than double that in the SA private sector (20/10 6 ) and 25% higher than that in the United States (40/10 6 people) [7]. Our findings suggest that appropriate legislative and regulatory measures are required to rationalize Zimbabwean radiology equipment in the urban private sector. While current unit concentrations for plain radiography and CT may promote access to imaging, the apparent oversupply potentiates self-referral, overutilization, unnecessary exposure to ionizing radiation and burgeoning healthcare costs [29][30][31][32][33]. Of note, Zimbabwe is one of 90 WHO member states (90/174, 52%) that have no national health technology policy [17].
Our finding that SA, a high middle-income country by World Bank criteria, has a greater overall density of diagnostic imaging equipment than Zimbabwe and Tanzania, both low-income countries, is intuitive.
The same is true for our demonstration that public sector imaging resources broadly reflect national per capita healthcare expenditure.
However, the relationship between healthcare expenditure, diagnostic imaging equipment resources and healthcare indicators is more complex. Despite Zimbabwe's annual per capita healthcare expenditure, and its public-sector plain X-ray equipment resources being three-times that of Tanzania

Conclusion
There exists an overall shortfall in basic radiological equipment resources in Zimbabwe, and there is inequitable distribution of existing resources. This study highlights the role of a national audit of registered radiology equipment in defining country-level health coverage and equity, and providing medium-term planning data.
What is known about this topic  Basic radiological services, such as plain X-rays and ultrasound, are required for effective primary care;  The World Health Organization (WHO) postulates that one basic X-ray and ultrasound unit for every 50,000 people will meet 90% of global imaging needs;  There is a paucity of detailed data on in-country registered radiological equipment resources, globally.

What this study adds
 It shows that access to basic X-ray equipment (11 units/10 6 people) in Zimbabwe's public healthcare sector is approximately half the recommended WHO benchmark (20 units/10 6 people);  It highlights the 5-fold disparity in basic public-sector X-ray resources between the least-and best-resourced regions, and the 16-fold disparity between public-and private-sector access to basic X-ray services;  It illustrates how a national audit of registered radiology equipment can provide insights into country-level health coverage and equity, and assist in medium-term healthcare planning, to meet WHO radiological benchmarks. Tables   Table 1: Zimbabwean population by region