An audit of licenced Zambian diagnostic imaging equipment and personnel

Introduction Estimates indicate that two-thirds of the world's population lack adequate access to basic medical imaging services integral to universal health coverage (UHC). Furthermore, sparse country-level radiological resource statistics exist and there is scant appreciation of how such data reflect healthcare access. The World Health Organisation posits that one X-ray and ultrasound unit for every 50,000 people will meet 90% of global imaging demands. This study aimed to conduct a comprehensive review of licensed Zambian radiological equipment and human resources. Methods An audit of licensed imaging resources, using the national updated Radiation Protection Authority and Health Professions Council of Zambia databases. Resources were quantified as units or personnel per million people, stratified by imaging modality, profession, province and healthcare sector, then compared with published Southern African data. Results Over half of all equipment (153/283 units, 54%) and almost two thirds of all radiation workers (556/913, 61%) are in two of ten provinces, serving one third of the population (5.49/16.4, 33.5%). Three-quarters of the national equipment inventory (212/283 units, 75%) and nearly ninety percent of registered radiation workers (800/913, 88%) are in the public sector, serving 96% of the population. Southern African country-level public-sector imaging resources principally reflect national per capita healthcare spending. Conclusion To achieve equitable imaging access pivotal for UHC, Zambia will need a more homogeneous distribution of specialised radiological resources tailored to remedy disparities between healthcare sectors and provincial regions. Analyses of licenced radiology resources at country level can serve as a benchmark for medium-term radiological planning.


Introduction
While healthcare workers worldwide embrace the notion of universal health coverage (UHC) as reflected in the United Nations (UN) 2030 Agenda for Sustainable Development, there is growing scrutiny of global radiological resources [1][2][3]. Health is centrally positioned within the UN 2030 Sustainable Development Goals (SDGs) and is addressed in one comprehensive goal (SDG 3), comprising thirteen targets [2,4]. Diagnostic imaging has the potential to contribute to achieving six of the SDG health targets. It can assist in reducing maternal and child mortality, deaths due to road traffic accidents and non-communicable disease (NCD) mortality, as well curtailing the TB/HIV pandemics, and improving reproductive health services [5].
Additionally, global radiological services would be substantially enhanced by the realization of a further two SDG health targets, namely improving coverage of essential health services and promoting training of health workers [6]. Thus, there exists considerable interdependence between health-related SDG targets and the extension of global imaging services [4,5].
Radiology is increasingly acknowledged as a pivotal diagnostic tool [4,7]. The World Health Organization (WHO) recognizes basic diagnostic imaging services as vital to any healthcare system and suggests that one basic X-ray and ultrasound unit for every 50,000 people (or 20 units per million) would address 90% of global imaging needs [8][9][10].
However, worldwide shortages of imaging equipment and personnel, as well as inequalities in access to services, are increasingly cited as barriers to UHC [11,12]. More than half the world's population lack access to even basic radiology services [13]. Furthermore, disparities in basic imaging services between and within nations are perceived as exacerbating health care inequalities [4,8,9]. The compilation and dissemination of country level statistics on medical devices was mandated by the World Health Assembly resolution WHA 60.29 of 2007 [14]. However, there are scant published data on licenced diagnostic imaging equipment resources at national level [8,9,15]. However, these data are confined to high-end imaging modalities and do not include basic equipment such as general radiography and fluoroscopy [8,9]. Worldwide, governments are experiencing increasing pressure to fund essential public-sector services, including healthcare [4,8,17]. The achievement of UHC poses unique challenges for each country, and is a function of the national economy, health budget, existing healthcare infrastructure, demographics, burden of disease, and donor funding [9,17,18]. This is certainly true for Zambia, a 752614 square kilometre, land-locked, lower-middle income Sub-Saharan African (SSA) country. Zambia, faces substantial healthcare challenges, including dual HIV and PTB pandemics, a high infant mortality rate, and increasing trauma and NCDs [19][20][21][22].
There are four main healthcare providers, namely the government, faith-based (not-for-profit) organizations, the mine hospitals, and private enterprise (for-profit). The government and faith-run institutions are considered public sector entities, servicing more than 90% of the population [22, [29][30][31]. The country's public health service mirrors the political administration, with 10 provinces and 105 districts. There are three tiers of public healthcare. The first provides preventive and primary services at Health Posts (n = 953), Rural Health Centres (n = 1839) and District Hospitals (n = 99). The second is responsible for curative care, through Provincial and General Hospitals (n = 34), while the tertiary level, provides specialist care through Central and University Teaching Hospitals (n = 8) [23,29].
Less than 4% of the population has private health insurance [32].
Over the past two decades, the Zambian Government has formulated strategies to address the most pressing healthcare challenges, such as access to basic care, infrastructure deficiencies, human resource shortages and the high dual burden of communicable and noncommunicable diseases [20,31]. Firstly, in 2001, Zambia was one of 54 African Union (AU) countries that adopted the Abuja declaration, pledging to work towards allocating at least 15% of total government expenditure to healthcare [33]. Secondly, in 2006, Zambia abolished healthcare user fees for rural patients, as the first step to free basic care for all [34]. Thirdly, from 2008, in line with the Ouagadougou Declaration, Zambia introduced mechanisms for community participation in healthcare provision, through the recruitment of Community Health Assistants (CHAs) and local volunteers [22]. South Africa, an upper middle-income country, revealed stark disparities between the public and private healthcare sectors, as well as geographical disparities within the public sector [9]. The analysis in Tanzania, a low-income African country, showed that public sector equipment resources were relatively equitably distributed across geographic regions, but the number of imaging units per million people is lower than WHO guidelines [8]. The Zimbabwean analysis revealed a strong urban private sector contribution to imaging resources [39]. There has been no comprehensive analysis of the radiology equipment and personnel resources in Zambia. Such a study will contribute to, and supplement, medium-term planning initiatives and provide a basis for assessing the status of UHC efforts in medical imaging. The primary aim was to conduct a comprehensive audit of licensed Zambian diagnostic imaging equipment and registered healthcare personnel. The secondary aim was to compare Zambian imaging resources with WHO guidelines on basic imaging equipment and recently published data from South Africa, Tanzania and Zimbabwe. The association between imaging resources, national economic indicators, and SDG health parameters for Zambia, South Africa, Tanzania and Zimbabwe was also assessed.

Methods
This was a detailed audit of licensed Zambian imaging resources,   Table 1 and Table 2 respectively reflect Zambia's diagnostic imaging equipment and personnel resources. Comparisons of Zambian, Tanzanian, Zimbabwean and South African radiology equipment resources and health/economic indicators are shown in Table 3 and    (Table 3 and  [8,9,32,39].

Discussion
Our study represents the first comprehensive review of Zambian diagnostic imaging capacity. To the best of our knowledge, it also represents the first unifying assessment of registered equipment and In resource-limited environments, notwithstanding the availability of diagnostic imaging equipment, the quality and safety of procedures may be compromised by a paucity of qualified imaging personnel [11,22,29]. This is especially true in sparsely populated rural areas [1,8,15]. Our finding that more than 40% of public-sector radiographic staff and all Medical Physicists are in Lusaka highlights the challenge of achieving a more equitable distribution of Zambian imaging personnel. By defining the national shortfall and the preferred distribution of basic radiography units going forward, the accompanying requirement for qualified radiographic staff can be extrapolated. Of note, enhanced access to basic imaging services increases the need for accurate image interpretation. It is thus likely that radiographic staff in rural areas will require appropriate training to assume an extended role, inclusive of basic imaging interpretation.
It is therefore commendable that the Zambian MoH is actively pursuing mechanisms for the certification or training of these professionals in order to help to address the deficits [22, 36,37]. Such local training ingenuities should be supported, as should the initiatives that enable Zambians to train abroad and return with these much sought-after skillsets. Our finding that 23% of equipment units are in the private sector, but only 4% of the population has medical insurance suggests that the private sector is partially fuelled by "outof-pocket" expenditure by those who have no cover.

Conclusion
To achieve equitable imaging access, pivotal for UHC, Zambia will need a more homogeneous distribution of specialised radiological resources tailored to remedy disparities between healthcare sectors and geographical regions. Analyses of licenced radiology resources at country level can serve as a benchmark for medium-term radiological planning.
What is known about this topic  Estimates indicate that two-thirds of the world's population lack adequate access to basic medical imaging services integral to universal health coverage;  Limited country-level radiological resource statistics exist and there is scant appreciation of how such data reflect healthcare access, especially in lower middle-income African countries.

What this study adds
 This study provides a comprehensive analysis of national diagnostic radiology equipment resources in a lower middleincome African country;  Analyses of licenced radiology resources at country level help define national deficits and can serve as a benchmark for medium-term radiological planning.

Competing interests
The authors declare no competing interests.

Acknowledgments
The authors acknowledge the Radiation Protection Authority of  Tables and figure   Table 1: Zambian diagnostic radiology equipment resources per million population by modality, province and by healthcare sector