How often have you popped antibiotics without quite knowing what infection you had? Whether it is fever, diarrhoea, or cough, medicines are heavily over-prescribed, while diagnostic tests are rarely used. Nearly one in two Indians with diabetes is unaware that he has the disease. Cervical and breast cancer are usually detected when they are advanced, resulting in poor survival rates.
In India, patient studies show that primary-care providers (urban and rural) make a correct diagnosis in less than a quarter of patients who present themselves with typical symptoms of angina, tuberculosis (TB), asthma, and pneumonia. These studies also show an excessive use of medicines and little testing. Not surprisingly, India is one of the world’s biggest consumer of antibiotics, and antibiotic resistance is a looming threat.
Laboratory tests are also important for public health. Every year, dozens of outbreaks occur without any clarity on the cause. An outbreak of fever could be due to dengue, malaria, influenza, chikungunya, or even scrub typhus, and the only way to know for sure is by laboratory testing.
In an ideal world, treatment will follow diagnosis and treatment will be tailored to the exact cause of the illness. Sadly, as the examples cited illustrate, this ideal process rarely happens. Lack of access to good, affordable tests and quality-assured laboratories is one reason why health-care providers skip the process of diagnosis and begin treatment with medicines.
An essential list
In a big step to address the widespread problem of inadequate access to diagnostic tests, the World Health Organisation (WHO) last week published the first ever essential diagnostics list (EDL).
The first EDL contains 113 tests; 58 are basic tests (e.g. haemoglobin, blood sugar, complete blood count, white cell count, pregnancy test) intended to detect and monitor a wide range of common communicable and non-communicable conditions. The remaining 55 tests can diagnose common infections, including HIV, TB, malaria, hepatitis B and C, the human papillomavirus (HPV) and syphilis.
While some of these tests are essential for delivering primary health care, others are meant for higher level health-care facilities with clinical laboratories such as district hospitals or community health centres.
What is the rationale for the EDL? Universal Health Coverage (UHC) is at the core of the WHO’s mission, and access to quality, affordable primary health care is fundamental to achieve UHC. In India, the government’s ‘Ayushman Bharat’ scheme will be centred around health and wellness centres that aim to deliver comprehensive primary care.
But quality primary health care cannot be delivered with only medicines. Patients need access to early and accurate diagnosis. How can health workers and doctors treat diseases if they can’t diagnose them? How can essential medicines be delivered, without essential diagnostics?
While the WHO published the first essential medicines list (EML) in 1977, the agency published the first EDL only last week. While India has had a national list of essential medicines (NEML) since 2003, there is no equivalent list of essential diagnostics. These reflect the low priority given to diagnostic tests.
Thanks to the Indian Council of Medical Research and WHO India, this will soon change. In March 2018, India began the process of developing a National List of Essential Diagnostics, to complement the NEML. Both lists, taken together, will form the basis of providing essential primary-care services. Both lists can be used to impose price controls, streamline supply chain, and ensure better access.
But lists alone will not change things. States will have to invest in strengthening laboratories (public and private), and make sure quality-assured testing services are freely available. This is already underway through the free diagnostics service initiative, and can be further strengthened with the National EDL.
In a study published in The Lancet , India was ranked 145 among 195 countries in terms of health-care access and quality, well behind other BRICS countries. Easy access to essential tests is the first key step in improving quality of care.
Dr. Madhukar Pai is the Director of Global Health at McGill University, Montreal. Dr. Kamini Walia is a Senior Scientist with the Indian Council of Medical Research, New Delhi. Both served on the WHO expert group that developed the EDL
