Limitations of access to diagnostic imaging and medications in the Northern Kivu Province of the Democratic Republic of the Congo

The Lancet Commission on Global Surgery (LCoGS) and the World Health Organization (WHO) resolution 68.15 recognized essential surgical care as a key component of universal health coverage[1, 2]. The LCoGS targets that by 2030, 80% of surgical needs should be met, focusing on improving access to essential surgery. Despite the recognition of this need, five billion people continue to lack access to essential surgery, 29% of whom live in Sub-Saharan Africa[3, 4]. Surgical care requires systems, including diagnostic imaging and availability of essential medications. Access to diagnostic imaging facilities in low- and middle-income countries (LMICs) has been shown to improve treatment and outcomes, and medications are a foundational component of healthcare[5, 6]. However, there is a severe shortage of imaging equipment in LMICs, with fewer than 1 CT scanner per million individuals in LMICs compared to almost 40 scanners per million in high-income countries[7]. Lack of these systems often necessitates that patients travel long distances in search of appropriate healthcare, leading to high costs and adverse outcomes[8].

While many LMICs are increasingly prioritizing healthcare, evidence-based health plans are hindered by the absence of accurate estimates of unmet needs, preventing sound investments. WHO data for availability of imaging is missing in many African countries, many of which do not have any data from the past decade[9, 10]. In the Democratic Republic of Congo (DRC), no informed surgical targets exist in the National Health Plan[11]. It was recently shown that there is insufficient access to essential surgical equipment and staff in hospitals in North Kivu, DRC[12]. However, there is a scarcity of up-to-date data regarding the availability of diagnostic imaging and essential medications in the DRC. Without this information, it is difficult to set priorities for the nation’s healthcare and convince stakeholders to invest in health.

This study aims to determine the availability of diagnostic imaging and essential medications in the DRC, as well as the effects of any lack of availability. It is the first of its kind in this population, and is aimed at providing data to inform strategic health planning. We surveyed healthcare providers and local community members in Butembo, North Kivu, DRC to ascertain the incidence and impact of the lack of diagnostic imaging and essential medications.

Study Characteristics

An IRB-approved cross-sectional survey was conducted to evaluate the current gaps in diagnostic diagnostic capacity as perceived by health care providers as well as the lived experiences of community members in Butembo, North Kivu, DRC. The total population in the catchment area is estimated to be 10 million people, as Butembo receives complex cases referred from Ituri and other neighboring health zones[13].

Ethical approval was obtained through the research ethics committee of the Graben Catholic University of Butembo. Given variable literacy rate among community members, participants were offered the choice of written or verbal consent.

Participants and Sampling Technique

The study took place at a university teaching hospital and at general public hospitals in Butembo. Between March and August 2024, healthcare providers (HCPs) and community members (CMs) were surveyed by research assistants, all of whom were medical students trained specifically in the study’s survey protocols. HCPs were recruited by the research assistants by selecting every third name from a list of all HCPs until the desired sample size was achieved. HCPs were asked about the availability of various resources and services, as well as the impact of the lack of certain resources on patient care.

CMs were recruited on a voluntary basis while they attended clinics. The inclusion criteria were: (1) resident of Butembo or Katwa; (2) age > 18 years; (3) able to understand the language of the verbal survey; and (4) able to respond appropriately. The strategy for recruitment was as follows: research assistants approached every clinic patient during the study period, explained the purpose of the study, requested written or verbal consent from patients who met inclusion criteria, and administered the survey verbally. By including all patients meeting the inclusion criteria, we aimed to reflect the diversity of views from CMs from various levels of education, income, and professions.

The questionnaire was administered by verbal interview, in the language most easily understood by the survey respondent (Nande, Congolese Swahili, or French). Data was entered directly into an electronic database (KoBo Toolbox) using the research assistants’ smartphones. Several questionnaire items used open-ended questions to solicit unstructured responses from CMs. These qualitative data were recorded by students using free text in the electronic database. The answers were translated into French and summarized by the students prior to entry into the database.

Variables

Variables collected included the availability of functional diagnostic equipment for imaging, including X-ray, ultrasound, mammography, electrocardiography, MRI, CT, and endoscopy; the availability of essential medicines; and the impact of a lack of imaging, diagnostic laboratory facilities, and essential medications.

Data Analysis

Summary statistics were used to provide a descriptive analysis of the data. Costs were reported in United States dollars ($). Participants answers were analyzed in frequencies and percentages. Data were analyzed using Stata version 16.1 (College Station, TX).

To understand the qualitative nature of the comments, we analysed free text written responses using grounded theory, an inductive methodology that generates conceptual categories from qualitative data[14]. Transcripts were analyzed using a constant comparative method with no a priori hypothesis to generate emerging and recurring themes. We used group open coding involving two investigators (KMC and MH) and resolved disagreements by discussion. Themes were grouped and refined to succinctly summarize the breadth of responses. Representative quotations were selected to illustrate the different themes.

Quantitative data

Forty HCPs were interviewed (Table 1). Median age was 41, and the majority (90%) were male. Most were medical doctors (80%), while the remainder were allied HCPs such as nurses. All HCPs reported having access to a functional X-ray machine and ultrasound, and a majority (83%) reported having access to a functional electrocardiography machine. No HCPs reported having access to MRI, CT, or endoscopy. All HCPs reported having to modify their prescriptions because their patient could not find the appropriate medication, as well as having patients who traveled outside the region to access diagnostic facilities. Many reported having had patients die due to a lack of functional imaging or diagnostic laboratory equipment (60%), and a substantial minority reported having missed a diagnosis due to a lack of functional diagnostic equipment (37%).

Eight hundred and eighty CMs were interviewed (Table 2). Median age was 30, and 54% were female. Over half had a university degree or postgraduate education (56%), and an additional 32% had a high school education.

Over half of CMs were very satisfied or satisfied with the diagnostic accuracy and services of local physicians (58%); 28% had a neutral opinion, and 16% were dissatisfied or very dissatisfied (Table 3). Out of those who were dissatisfied, the majority were primarily dissatisfied due to lack of imaging equipment (59%), while significant minorities reported lack of laboratory equipment (17%) and lack of good quality medications (12%).

Many CMs (42%) reported that they or a family member needed a specialty imaging investigation in the past two years, with the majority needing CT or MRI (49% and 23%, respectively). Of these CMs, only 41% reported that this examination has been carried out. As these imaging modalities are not available in Butembo, the majority needed to travel outside the DRC to access this investigation (72%), while a minority accessed it in another town within the country (28%). Cost to access this investigation ranged from $200-$2000 USD, with a median cost of $780. Very few CMs reported that the costs were covered by insurance (4%), and over one third needed contributions from family and/or friends (34%).

Of the 59% of CMs who had not accessed the specialty imaging, the vast majority reported that this was due to insufficient resources (80%) or death of the patient before resources were available (13%). The remaining CMs reported that the reason was due to insecurity in the region making travel difficult. Many CMs (82%) reported that their doctor’s diagnosis was wrong after they sought a second opinion in a better-equipped environment, with 40% reporting that this happened “sometimes” and 7% reporting that it happened “often”. Notably, 44% of CMs reported that one of their family members died because of a lack of specialist investigation.

Most CMs (78%) reported having experienced being unable to access a prescribed medication in local pharmacies, with 22% reporting that this happened “often” or “always”.

Qualitative data

The survey questionnaire for CMs included several open-ended questions to assess their experiences and attitudes to the healthcare services they received in the community. Three themes emerged from the qualitative analysis of the responses: (1) the Congolese government’s lack of support for the public health system; (2) seeking care in the private sector or abroad is often necessary, but expensive; and (3) experiencing debt due to healthcare costs. Illustrative participant quotations for each theme are presented in Table 4.

Here we describe the perceived impact of limited availability of diagnostic imaging and essential medications in Butembo, North Kivu, DRC. We identified severe regional resource constraints, identified by both HCPs and CMs. All HCPs have had to send patients outside the region to access MRI, CT, or endoscopy, and HCPs frequently modify their prescriptions due to lack of medication facility. Of note, we sampled a very large number of CMs, made possible by mobilizing medical students for community engagement. CMs who accessed imaging largely had to travel outside of the country, while many were unable to access imaging given insufficient resources. Notably, 44% of CMs reported the death of a family member due to lack of imaging resources, and most CMs reported being unable to access a prescribed medication in local pharmacies.

The study is one of the first to evaluate and document the unmet needs in terms of diagnostic capacity and medication availability in a region serving 10 million population. In the absence of proper diagnostic capacity and adequate access to medicines, the delivery of excellent surgical care to patients will never be achieved. This supports a previous finding that greater than 95% of the population in Central Sub-Saharan Africa does not have access to adequate surgical care[4].

Access to diagnostics and medications

The availability of medical imaging equipment per 1 million individuals reported by the WHO varies from country to country. While high-income countries often have at least 5 MRI machines per 1 million individuals, most African countries have less than 1[9]. 2013 data showed that there are no MRI machines in the DRC. In line with this, we found that, as of 2024, there are no MRI machines in Butembo, North Kivu. Similarly, while high-income countries often have at least 10 CT scanners per 1 million individuals, most African countries have less than one[10]. 2013 data showed that there are 0.07 CT scanners per 1 million population in the DRC. Notably, we found that for Butembo’s 10 million individuals, there are no CT scanners. Butembo’s complete lack of MRI and CT scanners demonstrates its poverty relative to other African LMICs – Rwanda has 0.4 MRI and 0.5 CT scanners per 1 million individuals, Uganda has 0.5 CT scanners per 1 million individuals, and Zimbabwe has 1.5 CT scanners per 1 million individuals[15–17].

Similarly, previous studies have found that access to essential medications in the DRC is severely limited. One study found that the average availability of medicines against non-communicable diseases was as low as 11% in the DRC; other studies have found lack of availability of common medications such as anti-retrotrovals and opiates[18–20]. Our study extends this work by examining the prevalence and impact of the lack of medications in a previously unstudied region. Indeed, all HCPs and 78% of CMs reported being able to access the necessary medications, thus needing to make substitutions or look elsewhere.

Perceived impact on the quality of services

The lack of essential equipment and supplies has been identified as a cause of poor outcomes in LMICs[21]. Similarly, unavailability of quality medicines in LMICs leads to poor healthcare delivery, low patient satisfaction, and distrust[22, 23]. Our findings demonstrate that this is also the case in the DRC. All HCPs have had patients travel outside of the region for proper diagnosis, and all have had to modify their prescriptions. A significant number also had patients die due to lack of functional diagnostic equipment. Similarly, the majority of CMs were not able to access the specialized diagnostic exam requested, which may partially explain why 44% reported the death of a relative due to the lack of specialized investigation.

Financial constraints

DRC is one of the five poorest countries in the world[24, 25]. An estimated 73.5% of Congolese people lived on less than $2.15 a day[26]. Spending for healthcare is thus not feasible for a large proportion of the Congolese people. In support of this, one study in the DRC found that four out of ten households were not able to pay the premium fee to maintain health insurance coverage, whereas another found that 90% of people in the DRC do not have health insurance[27, 28]. Thus, the high costs of accessing adequate diagnostic care of $780 ($200-$2000) puts the community in Butembo at risk of catastrophic healthcare expenditures[28]. Indeed, many participants reported that they had to go into debt or sell property to afford healthcare.

In the DRC, only 1% of the MoH budget was allocated to healthcare in 2014[29]. This percentage is significantly lower than that of other African governments, some of which have committed to spending 15% of their budget on health[30, 31]. Thus, the slim national budget may partially explain the scarcity of diagnostics and essential medications. Moreover, a previous study demonstrated that the greatest surgical disparities in Eastern DRC were due to infrastructure deficiencies[32]. A large majority of the hospitals in North Kivu are run by in the non-public sector (82%), which often comprises hospitals run by churches and other non-public charity organizations[12]. These hospitals may have large variation in available resources. Previous studies demonstrated a perceived better quality of care in non-public health facilities, leading to clients seeking care in the private sector[28, 33]. These previous studies also found that higher performance and lower out-of-pocket costs have been reported in non-public compared to public hospitals. However, our study identified that neither the public nor non-public hospitals in the region have adequate equipment or resources, as many individuals turn to facilities outside of the region.

Considering the gaps, this region would benefit greatly from financial investment improving access to imaging, including MRI, CT, and endoscopy; high quality diagnostic laboratories; and pharmaceutical facilities able to provide essential medications. These services are crucial for planning high quality service delivery. Ensuring access is essential for achieving universal health coverage (UHC) and sustainable development goals by 2030[15].

Future directions and implications

Given the fact that the area under study was involved in recurrent conflicts for almost three decades, funding is needed for more research comparing the unmet needs of the peaceful provinces to get a clearer picture and apply the findings to the whole country. More research is also needed to understand where political leaders stand in terms of their awareness of the gaps in access to surgical services faced by community members.

Our study serves as a call to action for the region. The findings of this study will be shared with main local leaders, including the Ministry of Health of North Kivu, and with the private sector. We aim to start the discussion of what policies to put in place to improve the dire needs .

Limitations

Our study had several limitations. Our use of a convenience sample of healthcare professionals and community members meant that our results may be limited by selection bias. Individuals who chose to participate may have been more strongly affected by lack of resources, which could lead to a misrepresentation about the extent of the lack of resources. However, we believe that the large number of individuals surveyed increases the generalizability of the responses. For future studies, we will apply for funding and conduct a study with a larger, randomly selected sample to improve generalizability. Second, free-response answers were translated into French and summarized by the research assistants prior to entry into the data system. This introduces potential bias and a lack of transparency in translation and summarization. Additionally, the omission of verbatim recording weakens the reliability and transparency of the qualitative data. We were not able to avoid this limitation, as we did not have the financial capabilities or time to record responses verbatim and have them professionally translated.

This study found that access to high quality functional diagnostic imaging, laboratory, medicines, and medical supplies was null in the North Kivu province of DRC. This region falls far short of the minimum goals set forth by international agencies and the LCoGS. The capacity was less than in other countries with comparable economic profiles. It is apparent that there are huge unmet needs that contribute to the profound unmet needs of this province. There is an urgent need to invest funding to improve the situation in this region of the DRC. The infrastructure and human capital needs are largely unmet and will require a much larger commitment of resources from the national government and MoH than currently allocated. The results of this study can provide a snapshot of DRC’s unmet capacity to inform recommendations on what is needed to solve the gap based on African guidelines.