80
N. Engel et al.
daily wages) increases and the patients might not be able to afford coming back
(Engel et al. 2015b).
Loss from diagnostic and treatment pathways can also happen within hospitals.
Patients who are asked to get a TB and HIV test done in a hospital outpatient department, for instance, need to queue, provide samples, and return to pick up results in
two different laboratories across the hospital compound. While hospital laboratories
make use of rapid tests, turnaround times are usually half a day. If the patient came
in the morning, he/she needs to find the doctor again after collecting results from the
laboratories. The doctor might have left by that time or the outpatient department is
closed and they are asked to come back the next day.
Providers suggested centralizing laboratories in hospitals compounds and improving interdisciplinary collaboration among public health center staff. Community
health workers suggested that testing at the doorstep could help strengthen trust
into the public health clinics among potential patients. However, they also emphasized that testing would have to be followed up with basic treatment and counseling
at the doorstep too, since absent drugs, follow-up tests, or doctors at the clinics, as
well as irregularly supplied tests to conduct at the doorstep, would spoil that renewed
trust again (Engel et al. 2015b).
7.2.2 South Africa
Very different from India, South Africa has a highly centralized diagnostic landscape.
Diagnostic testing in the public sector is provided by the National Health Laboratory
Service (NHLS), while a handful of large diagnostic companies provide diagnostic
services to private providers. This means that clinics and smaller hospitals send the
majority of their samples via courier to a centralized laboratory, usually in one of the
bigger cities, and results are sent back by courier, Internet, SMS, phone, or fax. A few
tests are conducted on the spot in public and private clinics. Among them are basic
screening tests (blood pressure, weight, glucose, rapid HB, and urine dipstick) and
the HIV rapid tests to establish whether someone is HIV infected. In selected public
clinics, the Xpert MTB/RIF, a molecular test that promises to diagnose tuberculosis
in 90 min, is being implemented [while the majority of the Xpert instruments have
been deployed in centralized NHLS laboratories (Cohen et al. 2014)]. For those tests
conducted on the spot, results are available within the same patient encounter. An
exception is Xpert MTB/RIF where large numbers of samples lead to backlogs and
increase the turnaround time from 90 min to 24 h (since only four samples can be run
in parallel) (Engel et al. 2015a); in addition, it requires 2,5 extra staff to operate the
device (Clouse et al. 2012). Treatment initiation can again lead to delays. In the case
of HIV, follow-up testing and counseling sessions mean that treatment is initiated
4–7 days after a positive result was established in clinics (Engel et al. 2015a).
The providers reported delays for those diagnostics that are run in centralized
laboratories and that no same-day results were available for those tests. Mainly due to
transportation challenges (long distances, poor roads, strikes, bad weather, shortages
N. Engel et al.
daily wages) increases and the patients might not be able to afford coming back
(Engel et al. 2015b).
Loss from diagnostic and treatment pathways can also happen within hospitals.
Patients who are asked to get a TB and HIV test done in a hospital outpatient department, for instance, need to queue, provide samples, and return to pick up results in
two different laboratories across the hospital compound. While hospital laboratories
make use of rapid tests, turnaround times are usually half a day. If the patient came
in the morning, he/she needs to find the doctor again after collecting results from the
laboratories. The doctor might have left by that time or the outpatient department is
closed and they are asked to come back the next day.
Providers suggested centralizing laboratories in hospitals compounds and improving interdisciplinary collaboration among public health center staff. Community
health workers suggested that testing at the doorstep could help strengthen trust
into the public health clinics among potential patients. However, they also emphasized that testing would have to be followed up with basic treatment and counseling
at the doorstep too, since absent drugs, follow-up tests, or doctors at the clinics, as
well as irregularly supplied tests to conduct at the doorstep, would spoil that renewed
trust again (Engel et al. 2015b).
7.2.2 South Africa
Very different from India, South Africa has a highly centralized diagnostic landscape.
Diagnostic testing in the public sector is provided by the National Health Laboratory
Service (NHLS), while a handful of large diagnostic companies provide diagnostic
services to private providers. This means that clinics and smaller hospitals send the
majority of their samples via courier to a centralized laboratory, usually in one of the
bigger cities, and results are sent back by courier, Internet, SMS, phone, or fax. A few
tests are conducted on the spot in public and private clinics. Among them are basic
screening tests (blood pressure, weight, glucose, rapid HB, and urine dipstick) and
the HIV rapid tests to establish whether someone is HIV infected. In selected public
clinics, the Xpert MTB/RIF, a molecular test that promises to diagnose tuberculosis
in 90 min, is being implemented [while the majority of the Xpert instruments have
been deployed in centralized NHLS laboratories (Cohen et al. 2014)]. For those tests
conducted on the spot, results are available within the same patient encounter. An
exception is Xpert MTB/RIF where large numbers of samples lead to backlogs and
increase the turnaround time from 90 min to 24 h (since only four samples can be run
in parallel) (Engel et al. 2015a); in addition, it requires 2,5 extra staff to operate the
device (Clouse et al. 2012). Treatment initiation can again lead to delays. In the case
of HIV, follow-up testing and counseling sessions mean that treatment is initiated
4–7 days after a positive result was established in clinics (Engel et al. 2015a).
The providers reported delays for those diagnostics that are run in centralized
laboratories and that no same-day results were available for those tests. Mainly due to
transportation challenges (long distances, poor roads, strikes, bad weather, shortages