82
N. Engel et al.
7.3 Discussion and Conclusion
Our results show how the specific diagnostic eco-systems of South Africa (largely
centralized testing with the prominent exception of HIV screening) and India (largely
peripheral testing spread across a multitude of providers) constitute very different
conditions for POC testing and how the major challenges to ensuring POC continuums are linked to this difference.
In India, successful POC testing hardly occurs in any of the settings and for any
of the diseases. Many of the rapid tests are used in laboratories where either the
single patient encounter advantage is not realized or the rapidity is compromised
due to human resources, manpower, and equipment shortages. In smaller peripheral private laboratories and private clinics with shorter turnaround times, rapid tests
are unavailable or too costly. The onus to follow through diagnostic pathways is
on the patients and providers use coordination mechanisms (opening hours, kickbacks) to ensure some form of POC continuum using older technologies. In South
Africa, the majority of testing happens in centralized laboratories, where delays are
accumulated due to transportation, human resource, and infrastructure challenges.
Providers’ strategies to deal with associated delays create new problems, such as
artificially prolonged turnaround times, strains on human resources, and quality of
testing, compounding additional diagnostic and treatment delays. While most tests
conducted on the spot can be made to work successfully as POC tests, delays remain
with regard to treatment initiation.
In both countries, actors use different strategies to overcome these challenges.
These adaptive strategies to make POC testing work are in both countries rather
fragile and ad hoc, dependent on locally negotiated solutions, personal commitment,
available human resources, and relationships. While some are successful in ensuring
a timely diagnosis, others lead to disruptions, unnecessary testing, or delays with at
times unclear implications for quality of diagnosis. In India, strategies for coordinating between private providers and laboratories with kickbacks or treating empirically
right away are aimed at avoiding losing patients, and in this way ensure some form
of POC continuum. However, they also increase chances for malpractices (wrong or
unnecessary tests might be ordered, inadequate treatment might be prescribed) and
may lead to mistrust from patients into the health system. In South Africa, strategies
of dealing with delays associated with centralized testing actually increase diagnostic
delays (such as telling patients to come back even later) or put additional strains on
the health system (such as doctors delivering results to remote clinics). Testing on the
spot, for instance, HIV testing, requires healthcare providers to maintain functioning
relationships to other providers to overcome stockouts and excess workload, while
their adaptations in conducting HIV rapid tests to continuously changing test kits or
patient demands can foster mistrust among providers.
Patients embody very active roles in managing their diagnostic journeys. In India,
the system relies almost entirely on the patient to ensure the POC continuum across
homes, clinics, labs, and hospitals, amidst a multitude of public and private providers
with divergent and often competing practices in settings lacking material, money, and
N. Engel et al.
7.3 Discussion and Conclusion
Our results show how the specific diagnostic eco-systems of South Africa (largely
centralized testing with the prominent exception of HIV screening) and India (largely
peripheral testing spread across a multitude of providers) constitute very different
conditions for POC testing and how the major challenges to ensuring POC continuums are linked to this difference.
In India, successful POC testing hardly occurs in any of the settings and for any
of the diseases. Many of the rapid tests are used in laboratories where either the
single patient encounter advantage is not realized or the rapidity is compromised
due to human resources, manpower, and equipment shortages. In smaller peripheral private laboratories and private clinics with shorter turnaround times, rapid tests
are unavailable or too costly. The onus to follow through diagnostic pathways is
on the patients and providers use coordination mechanisms (opening hours, kickbacks) to ensure some form of POC continuum using older technologies. In South
Africa, the majority of testing happens in centralized laboratories, where delays are
accumulated due to transportation, human resource, and infrastructure challenges.
Providers’ strategies to deal with associated delays create new problems, such as
artificially prolonged turnaround times, strains on human resources, and quality of
testing, compounding additional diagnostic and treatment delays. While most tests
conducted on the spot can be made to work successfully as POC tests, delays remain
with regard to treatment initiation.
In both countries, actors use different strategies to overcome these challenges.
These adaptive strategies to make POC testing work are in both countries rather
fragile and ad hoc, dependent on locally negotiated solutions, personal commitment,
available human resources, and relationships. While some are successful in ensuring
a timely diagnosis, others lead to disruptions, unnecessary testing, or delays with at
times unclear implications for quality of diagnosis. In India, strategies for coordinating between private providers and laboratories with kickbacks or treating empirically
right away are aimed at avoiding losing patients, and in this way ensure some form
of POC continuum. However, they also increase chances for malpractices (wrong or
unnecessary tests might be ordered, inadequate treatment might be prescribed) and
may lead to mistrust from patients into the health system. In South Africa, strategies
of dealing with delays associated with centralized testing actually increase diagnostic
delays (such as telling patients to come back even later) or put additional strains on
the health system (such as doctors delivering results to remote clinics). Testing on the
spot, for instance, HIV testing, requires healthcare providers to maintain functioning
relationships to other providers to overcome stockouts and excess workload, while
their adaptations in conducting HIV rapid tests to continuously changing test kits or
patient demands can foster mistrust among providers.
Patients embody very active roles in managing their diagnostic journeys. In India,
the system relies almost entirely on the patient to ensure the POC continuum across
homes, clinics, labs, and hospitals, amidst a multitude of public and private providers
with divergent and often competing practices in settings lacking material, money, and