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Essential Diagnostics in Public Health Services
Conversation between Dr Adithyan G.S. (AGS), Dr Yogesh Jain (YJ) and Dr Mayank Sharma (MS).
AGS: It is an absolute privilege to welcome Dr Yogesh Jain to this conversation, and we are also joined by fellow public health professional Dr Mayank Sharma. There are studies that estimated that less than one-fifth of the population has access to appropriate and essential diagnostics at the primary health care level. As we are all aware, in 2015-16, the Government of India announced a free diagnostics initiative, and almost in parallel, the WHO developed its first essential diagnostics list, and in 2019, ICMR also came up with a national essential diagnostic list. Advancements in the field of diagnostics are relatively recent when compared to developments in the area of drugs. So my first question is about the history.
Why has this not happened much earlier – say when NRHM began in 2005? What triggered the change now?
YJ: Thanks, Adithyan. The situation was that in a traditional primary care setting, the proportion of outpatients who got an investigation would be less than 5%. But drawing on both my primary care experience and on literature, I would say that in most general practices, at least 50% of out-patients would require some diagnostic investigation to address their health problem. In the past, the emphasis has been on the doctors’ clinical skills and the presumed intuitive ability of the doctor to make a diagnosis. Gaps in therapeutic care, like lack of access to surgery, were appreciated, but not with diagnostics. When investigations got recognition, it was usually for a vertical national program for conditions like tuberculosis, malaria, or anaemia in pregnancy. These were the priorities for which the government felt accountable- the rest was “general outpatient” care whose outcomes were not considered. Other laboratory investigations, especially for NCDs, were not offered except at higher levels of healthcare. It is only with the shift from selective to comprehensive health care that the gaps in diagnostics are being acknowledged and addressed. But even now, it is very incomplete and not getting the emphasis this requires.
AGS: This view that at the primary care level, treatment based on patients’ symptoms and a clinical examination has been considered adequate. This view persists. Why do you think that a much higher level of diagnostic utilization is essential, especially considering that it would add to the costs of healthcare?
YJ: When we refer to diagnostics, we are referring to a wide range of services that includes laboratory diagnostics, imaging and electrophysiology (ECG/EEG). Diagnostics rationalizes care. In its absence, doctors resort to what is called “shotgun therapy”, where you give treatment simultaneously for a number of conditions, hoping one of these will be correct. Such syndromic treatment, as it is also called, is common for conditions like fever, white discharge, burning urination, weakness, pains, etc. or the other common complaints that people come with. Secondly, disease-specific care, as compared to symptom-based care, because it is focussed on a confirmed cause, has the potential to lower costs of care, though this need not always be the case. Then it helps doctors or nurses to be more confident about diagnosis and prescriptions, and helps also build up competence. It also builds more trust in the individual patient and more public health understanding in the community. There are public health tests like fecal contamination of drinking water that are also important.
AGS: So, why the neglect?
YJ: To my mind, there are three important reasons.
In the process of training both doctors and nurses, diagnostic specialities have been relegated to second place as being “paramedical” or “para-clinical”. Biochemistry, pathology, microbiology and even radiology are considered as appendages to the clinical consultation, whereas they should be part of it.
Secondly, our primary healthcare systems have often prioritized access more than quality, especially if it is not part of a national programme. You could see this at work in health camps where a doctor with a stethoscope and a pharmacist dispensing drugs are projected as adequate for healthcare. So this entire paradigm where you are offering only a bare-bones access rather than comprehensive good quality care is another reason.
It is also the culture of medical practice imbibed from medical college days, when residents address the over-crowded outpatient clinics, by a sort of triage, where they pick on a few “interesting” cases, while “disposing” of the rest. True, many of the latter may be self-limiting, but this notion of a “general OPD” consisting largely of symptomatic, minor illness is a trivialization of primary care. Every case of cough, even if it is unlikely to be tuberculosis, needs a proper diagnosis and treatment plan. Similarly, most skin patches, even if not leprosy, require an adequate scientific microscopy-based diagnosis. Diagnosis by therapeutic trial rather than laboratory diagnosis is another problem. Even if therapeutic trials were pragmatic choices once, it is no longer acceptable, and such an approach would lead to wasteful and even wrong or harmful care. An example of this is the dangerous rise of anti-microbial resistance as a public health problem, where the lack of a diagnostic-based prescription is one major reason.
A good example of the trivialization of primary care is the way anaemia is addressed. Anaemia is one of the commonest illnesses, with considerable adverse individual and social impact. But, even in the year 2025, in the public health system, only when treatment fails for a syndromic therapy of anaemia, which is being done by offering iron to everyone with anaemia, do we consider further laboratory testing. Even for confirming anaemia, the Sahli’s is of limited reliability and though digital substitutes are sanctioned, they are poorly standardized and very patchy in their deployment. Without the diagnostic guide, we offer treatment which can be potentially harmful, like giving iron to someone where other therapies are indicated. But this neglect is at a very ideological level.
AGS: Thankfully, there does seem to be improved recognition of the importance of diagnostics. We all acknowledge the essential list of diagnostics in place and that too a list stratified by level of public health facility. However, there are multiple essential diagnostic lists in circulation in India. How do they compare, and which should we refer to?
MS: There have been diagnostic lists earlier associated with the introduction of standard treatment guidelines in many states. But these seldom got implemented. Even the NHM, for all its strengths in other reforms, remained largely wedded to the selective approach. The game changer was the adoption of the free diagnostics services initiative (FDSI) as part of the changes with came with the National Health Policy 2017. This list was only for guidance and there are examples of states that have gone beyond, including Tamil Nadu and Maharashtra that I know of. Post the WHO list of 2018 and with the launch of Ayushman Bharat – Health and Wellness Centres, the list of diagnostics at the level of sub-centre was expanded from 7 to 14 and for the PHCs from 20 to 64. CHCs now had a 127 diagnostics list. Since then, verticals like TB have also added on new diagnostics. These additions to the lists are usually introduced through NHM circulars as part of its guidance under the FDSI.
In addition, the NHM periodically updates the Indian Public Health Standards (IPHS). The most recent update was in 2022, and this was also in response to the call to strengthen laboratories that emerged as a result of the COVID-19 response. Whenever the IPHS is upgraded, it incorporates all the orders under the FDSI. State departments of health follow this FDSI/IPHS lists. The ICMR essential diagnostics list is more of a reference document. The current ICMR recommendation is still a draft, but it does recommend more tests. It could have relevance for the Integrated Public Health Laboratories (IPHL).
AGS: But how are these lists being operationalized?
MS: There is a push to implement it at the level of policy. In the initial years, implementation of this initiative was a conditionality for the sanction of annual NHM funds. Then, in 2020, as a response to the pandemic, there was a sense of urgency in strengthening public health laboratories. It was decided to establish 730 Integrated Public Health Laboratories (IPHLs) with funding assured under the Ayushman Bharat Health Infrastructure Mission (ABHIM). A detailed guideline on IPHL was released by NHSRC in 2021. This included details of human resources, equipment, infrastructure, and a list of tests that must be available. IPHLs were each to have one pathologist, one microbiologist, one biochemist and 8 laboratory technicians.
This plan also envisaged setting up Block Public Health Units in every block. One of the three components of the BPHU was a Block Public Health Laboratory (BPHL), the other two being the public health unit and a data analysis unit. Funding for this was made part of the PM-ABHIM for 11 States, and funding was also assured from the 15th Finance Commission transfers to the states. The BPHLs also provided for an epidemiologist. It was envisaged that BPHL would also act as the hubs for many tests where samples were collected at the spokes, which would be the PHCs and sub-centres. And IPHL would act as the higher level of hub, serving BPHUs also. Molecular diagnostics were introduced at the block and district levels.
AGS: This is a fairly impressive and comprehensive plan at the policy level. However, when we were preparing for this conversation, we found that implementation was far behind expectations. We also found that though there was some understanding of the policy initiatives, there is very little official information, let alone evaluation on how effectively this has been rolled out. Our preliminary understanding is that the better states are one-third of the target, whereas in many states, it could be even less. This needs confirmation. We hope to present some insights from the states soon… I would like both of you to reflect on the challenges.
MS: Many states have picked it up. But even states like Tamil Nadu and Rajasthan, which have been forerunners in providing medicines to the district health systems, are struggling with diagnostics. The government has targeted 730 IPHLs and 3320 BPHUs to be operationalised by FY 2025-26, which means we just have one more year.
At the periphery, procurement and logistics of the point of care tests and other equipment required is a challenge. This is not a one-time effort of procuring and distributing. For newer tests, equipment specification needs to be finalised and many of these equipment require consumables for each test to be performed. Some of these consumables have a short shelf life and are close-ended, which means that only the equipment manufacturer provides the consumables. Often supply of such equipment is done as a one-time purchase instead of as a regular supply chain management. We have seen examples of districts being asked to take over reagent supplies under local purchase, which the districts struggle with. But some of the reagents, especially for molecular testing cannot be done at these levels. There are times when the tests including testing for anemia with digital hemoglobinometer, cannot be conducted for want of consumables and equipment replacement. Then, there is a requirement to transport samples from the periphery to the nearest hub laboratory. The volumes from each centre, the periodicity of sample transfers, the time taken for reporting back and even the accountability for prompt reporting on samples received from the periphery are a challenge too.
But there are states that have taken an initiative to make their own comprehensive list of tests beyond the essential list in the national lists, of which some tests are outsourced, and others are done in-house. This duality has its own set of problems.
AGS: You mention outsourcing of tests under PPP (private-public partnerships) arrangements? What is the experience with these?
YJ: These public-private partnerships are actually a reflection of the lack of seriousness that public health services are giving to diagnostics vis a vis drugs or other service delivery components. They shift the tasks, mostly unsuccessfully. Many states began the outsourcing process by floating Requests-for-Proposals (RFPs) to the private sector for the provision of diagnostics, which were later withdrawn because there was little capacity even in the private sector to serve the public systems’ requirements.
Madhya Pradesh, which I have access to information about, has outsourced diagnostics in all facilities up to the medical college. As a result, the entire laboratory technician workforce is idle or just collecting samples. There is no quality assurance in the outsourcing, on timeliness, or accuracy. Some of the states have done transfers of PPP for certain investigations, like imaging, or for a few higher-end tests. So, it’s a very varied pattern in the country. I think it should be the task of NHSRC or similar national institutions to compile the state-wide reports on this and share it in the public domain to promote cross-learning. (We are trying to document the current situation voluntarily, but that is work in progress. There are three past assessment reports or case studies of 2018 from Maharashtra, Chhattisgarh and Andhra Pradesh, done in collaboration with NHSRC, but we did not locate anything recent.)
MS: When the FDSI started up, it was recommended that high-volume, low-cost tests can be done in-house, like blood hemoglobin or blood sugar estimation in any sub-centre, whatever can be done with a semi-autoanalyzer at a PHC. This would include the standard blood renal, lipid and liver tests. Only low-volume and high-cost, advanced tech tests like thyroid hormones should be outsourced. This was itself based on the experience of a few states. Some states did pick it up. If you look at the NHSRC website, it mentions eleven states that have gone for an outsourced model or a PPP contract for lab services, and the remaining states are doing it in-house. But there were challenges.
Constructing contracts for procuring diagnostic services for a state-wide system was not easy. States differed in what was to be outsourced and what was in-house. The integration between the two modes of organizing diagnostics, outsourcing, and in-house testing was confusing. Earlier, all diagnostics that were done in-house were priced and the user fees thus collected were a major source of funds for hospital development committees. This practice of user fees was continued for the basic tests which were done in-house, but now the costlier tests that were being outsourced were done for free. This could lead to a situation where basic tests were less utilized while high-end tests that brought in higher revenues to the private partner were over-utilized. User fees for in-house tests were removed in Maharashtra, but I am not sure about other states. Given these problems of contracting and gaming the system for profits, the choice of the outsourced private agency could often be a public organization. Like in Maharashtra, it is the HLL, a public company. In Tamil Nadu, higher-end imaging diagnostics are provided by TNMSC, which is then not really outsourcing, but a different form of organizing public services. In other services, Tamil Nadu has not gone for any outsourcing.
With the introduction of IPHL and BPHUs, there is a renewed focus on moving back to providing the tests in-house. There are funds available, and there is much interest in both the purchase of equipment and building up of infrastructure as per the deadlines, even if the latter is not always essential. The IPHL were modelled on Hamar labs in Chhattisgarh to provide all tests in-house making use of hub and spoke mechanisms as necessary. It is not a model that calls for outsourcing.
AGS: Linked to the same question, is a hub-and-spoke mechanism the new norm? With high-tech, high-cost tests done in the hub and low-cost, low-tech, high-volume tests done at the spoke. It could be operationalized as PPP or completely government-based as in Tamil Nadu.
YJ: Yes, this makes sense, especially if all of it, both hub-and spoke is by public providers. But it still needs far more improvement. The sort of detailed guidance that Tamil Nadu is providing is not available in other states. Other states could learn from it. But I think the hub-and-spoke models are as good as the health system overall is in different states. In Madhya Pradesh, it is in tatters. There is no punitive action for delayed reports or for no reports coming in. For example, if someone submits a sample for HPLC (High-performance liquid chromatography) for diagnosis of sickle cell disease, there is almost no assurance of the report coming in, unless someone calls up and sends a person to the hub to get the report. The other problem is sample transport. As of now, it is far too uncertain and unreliable. It needs specific investment in this component. I don’t think sample-transport through drones has come of age, though there are a few experiments. So it will have to be people in vehicles. In tuberculosis, sputum sample transport has become institutionalized with the district as the hub, but for others, it is the local courier with all its inefficiencies and inequities in coverage.
MS: I think the hub and spoke model is here to stay and actually enables us to carry out a larger number of tests, even at the peripheral level facilities. If not for this, patients would need to be referred to a higher facility or move to the private diagnostic centres to get the full complement of tests prescribed. Patients having to visit multiple laboratories often in the private sector to get their full complement of tests done is a practice that should stop completely. Peripheral facilities need the consumables for sample collection, and then transport could be via a local PPP or in-house like the “diagnostic runners’ that Tamil Nadu employs. And reports can and should be sent back digitally. It has been taking time for some of the states to stabilize, but it has to be done. I also think that if BPHUs act as the hub for tests from PHC and SC instead of transporting all the way to the district lab or a state lab, much can be achieved. Only some tests like biopsy samples in cancer diagnosis need to go to district or regional sites. Even for this, a single-state laboratory is not a good idea. However, one caution: when attention shifts to what is going to the hub, outsourced or not, the importance of quality laboratory work for the remaining in-house facility-level tests should not be lost. Unfortunately, that happens all too often. As a result of inefficiencies in both modes of organization of testing, though we have an impressive list of tests to be provided, practically, we have seen that across many states, the real number of tests is actually a small subset of this list of essential tests.
YJ: I have another major concern with the hub and spoke strategy. How does this model work for emergency care requirements? A large proportion of diagnostics are needed for emergency care, whether it is in the labour room or whether it is in the intensive care units that have been mandated at all district hospitals and even at some CHC levels. You cannot expect a hub-and-spoke model to answer the emergency requirements for diagnostics.
MS: This problem is largely addressed by the fact that facilities that are actually providing emergency care are also the hub-laboratories, for example the District Hospitals or medical college hospitals. This of course has to be ensured.
AGS: Just to add to these issues. Another field observation is the long waiting hours for patients in a primary healthcare facility to get their results. They often have to return another day, and when this happens for routine chronic illness follow-up it becomes impossible. So this, again, will delay and discourage the patients. This is a challenge in the organization of the service delivery and in how it’s been structured.
MS: I think most tests can be done within the same hour or at least by afternoon. Outpatients should be functional in the afternoons for such follow up. Rarely it can extend to the next day. This is more feasible with in-house tests or having more hubs and an efficient sample transport system. For tests sent to a hub, whether outsourced or not, there will be a sample collection cut off time.
AGS: One of the big leaps forward in recent times is a shift in TB diagnosis to a much greater, almost exclusive reliance on molecular diagnostics- CBNAAT and TrueNAT in place of microscopy. How is that faring? And access to X-rays too?
MS: CBNAAT has been difficult to establish below medical colleges and DH because of the supporting infrastructure needed. In practice, in most states, Truenat has been used, but this too at the district level mainly and to some extent sub district level too. Block-level access is limited, and below blocks, molecular diagnostics for TB are not even attempted. Whereas diagnostic microscopy can extend to the PHC. The tuberculosis programme (NTEP) is one programme where public services provide support to patients who seek care even in private sector. The volumes needed to test and centralization of testing leads to delays and even service gaps. But there is also a problem with getting reagents. There have been times when districts are asked to procure reagents, which is difficult.
YJ: My main concern with these innovations is the readiness with which we undermine and decrease access to systems we have built up over decades before the new technology is really deployed. Diagnostic microscopy must be retained and must continue to contribute in a major way to diagnostics. A premature withdrawal is uncalled for. Even later, when TrueNAT has become the main diagnostic, for professional reasons, the skills and practice of microscopy must be retained.
AGS: Another burning question is on irrational diagnostics. PPPs for high-cost packages and so-called deluxe package, leads to a proliferation of their use. So it’s not just in terms of affordability, but also in terms of ethical practice, it’s becoming a huge challenge. How can we effectively regulate that access to diagnostics remains rational, especially for the poor?
YJ: Irrational use of diagnostics, parallels and shadows irrationality in the use of drugs also. The ways to handle irrationality are the same, and we can learn from past work on promoting rational drug usage experience. Medical audits and prescription audits must include both drugs and diagnostics. Unfortunately, medical audit processes in our health system have not been given the importance that they deserve, and I think we need to get this in place. The other is, even at a policy level, to disallow packages of test approaches, where when one test is required, a package of 10 tests could be ordered. A very frequent practice in the private sector. The other is protocols for the indications and frequency of testing in chronic illness patients on regular follow-up.
I would caution that in public services, under-utilization is still the pattern. However, irrational overuse is creeping into public services like railways, defence and even central government health services also. Again, the way forward is in medical audits. A related issue is the quality assurance of diagnostics. Too little is said and done about it.
AGS: There is a strong promotion of ‘point-of-care’ tests for infections and NCDs, and this could avoid pressure on laboratories. What is your opinion and the cautions with regard to this?
YJ: There is merit in going for point-of-care tests. Clearly, that cannot be denied. But one big concern is whether the trade-off on diagnostic accuracy is justified by the decreased turn-around time in getting the report. Delayed reports can lead to the denial of care and adverse outcomes. But, less accuracy may make a second round of confirmatory tests mandatory. When point of care tests were under innovation for sickle cell anaemia, the benefits were obvious, for access to the gold standard, the high tech HPLC test is limited. There were soon over 98 innovators vying for ICMR approval. But post-approval in every batch of POC tests, is the quality and therefore the diagnostic accuracy the same. Currently, we cannot judge this, and therefore the HPLC remains in its confirmatory role.
My second concern about point-of-care tests is that they are often temperature sensitive with short shelf-lives and, under our hot climate particularly prone to error. Yet another concern is the loss of other laboratory skills as POC tests take over. And finally, they are much more expensive than the tests they replace. After introducing it, we do not have the money to keep it going. I fear this may happen in tuberculosis. In summary, the four concerns are uncertain quality, temperature concerns, attrition of skills and finally the costs.
MS: I would argue that POCs could be a good value addition if planned well. Also, the decision on introduction must be informed by cost-effectiveness studies that take the costs of confirmation, and the problems of diagnostic accuracy into consideration. I am more hopeful that many of these problems would be addressed and we would arrive at the right mix of POC and laboratory-based tests. The emphasis would be on continued learning and adaptation.
AGS: What investigation, including point of care techniques, are currently available with the ASHAs or community health workers? Do you also think there is scope to increase this?
YJ: The system tends to trivialise the capability of what peripheral health workers like ASHAs and CHOs. Presently, most places in the country are allowing them only a rapid diagnostic test for malaria, not even for dengue, and the urine pregnancy test (UPT). In my work in an NGO, we were allowing almost eight to nine tests to our community health workers. This included blood sugar, urine albumin and sugar, sputum collection for tuberculosis testing, dengue, and solubility test for sickle cell. They were also collecting blood smears for malaria and filaria-but this assumes the support of a nearby PHC or block laboratory to send it to.
AGS: One of the problems of both irrational care and lack of diagnostics acting as some sort of vicious cycle is Anti-Microbial Resistance. So, are there other ways to mitigate this problem?
YJ: We must not socialize the poverty of health systems. We say, “Oh, this is all that we can offer, because only this much is feasible”. We seek to dumb down and limit the use of diagnostics rather than see what it takes to implement them. If it’s a complex solution, so be it. Not every need for diagnostics can be solved by a point-of-care test. Antimicrobial resistance is now increasingly recognized as a great strain on the budget, on the healthcare system and on overall social health. Microbiological cultures are difficult to establish, and as of now, there are no shortcuts. While the damage of symptomatic treatment is most recognized with antibiotic resistance, it is also true of non-communicable diseases. Without good diagnosis, anginal chest pain indicative of a coronary artery disease cannot be recognized and treated, secondary epilepsies that admit of curative treatment are missed, the complications of diabetes on the eye, the heart and the kidney are missed and so on. In its absence, mere access will not lead to desired outcomes.
AGS: Where are we with molecular biology-based tests like PCR? We know they are introduced in the public health system, especially for TB and HIV care. These tests promise faster, more accurate diagnosis and better patient outcomes. But can we balance the potential benefits of these advanced technologies with the realities of primary healthcare delivery, particularly in rural and underserved areas?
YJ: So yeah, molecular biology tests are important, and they are here to stay. They are useful, but in a context, and I think they would only be supplementary tests to the usual, traditional diagnostic test for at least the foreseeable future that I can think of. I would certainly not be a champion of advising, even in tuberculosis, the replacement of microscopy with the molecular biology test that is being recommended by multinational champions. And I think that’s a dangerous way to dismantle a system that is already there, when there are concerns on the budgetary impact of molecular tests as well as the preparedness of the health system to deliver the molecular diagnostics to everyone. As of now, many states are offering only molecular biology for tuberculosis, only at a district hospital level, and only very few states may be offering it at a CHC level.
MS: There’s just one comment I want to add. Many of these are single-use platforms, and how do we view them versus multi-disease testing? There’s a huge capital cost that goes into investing when a government body actually procures such a platform. So, we need to be actually looking at this much more holistically and at multiple disease testing platforms.
AGS: Coming to the advanced Viral Research and Diagnostics Laboratories (VRDLs) established by ICMR. Under this scheme, 125 VRDLs (10 Regional; 25 State Level, 90 Medical College Level were established with a target of 42 more in the 15th Finance Commission period. Are these centres delivering care well?
YJ: This VRDL scheme was envisaged to help coverage of the entire country for timely diagnosis/identification of viruses during outbreaks of epidemics, for generation of data about viral diseases for facilitating quick deployment of resources & measures to save the human lives. Overall, except for the fillip during COVID-19, implementation is erratic. The data is collected in the NIE (National Institute of Epidemiology) data systems, but it seems to parallel the work of the IDSP (Integrated Disease Surveillance Programme). However, I could not find any annual reports of any of these labs that are published. We really are not doing well at a senior level in laboratory technology. I think our consensus should be that if it is part of service delivery, then it is better placed under the Department of Health and integrated with IDSP rather than a stand-alone under DHR and ICMR. ICMR is not geared for service delivery. ICMR’s focus should be largely on research and innovation, where a lot more is being done. Implementation, including much of implementation research, is much better under the Dept of HFW and its network of research institutions.
AGS: What about microbiology and pathology? Are these being implemented at the same pace?
YJ: It is essential that both these services with specialist support is available at the district level. It cannot be limited to medical colleges. A good level of microbiology services has become urgent with the rise of AMR. Similarly, with the rise of NCDs, including cancers, cell and tissue pathology is also essential. In the latter, there is a considerable scope for telemedicine support, for the biopsy slide is, after all, a largely visual examination. Teleconsults are also important since biopsy diagnosis necessarily requires a three-way communication between the clinician, the person who took and prepared the sample and the senior pathologist whose opinion is final. Many hub-and-spoke models which introduce biopsy diagnosis do not invest in such consultation on a regular basis, and this leads to delays, wasted efforts (as when the quality of the sample is questioned) and diagnostic errors. Such regular consultation is also useful in microbiology reporting. But, given the huge delays in turn-around time, we must introduce time standards for reporting and tackle the reasons for delays. AI could have a supportive role.
The other big challenge in this is getting the specialists in place. We need all three- the pathologist, the microbiologist and the biochemist in place. For the latter two, there are those with non-MBBS postgraduate qualifications, and this could help. The position is much improved, but much more innovation is required to address this challenge. In the interim, teleconsultations, facilitated referrals, and other innovations must step in. This is not a long-term agenda, it is long overdue.
AGS: We are running out of time and space to discuss radiology. We know that in most states X-rays are available up to CHCs and in some states it is being extended to PHCs. We know that as part of the TB elimination programme, hand-held X-rays have been introduced widely. We also know that most government medical colleges have CT scans, and some district hospitals also. But if there are a few comments that could be welcome.
YJ: I think this has to be part of a separate conversation. The expansion in radiology services is welcome, but the rollout is uneven across states. If there is a radiology technician in place to do the imaging, then with telemedicine, it becomes possible to get a radiologist consultation. These developments in technique and technology are rapidly changing the scene. In radiology, even more than in pathology, the introduction of AI shows great promise. But I must emphasize that AI must be used as an aid to the radiologist and not a substitute for him or her. I am not talking about the loss of jobs but about the nature of technology itself. AI systems cannot be held accountable, and their interpretation has limitations. But yes, it can help.
MS: I was going to say that there are cases where AI is helpful. It reduces the work-load in mass screening as being done for TB, it hastens reporting, prevents missing out on cases and increases the confidence on the report. We shouldn’t see that as a replacement of somebody’s job or somebody’s role, but adding value and improving the diagnostic reporting.
AGS- Could we attempt a joint summary?
YJ/MS/AGS: The recognition of the importance of diagnostics in public health services is most welcome and long overdue. In practice, in most states at the HWC level, only 5/14 tests are being done, and at the PHC level, only about 20/64 and at the CHC level, also about the same. At the district level, the rollout of IPHLs and BPHUs is far behind schedule. Therefore, despite the policy initiatives, the situation on the ground seems to be a persistent out-of-pocket expenditure in the public health facility due to user fees for diagnostics or many diagnostics having to be done outside in private laboratories.
The priority should be to develop district-specific plans to achieve universal access to the listed diagnostics within the next 18 months, which was the deadline the government had set itself. It is important to set up a full-time technical team either within the directorate or the SHSRC (if the latter is functional) to expedite this. Such a team is required because it’s not a one-time effort, but a process of constant visits, audits, learnings, feedback and improvements and reviews that must proceed to address the barriers. We can learn many technical innovations from existing and past PPPs, but for reasons discussed, scaling up is more likely to happen if both hub and spokes are publicly owned and administered. And while the inputs in terms of infrastructure and human resource are important, the processes in terms of consumables and minor equipment logistics, decisions on in-house versus testing at the hub, transport of samples, promptness of reporting, quality assurance and tele-consultations, especially for pathology and microbiological tests require much greater attention, learning and adaptation. Process improvement need not wait for infrastructure improvements.
The shift to molecular diagnostics and point-of-care (POC) kits is welcome, but there must be no weakening of existing laboratory systems in anticipation of such a shift or even after this shift. Good health technology assessment (HTA) studies, health systems preparedness assessments and quality assurance mechanisms should precede scaling up of molecular diagnostics and POC. The VRDLs must be much better integrated with the public health laboratory structure, and its implementation done by or in close coordination with the NHM structure.
In summary, for access to mean effective access, a much better implementation of the diagnostics component is called for. Here, both policy and finances may not be as much of a barrier as the ability to build public institutions that are constantly learning, adapting and improving.
Acknowledgments:
The information about the current situation in the states was collected by an interview schedule administered by one of the RTH collective friends in each of the states. We thank every one of them for the voluntary time and effort they have given to this work. We also gratefully acknowledge Mr Sajan Bhandarkar and Mr Sushil Patil for their contribution to understanding the background and developing this conversation. Our thanks to Prof T Sundararaman for the final editing of this conversation and to Ms. Roubitha David for the recording and transcription.
Reading List:
- Understanding what really helps to ensure access to diagnostic services in the Indian Public Health System: a realist synthesis of the Common Review Mission reports (2007-2021)
- State of Health in Rural India by TRIF (Section 5 covers diagnostics)
- Introducing a national essential diagnostics list in India by folks from ICMR
About the Participants:
Dr Adithyan G.S. is a public health professional with nearly a decade of experience spanning national, international, and field-level engagements. He has worked with various organizations such as the WHO South-East Asia Regional Office (SEARO) and the National Health Mission (NHM) in Tamil Nadu, as well as in academia. His expertise lies in primary health care, universal health coverage, and health systems strengthening, with a strong focus on policy implementation and program management. He holds a master’s degree in public health from the Tata Institute of Social Sciences and is currently pursuing his PhD in Public Health (on Primary Health Care) at IIT Madras.
Dr Mayank Sharma is a public health practitioner with experience in strengthening health systems in India. Currently serving as Senior Program Officer – Health Systems Strengthening at PATH, an international nonprofit, Dr. Sharma is based in New Delhi and works on projects that enhance primary healthcare delivery and health innovations across various Indian states and countries in the South Asia region.
Dr. Sharma has previously worked with the Ministry of Health and Family Welfare, Government of India, as Consultant for Public Health Policy and Planning. Over the last decade, he supported the National Health Mission (NHM) and its sub-programs, including Tuberculosis control, Sickle Cell Disease elimination, and Non-Communicable Diseases (NCDs). He was extensively involved in the initial rollout of India’s flagship program for comprehensive primary healthcare, ‘Ayushman Bharat – Health and Wellness Centres,’ now known as ‘Ayushman Arogya Mandir.’
Dr. Sharma holds a master’s degree in public health from the Tata Institute of Social Sciences.
Thanks for considering this ever neglected topic! There is so much more to the Diagnostics mafia world. Waste management and Injury or exposure protocols – including for radiation, chemical fumes, infectious hazards are not in place. Neither is regulated disposal into the environment. Hep B vaccination of those working in private and public sector labs is not brought up by most employers unless fought for. Dubious Widal continues to be one of the most favourite tests even in District hospitals let alone in small and large private sectors while true surveillance of Typhoid fevers is lacking. Similarly of other endemic conditions. CT and ‘panel’ testing has become a fashion after COVID. Full body check up packages offered by private entities have creeped into villages. Wish public sector could at least establish sample collection and report dispensing and intervention door to door for disabled, single and vulnerable. Quality of diagnostics techs was always poor at entry because of the casual attitude of the system towards ‘Para’ branches. Now because of the failing med ed systems as well, we will increasingly have a deadly combination of quack clinicians and diagnostic technicians with charges steadily and surely rising like that of gold! Only hope is on curated AI then!
Hope these conversations reach the ears and space in between the two of some doer! Thanks again.