Understanding barriers to diagnostics access in Madagascar

Agricultural labourers walk through a field in Madagascar

Working with the community-based organisation Ankizy Gasy, we interviewed 43 individuals living in rural and semi-rural communities in Madagascar to understand availability of diagnostics, and to understand barriers to accessing diagnostics.

This rapid assessment found a complex diagnostics environment marked by high out-of-pocket spending for diagnostics relative to income, relatively long distances to get to primary healthcare centres, doctors prescribing antibiotics with incomplete diagnostics regimens or no diagnostics at all, poor clinical practices on diagnostics (such as use of inaccurate terminology), and insufficient data about stockouts. We noted that because rapid malaria tests are provided for free, doctors offer these more regularly, but upon a negative result are unable to recommend additional tests because of the cost barrier. We also found that rural communities overwhelmingly wanted more accessible and affordable testing – and perceived that people they knew were dying from ‘unknown diseases’.

We made several observations of issues that need addressing:

  • Cost-prohibitiveness of diagnostics and ensuring tests are fully funded by the state.
  • Accurate and respectful descriptions of diagnoses to patients.
  • A lack of outreach to rural communities on available and free tests.
  • More in-depth and comprehensive analysis of availability and functionality of diagnostics equipment.
  • Better guidelines around abortion care, including what needs to be done if there is an incomplete abortion, and what to say to patients.
  • Inappropriate use and prescription of antibiotics. Risks of antimicrobial resistance – despite viral infections, individuals are given antibiotics, as well as antivirals.
  • ‘Fatigue’ as a common assumption and diagnosis, despite incomplete testing regimens.
  • The lack of availability of COVID-19 rapid tests at primary healthcare level.

The following urgent reforms are needed:

  • Universal health coverage for diagnostics | Tests that are fully funded by the state, and made available in all public health facilities.
  • Better clinical practice around diagnostics | Including accurate and respectful communication of confirmed diagnoses to patients and avoiding prescription of antibiotics if diagnostics regimens are incomplete.
  • Trained & salaried community health workers bringing rapid tests to communities | Poor road infrastructure means that a 5.5km trek to the nearest primary healthcare centre is a deterrent for access to tests.
  • Facilities with point-of-care testing closer to rural communities | As aforementioned, there is poor road infrastructure and travelling to healthcare centres often takes an entire day, with many taking time off from informal jobs and losing a days’ income.