Exclusive interview: Dr Mikashmi Kohli on why essential diagnostics matter in realising universal healthcare

Health Issues India talks to Dr Mikashmi Kohli, PhD, a postdoctoral fellow of the Department of Epidemiology, Biostatistics and Occupational Health at McGill International TB Centre, about a recent study she co-authored with Dr Madhukar Pai about the importance of essential diagnostics in the path towards universal healthcare. The study, “Essential Diagnositcs: A Key Element of Universal Health Coverage”, can be accessed here.

• Your study goes to great lengths to emphasise the importance of diagnostic tests in the push for universal health coverage? Why have health systems overlooked this until now?

One possible reason for the health systems or even major organizations overlooking the importance of diagnostics is because of our limited vision. In 1975, the World Health Assembly asked WHO to assist member states in procuring essential drugs with good quality and reasonable costs. That was an important concern at that time and measures were taken to solve the problem of inadequate access to medicines. There have been access campaigns for medicines for decades now, but nothing like this has ever happened for diagnostics because it was thought that medicines alone saved lives. However, we forgot that without diagnostics, medicine is blind and improper diagnosis can lead to over or under-utilization of drugs causing drug resistance or increased mortality, respectively. Thankfully, WHO now acknowledges the importance of essential diagnostics, and has published the first Essential Diagnostics list last year Additionally, India is the first country to develop its own national essential diagnostics list which is inspiring other countries to do  the same.

Another reason could be the lack of quality point of care and affordable diagnostic tests for many years. Most large diagnostic companies are in developed countries and they developed products designed for centralized laboratories. They were not interested in investing in simple, affordable, point-of-care solutions. In the absence of rapid tests at the point of need, clinicians in low/middle income countries have learnt to rely on their clinical skills and empirical therapies. However, things have changed now and there are many good point-of- care tests available (see WHO Essential Diagnostics List). It is important for the doctors to be aware of these newer technologies and administer relevant tests before reaching a final decision on treating the patient.

“The stakeholders need to give diagnostics their due importance. In particular, the Indian government needs to invest more in health, and strengthen diagnostic and laboratory capacity across the various levels of the health system. It is great that India is developing a National EDL, and we hope this list will be implemented to improve access to essential tests.”

• What do you identify as being the biggest obstacle to patients accessing essential tests and other diagnostics?

My first concern is that these diagnostics tests are not even available to be accessed by patients. The biggest obstacle is the unavailability of affordable diagnostics at the primary healthcare level. In a pilot study in 3 districts in India that we conducted, we found that some tests listed in the WHO EDL were not available at all in any of the districts. Also, for infectious diseases like hepatitis B and HIV, the availability was less than 50% in some districts. We are now doing similar studies in other countries to document access to tests on the WHO EDL.

• Affordability is a major hurdle for accessibility in India. What do you think is the solution for this?

There are many possibilities to cross this hurdle. The stakeholders need to give diagnostics their due importance. In particular, the Indian government needs to invest more in health, and strengthen diagnostic and laboratory capacity across the various levels of the health system. It is great that India is developing a National EDL, and we hope this list will be implemented to improve access to essential tests.

India has a huge private health sector and we need to utilize it via public-private partnerships.

Via innovative PPP models, private labs, patients, and test manufacturers can all benefit. IPAQT is one such example working for TB and HIV/hepatitis diagnostics. In our study published in the lancet ID, one of the districts outsourced the diagnostic testing to a private laboratory which helped get better access to diagnostics for the patients. 

“Without diagnostics, medicines cannot be optimally used. Can you imagine managing a diabetic patient without having access to blood sugar testing? Or treating tuberculosis without knowing whether the patient has drug-resistant forms of the disease?”

• Your study states that poor-quality care is a bigger driver of mortality than lack of access to healthcare. How does improved access to diagnostics improve the quality of patient care?

Without diagnostics, medicines cannot be optimally used. Can you imagine managing a diabetic patient without having access to blood sugar testing? Or treating tuberculosis without knowing whether the patient has drug-resistant forms of the disease? Treating patients without proper diagnostic testing can lead to either overtreatment which may lead to drug resistance or no treatment at all which can have bad consequences for the patient.

Good quality patient care can only be achieved if the patient has access a complete unfragmented healthcare system and diagnostic testing plays a crucial part in that.

• Your study analysed three Indian districts and found all three had “major gaps in test availability”. Is this reflective of India’s public health system as a whole?

That study was a pilot – the first study to benchmark access against the WHO EDL. We are now in process of conducting a nationwide study which will help give an overall understanding of the national diagnostic landscape in India. This time, we will benchmark against India’s national EDL.

“In a recent United Nations report, it was estimated that if the current trend of “treat and then test” is persistent, by 2050 drug-resistant infections could kill 10 million people annually.”

• You also mention “huge variations across the districts/states”. Inequality in terms of the accessibility and quality of care is something Health Issues India has covered before. In terms of diagnostics, how do government bodies at the central, state, and district levels resolve this issue?

At the central level, without a doubt the government needs to increase their budget allocated for the health sector. India spends just over 1% of the total GDP on healthcare. For a population of over 1.3 billion, this would need to be increased to at least 2.5% in order to achieve universal health coverage.

At the state and district level, it is important to judiciously use the funds allocated. Creating awareness amongst the medical officers and other laboratory staff on the importance of diagnostics will help. Also, regular monitoring and audits for availability of kits, calibration of instruments and method of performing the tests in each district will be useful.

• Lack of access to quality diagnostics is linked to drug resistance. For our readers, could you expand on this connection?

When you go to a doctor’s clinic with a problem and the doctor prescribes you drugs without doing any diagnostic tests, it is like shopping in a candy store where you can pick whichever candy you like and if you don’t like the taste of that candy, you can always get another one. However, doing this when prescribing drugs can be very harmful for the body. If you take the wrong drug, firstly it won’t improve your symptoms and secondly, the microbes inside our body start becoming resistant to that wrong drug. So, in future, if ever you actually need that drug, it will not work against the microbe. This is how the problem of antimicrobial resistance is now a major concern globally. In a recent United Nations report, it was estimated that if the current trend of “treat and then test” is persistent, by 2050 drug-resistant infections could kill 10 million people annually.

In order to avoid all this, it would be smart to get a diagnostic test done, be sure of what you are suffering from and then take required drugs to treat the illness.  

“I am glad that diagnostics is starting to get its due importance in the field of global health. The WHO EDL and India National EDL is now inspiring many countries to develop their own national essential diagnostics list. There are many developments happening in this field and people are now understanding that diagnostics matter.”

• What should be the priority in expanding access to diagnostics for patients going forward?

First priority is to have availability of diagnostics that covers equipment, consumables and infrastructure too. If all this is not available, how can it be accessed by the patients. The public and private sectors need to start working together and find ways to make diagnostics accessible to the patients. And of course, adequate funding will be required to make this a reality.

Additionally, we also need to spread awareness on the importance of diagnostic testing to shift the paradigm from empirical treatment to treating the patients with diagnostic evidence.

• Do you have anything you wish to add?

I am glad that diagnostics is starting to get its due importance in the field of global health. The WHO EDL and India National EDL is now inspiring many countries to develop their own national essential diagnostics list. There are many developments happening in this field and people are now understanding that diagnostics matter. Many companies are developing point-of-care rapid tests and evaluating them in resource-limited settings. But it’s a long road and we are just getting started!

Antimicrobial resistance is increasing at a rapid rate globally and now we can say that nothing in the field of medicine makes sense except in the light of diagnostics! It is important that governments of every country actually start delivering what is being said or written in documents about accessibility to good quality healthcare system and I will reiterate that diagnostic testing plays a crucial part in it. Our promises need to be backed up by relevant actions too.

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Dr. Mikashmi Kohli is a postdoctoral fellow at McGill University, Canada. She completed her PhD in Molecular Medicine from the All India Institute of Medical Sciences, New Delhi. Having worked in India on diagnosis of TB, especially extrapulmonary TB, she developed a strong interest in diagnostics and EPTB research.

Currently, she is working on understanding the availability and access to diagnostics in primary healthcare settings in LMICs and ways to improve the diagnostic landscape in these countries. She has also been working with the Cochrane Systematic Review team on diagnostic accuracy of molecular tests in TB. She is passionate about diagnostics in Global Health and implementation of basic science research in the global health scenario.