Practice Implementing a mobile diagnostic unit to increase access to imaging and laboratory services in western Kenya Roshni Dhoot,1 John M Humphrey,2,3 Patrick O'Meara,3,4 Adrian Gardner,2,3 Clement J McDonald,5 Kelvin Ogot,6 Sameer Antani,5 Joseph Abuya,7 Marc Kohli8 To cite: Dhoot R, Humphrey JM, O'Meara P, et al. Implementing ABSTRACT Summary box a mobile diagnostic unit to Access to basic imaging and laboratory services remains a increase access to imaging major challenge in rural, resource-limited settings in sub- and laboratory services in ► Access to basic imaging and laboratory services Saharan Africa. In 2016, the Academic Model Providing western Kenya. BMJ Glob Health in rural, resource-limited settings in sub-Saharan 2018;3:e000947. doi:10.1136/ Access to Healthcare programme in western Kenya Africa is limited, particularly in areas facing a high bmjgh-2018-000947 implemented a mobile diagnostic unit (MDU) outfitted with burden of tuberculosis. a generator-powered X-ray machine and basic laboratory ► In 2016, the Academic Model Providing Access to Handling editor Seye Abimbola tests to address the lack of these services at rural, low- Healthcare programme implemented a mobile diag- resource, public health facilities. The objective of this paper nostic unit (MDU) with a generator and wireless digi- Received 11 May 2018 is to describe the design, implementation, preliminary tal radiography which has taken over 4500 X-rays to Revised 8 August 2018 impact and operational challenges of the MDU in western date, detecting abnormalities in approximately 30% Accepted 9 August 2018 Kenya. Since implementing the MDU at seven rural health of images. facilities serving a catchment of over half a million people, ► Benefits of the MDU include high rates of detection over 4500 chest radiographs have been performed, with of abnormal X-ray findings, improved patient access © Author(s) (or their one or more abnormalities detected in approximately to radiology services and increased patient engage- employer(s)) 2018. Re-use 30% of radiographs. We observed favorable feedback ment; transmission of primary radiology reports is a permitted under CC BY-NC. No and uptake of MDU services by healthcare workers and challenge. commercial re-use. See rights patients. However, various operational challenges in the ► Implementing a mobile vehicle equipped with X-ray and permissions. Published by design and construction of the MDU and the transmission BMJ. capabilities and basic laboratory services is a fea- and reporting of radiographs in remote areas were sible and potentially scalable means to increase 1School of Medicine, Indiana encountered. Our experience supports the feasibility of access to these services in resource-limited areas. University, Indianapolis, Indiana, deploying an MDU to increase access to basic radiology USA and laboratory services in rural, resource-limited settings. 2Department of Medicine, Indiana University, School of Medicine, Indianapolis, Indiana, The optimal strategy to increase access to USA radiographic imaging in these settings is not 3Academic Model Providing BACKGROUND well understood. Access to Healthcare (AMPATH), Access to basic imaging and laboratory Access to radiology services in resource-con- Eldoret, Kenya 4Wataalamu Repair and services remains a major challenge in rural, strained settings in sub-Saharan Africa is Maintenance, Eldoret, Kenya resource-limited settings in sub-Saharan particularly critical when one considers the 5National Library of Medicine, Africa. In Kenya, 74% of the population live unmeasured burden of tuberculosis (TB) National Institutes of Health, in rural areas with low population density, and the major role of chest radiography in Bethesda, Maryland, USA serviced by health outposts that lack basic TB detection and control.4 Kenya is among 6Radiology and Imaging radiology equipment, trained radiologists and 30 countries that together carry the world’s Department, Moi Teaching and 1 5 Referral Hospital, Eldoret, Kenya laboratory tests. Moreover, 90% of Kenya’s highest country-level burdens of TB. The 7Department of Radiology, radiologists are estimated to be working 2016 Kenya TB Prevalence Survey found a Moi University, Moi University, in urban settings, with 76% (80 of 105) of national TB prevalence of 558 cases per 100 College of Health Sciences, radiologists in Kenya concentrated in three 000 people, more than twice that of previous School of Medicine, Eldoret, 2 5 Kenya major cities. Similar disparities in access estimates by WHO. Moreover, more than 8Radiology and Biomedical to radiographic imaging services exist else- 40% of TB cases remained undetected and Imaging, University of California where in East Africa. In Uganda, for example, untreated. TB case detection has been shown San Francisco, San Francisco, 56% of patients requiring imaging receive to decrease with increasing distance from California, USA such services in urban areas compared with a hospital, with patients living further from Correspondence to 10%–13% of patients in rural areas, and an the facility at higher risk of more severe TB 6 Dr Marc Kohli; estimated 90% of radiographs performed do disease. Chest radiography is recommended marc. kohli@ ucsf. edu not have an accompanying imaging report.3 by WHO as a screening tool for TB given Dhoot R, et al. BMJ Glob Health 2018;3:e000947. doi:10.1136/bmjgh-2018-000947 1 BMJ Global Health its high sensitivity.4 However, the lack of radiographic 14 months without any functional X-ray unit. Several of imaging capacity in rural areas remains a major barrier to the facilities serviced by the MDU have only intermittent implementation of this recommendation. Several studies access to electricity and Internet. have described the use of mobile radiography units to Within the four sub-counties, AMPATH supports HIV address the burden of TB in rural areas.6–8 service delivery in 66 MOH facilities including one county The Academic Model Providing Access to Health- referral, three sub-county hospitals, eight health centres, care (AMPATH) programme is a consortium of North 53 dispensaries and five private owned/faith-based facil- American Universities working in collaboration with the ities. Two of these facilities, the county referral hospital Kenya Ministry of Health (MOH), Moi University College and one sub-county hospital, currently have functional of Health Sciences, and Moi Teaching and Referral X-ray facilities. The MDU currently travels to seven Hospital in western Kenya.9 By engaging in the delivery AMPATH-supported MOH facilities in Busia County on of health-promoting services to individuals and popu- the westernmost border of Kenya: Angurai, Bumala A, lations in low-income environments, AMPATH and its Bumala B, Khunyangu, Matayos, Mukhobola and Port partners aim to build health systems in the public sector Victoria (figure 1). On average, it takes approximately 2 that deliver and sustain essential healthcare services, hours to travel from the communities AMPATH serves to develop human capacity through training and education, Busia County hospital, at a cost of between 500 and 1500 advance research, eliminate health disparities and mutu- Kenyan shillings (US$5–15) by public transport such as a ally strengthen institutions. As part of this population motorbike, mini-bus or shared taxi. health strategy, AMPATH designed and implemented a truck called the mobile diagnostic unit (MDU) that was Design outfitted with an X-ray generator, computed radiography The MDU design, customisation and installation were system and gasoline generator. The MDU was first oper- performed locally. The MDU is a standard Isuzu canter ationalised in September of 2014. In 2016, the MDU chassis (3–4 tonnes) with a custom-designed, insulated/ was augmented with digital radiography and laboratory refrigeration box body, complete with integrally welded, testing. Following these upgrades, the MDU has trav- mild steel radiation shielding and washable interior plastic elled daily to rural health outposts within the AMPATH surfaces. The body was further customised with elements network to deliver radiology and laboratory services. The including a power control system, anchoring points for objective of this paper is to describe the design, imple- equipment, roll-out drawer-mounted AC generation and mentation, preliminary impact, and operational chal- fuel can. The design incorporates several elements aimed lenges of the AMPATH MDU in western Kenya. at safety including a negative pressure ventilation system, multipoint redundant electrical grounding, strategi- cally placed mild steel radiation shielding, ample inte- DESIGN AND OPERatION rior space and lighting, patient privacy curtain and an AMPATH program integrated ramp for non-ambulatory patients (figure 2). AMPATH started an HIV care and treatment program in Implementing a high-frequency X-ray generator in a 2001 and has since expanded to about 500 clinical sites mobile capacity, free from mains power, was challenging. in western Kenya that have enrolled over 200 000 patients Due to a lack of detailed information regarding peak with HIV with approximately 1500 new patients enrolling power consumption of the X-ray generator, the AC power each month.10 AMPATH also supports MOH delivery of generator was initially undersized, and the X-ray gener- primary healthcare, chronic disease care, specialty care ator would not consistently fire without power alarms and supports community activities including commu- and failed exposures. After extensive testing,