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Review
. 2021 Nov 27;398(10315):1997-2050.
doi: 10.1016/S0140-6736(21)00673-5. Epub 2021 Oct 6.

The Lancet Commission on diagnostics: transforming access to diagnostics

Kenneth A Fleming  1 , Susan Horton  2 , Michael L Wilson  3 , Rifat Atun  4 , Kristen DeStigter  5 , John Flanigan  6 , Shahin Sayed  7 , Pierrick Adam  8 , Bertha Aguilar  9 , Savvas Andronikou  10 , Catharina Boehme  11 , William Cherniak  12 , Annie Ny Cheung  13 , Bernice Dahn  14 , Lluis Donoso-Bach  15 , Tania Douglas  16 , Patricia Garcia  17 , Sarwat Hussain  18 , Hari S Iyer  19 , Mikashmi Kohli  20 , Alain B Labrique  21 , Lai-Meng Looi  22 , John G Meara  23 , John Nkengasong  24 , Madhukar Pai  25 , Kara-Lee Pool  26 , Kaushik Ramaiya  27 , Lee Schroeder  28 , Devanshi Shah  29 , Richard Sullivan  30 , Bien-Soo Tan  31 , Kamini Walia  32
Affiliations
Review

The Lancet Commission on diagnostics: transforming access to diagnostics

Kenneth A Fleming et al. Lancet. .

Erratum in

  • Department of Error.
    [No authors listed] [No authors listed] Lancet. 2021 Nov 27;398(10315):1964. doi: 10.1016/S0140-6736(21)02275-3. Epub 2021 Nov 8. Lancet. 2021. PMID: 34762858 Free PMC article. No abstract available.
No abstract available

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Conflict of interest statement

Declaration of interests TD declares minor shareholdings and an unpaid directorship at CapeRay Medical, which was an institution-based activity. WC declares he is the chief executive officer of a telemedicine company providing general medical consultation. All other authors declare no competing interests.

Figures

Figure 1
Figure 1
Diagnostics are essential for universal health coverage Diagnostics are used to guide treatment of patients as well as population-level surveillance, both of which affect health and economic outcomes. These outcomes, in turn, have a multifaceted and substantial impact on achieving specific goals of universal health coverage.
Figure 2
Figure 2
Cascade of care for different health conditions Figure shows that the diagnostic gap is the largest gap for five of the six conditions. For hepatitis B virus infection, the only study is of Australia. Further details regarding the data shown are included in the appendix (pp 4–5).
Figure 3
Figure 3
Availability of basic diagnostics by tier in ten low-income and middle-income countries in various years, 2007–18 The heat map provides information on the proportion of facilities at each of the two levels that had specific diagnostic investigations available. Countries were ranked in descending order of average availability of all investigations, taking the average across both tiers. Average availability was calculated first by weighting facilities to be representative of their numbers nationally, and then simple averages of availability were taken, omitting those investigations for which no information was available. Availability was also sorted left to right in decreasing order of availability across countries (ie, the most readily available diagnostics were at the left of each of the two panels, and the least available at the right). At both levels of primary care, ten basic tests and examinations were included, while four more advanced investigations were added at hospital level, which require laboratories or more advanced imaging.
Figure 4
Figure 4
Maps of Malawi and Senegal population access to HIV and glucose tests Proportion of the population in Malawi (county level; A) and Senegal (commune level; B) that have access to HIV and glucose tests. Access is defined as being within 2 h travel of a facility offering a test: data for Malawi are for 2013–14, grouped into 256 counties; data for Senegal are for 2012–13, grouped into 433 communes.
Figure 5
Figure 5
Global market shares of diagnostics and pharmaceutical purchases in 2015–19 by world region The majority of global purchases of diagnostics and pharmaceuticals are from high-income countries in North America and Europe. *Germany, the Netherlands, Italy, Hungary, and Denmark. †China, Japan, South Korea, Australia, and Saudi Arabia. ‡Latin America, Russia, India, Indonesia, and rest of the world. Sources for this figure are included in the appendix (p 14).
Figure 6
Figure 6
Global market share for four top suppliers of diagnostics and pharmaceuticals, by region of headquarters in 2015–19 Manufacturers with headquarters in high-income countries dominate global supply of diagnostics, but provide a much smaller proportion globally of pharmaceuticals.
Figure 7
Figure 7
Allocation of management of conditions, by tier and level of acuity These 19 conditions are derived from predicted top 20 conditions in the global burden of disease for 2030 and 2040 (a total of 23 distinct conditions) in table 4. Trauma (here) combines four global burden of disease conditions, namely falls, interpersonal violence, road traffic injuries, and self-harm (table 4). Antenatal care refers to neonatal preterm birth (table 4). Neonatal encephalopathy (table 4) is not included here (the level of care required is only at referral hospitals in most LMICs, and not widely available). Congenital defects (table 4) is also not included here, given that more guidance is required for LMICs. Hence, 19 distinct conditions are shown. LMIC=low-income and middle-income country.
Figure 8
Figure 8
Diagnostics capabilities required at each tier, to address top 20 future global burden of disease conditions in national EDL (ie, GBD-20 EDL) More complex equipment needs (and associated workforce skills) are required at higher tier facilities. EDL=essential diagnostics list. POC=point-of-care.
Figure 9
Figure 9
Digitalisation facilitates innovative tools to support diagnostic testing Digitalisation and its potential benefits rely on the integration of two particular technologies, namely information and communications technology and artificial intelligence. This figure was produced by Catherine Hidalgo for this Commission.
Figure 10
Figure 10
Median benefit–cost ratios to diagnose and treat six conditions in low-income and middle-income countries Data are from table 5. Middle-income regions include Latin America, and the Middle East and north Africa. Low-income regions include South Asia and sub-Saharan Africa.
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Comment in

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