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Bringing MRI to Low- and Middle- Income Countries: Directions, Challenges and Potential Solutions

Sola Adeleke¹, Sanjana Murali², Hao Ding², Fope Adedeji³, Cathy Qin⁴, Johnes Obungoloch⁵, Tamir Sirkis⁶, Iris Asllani⁷, Ntobeko Ntusi⁸, Regina Mammen⁹, Udunna Anazodo¹⁰, and Thoralf Niendorf¹¹
¹School of Biomedical engineering and imaging sciences, King's College London, London, United Kingdom, ²School of Medicine, Imperial College London, London, United Kingdom, ³School of Medicine, University College London, London, United Kingdom, ⁴Department of Radiology, Imperial College Healthcare Trust, London, United Kingdom, ⁵Department of Biomedical Engineering, Mbara University of Science and Technology, Mbara, Uganda, ⁶Royal Berkshire NHS Foundation Trust, Reading, United Kingdom, ⁷Department of Biomedical Engineering, Rochester Institute of Technology, New York, NY, United States, ⁸Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa, ⁹Department of Cardiology, Essex Cardiothoracic Centre, Chelmsford, United Kingdom, ¹⁰Montreal Neurological Institute, McGill University, Montreal, QC, Canada, ¹¹Berlin Ultrahigh Field Facility, Berlin, Germany

Synopsis

Keywords: Low-Field MRI, MR Value, Accessible MRI; Affordable MRI; Sustainable MRI

While innovations in MRI technology continue to advance healthcare in the global north, there is a persistent disparity in MRI access and research opportunities in low- and middle-income countries (LMICs). Reasons for this longstanding disparity include technological, economic, geopolitical, and social factors. As awareness of the situation expands, concerted efforts are underway to address it by developing sustainable approaches designed with and for local communities. Here, we provide a framework of such approaches by tackling different aspects of MRI development and access in LMICs.

Introduction

MRI is a mainstay of diagnostic imaging and evaluation of various clinical conditions(1-9). Despite this essential role, it is estimated that 66% of the world lacks access to MRI(10-12). As low and middle-income countries (LMICs) undergo the 'epidemiological transition' from communicable to non-communicable disease(13-16), access to MRI is becoming a pressing issue with significant health consequences. It is estimated that scaling up diagnostic imaging could prevent 2.46 million cancer-related deaths worldwide(17,18). Despite its potential in LMICs, MRI remains a technically challenging modality, requiring significant investment and trained personnel. These barriers are compounded by lack of public investment, adequate infrastructure, and reliable energy supply(11). In this work, we propose some possible solutions for developing accessible MRI with a focus on bringing MRI to LIMCs.

Methods

In order to develop this comprehensive solutions framework, we reviewed existing literature on the development of affordable MRI. In addition to evaluating the literature that focused on local hardware/software challenges, we also explored how other less-reported factors, such as local macro/microeconomic policies could impact its implementation. Literature searches were performed on Medline, Embase, and the Cochrane Library electronic databases for articles published in English from inception until 1 Nov 2022. The following search terms were used (including synonyms and related words): "affordable magnetic resonance imaging", "low field MRI", "rapid MRI", "MRI local production", "cost-effective MRI". The Boolean operators AND/OR/NOT were used together with the MeSH/keywords above. Truncations/wildcards and symbols (*/?) were employed to ensure coverage of all the variations of related keywords.

Results

The MRI density in LMICs is significantly lower than in high-income countries (HICs), with 1.1 MRI units per million population (pmp) in LMICs compared to 26.5 MRI pmp in HICs(19,20), as outlined in Figure 1. The scanner magnetic field strength correlates with a country's income group, with HICs having significant proportion of high field scanners (B0 ≥ 3T) compared to LMICs(10,21). Alongside inter-country disparity is intra-country disparity, with a higher density of MRI scanners seen in urbanised regions than in rural communities (10,22-24). From the macroeconomic perspective, LMICs tended to allocate a lower proportion of their budget towards healthcare, spending 5.41% of GDP compared to 12.46% in HICs(12). In tandem, these factors have made MRI out of reach of millions of people despite MRI’s positive impact on quality-adjusted life years (QALYs)(25,26). 40% of healthcare spending in LMICs is still out-of-pocket(27,28). Figure 2 shows the average individual healthcare expenditure as a percentage of income. MRI scanners have specific infrastructure requirements, such as state-of-the-art hardware/software, uninterrupted power supply, cryogenic liquids, imaging suites and safety zones, which are major challenges in LMICs(22). For example, only 8 out 54 African countries are serviced by a major provider of cryogenic liquids(29). Lack of adaptation of new technology to local environment is responsible for 14-19% of donated medical equipment becoming out of service(22,30,31). Social issues such as scarcity of radiology/clinical scientists training programmes, preclude many from maximising the value of MRI. On a patient level, healthcare illiteracy is also an issue. For many patients, visiting a physician is a source of anxiety. Some might prefer alternative remedies due to distrust in modern healthcare(32). Here, initiatives like the Consortium for Advancement of MRI Education & Research in Africa (CAMERA) - a network of African experts, global partners, and ISMRM/ESMRMB – will be instrumental in implementing novel strategies to advance MRI access and research in Africa and to develop targeted training programs for healthcare providers and the public(33).

Discussion

We have developed a solutions framework for increasing MRI access in LMICs. The multi-factorial approach outlines a series of steps that, undertaken together, could significantly improve MRI access in areas that are missing out on all MRI technology has to offer. The backbone of the accessibility framework is based on the adaptation of technological aspects of MRI to improve accessibility. The ideal scanner should be suitable for imaging different body parts without excessive expenditure but with accessible and made-to-last components. All these with minor/modest compromises on image quality and spatial resolution. Various components of MRI have to be evaluated such that some non-essential components could be stripped back without losing image quality. For instance, our development demonstrates that a modular and flexible multi-purpose RF array configuration bodes very well by substituting an arsenal of traditional dedicated RF coils (Figure 3). Owing to its adaptable design and multi-purpose nature the approach supports MRI of the carotids, temporomandibular joints, musculoskeletal system, heart, liver, spine, abdomen and the brain etc. Deep learning-based reconstruction algorithms could also benefit (ultra) low-field MRI due to their enhanced immunity to noise and the reduction of reconstruction artifacts(34,35). AI could help lower the technical specifications for gradient linearity and magnetic field uniformity, promoting further cost reductions for MRI hardware. Finally, portable MRI can reach rural individuals and allow for earlier diagnosis of patients who cannot access conventional MRI facilities or are mistrustful of modern technologies.

Conclusion

MRI has the potential to become widely available in LMICs. With the rapid expansion of the technology, it will not be long before feasible solutions become widely available.There is a need to emphasise community engagement and co-creation to adapt the MRI machinery to local needs and make it more sustainable.

Acknowledgements

No acknowledgement found.

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Figures

A bar chart showing, from largest to smallest, the average amount per capita spent on healthcare in each country as a percentage of overall income per capita. In HICs, healthcare spending is mandatory and in many countries is taken as a proportion of taxes. In many LMICs, the largest proportion is voluntary expenditure based on utility of healthcare, so while the percentage is low, it is all individual cost. The data for this chart was taken from the OECD healthcare spending data(36) and the average income information was taken from the worlddata.info website(37).

A bar chart displaying the MRI units per million population, according to the Organization for Economic Co-operation and Development (OECD). The data are organized by density, with Japan having the highest density at 55.21 units per million population. Bar chart is from Qin et al, Eur Heart J Cardiovasc Imaging. 2022;23(6):e246–e260(38).

An example of a modular RF array. This configuration uses a hexagonal building block comprising 4 RF channels and is scalable from 4 to 32++ RF channels to conform to various target anatomy. Owing to its adaptable design and multi-purpose nature it supports MRI of the carotids, temporomandibular joints, the musculoskeletal system, the heart, the liver and the spine to name a few. The modular multi-purpose RF array configuration bodes very well to substitute an arsenal of traditional dedicated RF coils. This approach benefits cost reduction for equipment and maintenance.

Proc. Intl. Soc. Mag. Reson. Med. 31 (2023)

1598

DOI: https://doi.org/10.58530/2023/1598