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91 Under-recognised implications of overuse and misuse in low-resource settings and emerging healthcare markets: narratives from ‘remote’ northern quebec and rwanda
  1. Genevieve Bois1,
  2. Imran Sajid2,3
  1. 1McGill University, Montreal, Canada
  2. 2West London Clinical Commissioning Group, London, UK
  3. 3University of Global Health Equity, Kigali, Rwanda


Overuse and inappropriate use of healthcare is often perceived as an issue for high-resource settings where there are diminishing population-health returns from increased healthcare expenditure. However similar problems of biased clinical decision-making, information asymmetry and inequitable distribution of resources exist in any setting. Inappropriate healthcare use within even more constrained markets of low-resource settings (LRS) have even more acute implications of opportunity costs to both patients and systems. We discuss narratives from two low-resource settings as well as the lack of policy and research initiatives in such settings.

A search of MEDLINE, EMBASE, GoogleScholar shows almost no published literature exists regarding issues pertaining to overdiagnosis and overtreatment specific to low-resource and emerging healthcare markets.

Examples of increased harm from medical overuse in low-resource settings and increased opportunity costs are common, via patient co-pays, travel or missed work, in addition to anxiety and change in perceived health status for low-value diagnostic tests, consultation visits or treatments. An additional issue can be stock-outs as a result of poor medication stewardship (eg. antibiotics).

Higher background incidence of more serious disease in such settings does infer more utility from point-of-care or earlier access to diagnostics compared to high-resource populations (with a lower incidence of serious disease). Low-resource settings therefore represent a potentially high-value setting for such technologies, to avoid costly and complex urgent air evacuations and tailor the treatment in case of an urgent or life-threatening condition.

In some scanerios, diagnostics can represent high profitability. For providers, this can allow cross-subsiding for other cash-loss, yet vital services. Particularly in low-resource settings where several specialities have limited-to-no funding, eg palliative care, there may be an argument towards diagnostic over-provision to subsidise such services. Ethical dilemmas are present regarding useful and large external investment in healthcare markets and positive GDP growth, versus ensuring appropriate use of technologies. Healthcare investment in LRS generally drives GDP growth both directly and indirectly. However due to more constrained resources, opportunity costs are higher and therefore lower cost-effectiveness thresholds are necessary (eg significantly less than WHO recommended 1–3x annual GDP-per-capita to be spent per QALY) which has significant implications for policy-makers.

Lower health literacy is associated with greater information-asymmetry which can be problematic. Historically paternalistic care can render shared decision-making difficult, in addition to potential cultural and linguistic barriers. A fractionated health system (Rwanda) or a system with high turnover of staff (rural Québec) also contributes to less developed longitudinal relationships with providers and less opportunities for shared-decision making.

Waste in constrained settings represent a much more significant opportunity cost for both patients and systems and is currently not a research priority. Tackling overuse in areas with few resources, high turnover and cultural barriers is challenging and will require significant policy-level motivation to address.

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