Picture a health post two hours’ walk from the nearest district hospital. A nurse has a new point-of-care analyser, donated with a year’s supply of cartridges. A woman comes in with symptoms of diabetes. The device works exactly as promised: in a few minutes it confirms high blood glucose.
Then the nurse checks the medicine shelf. There is no metformin this month.
The test has done its job. The patient has learned she has a chronic disease and been sent home without the means to treat it. That is not a diagnostic success. It is a diagnostic stranded in a system that was not ready for it.
The gap is real
The need is not in doubt. The Lancet Commission on Diagnostics, published in 2021, estimated that 47 percent of the world’s population has little or no access to diagnostics. The gap is widest at the front line: the Commission found that only about 19 percent of people in low and lower-middle income countries have access to the simplest diagnostic tests at the primary care level, other than tests for HIV and malaria.
Point-of-care tests look like the obvious answer. They are small, fast, often battery-powered and can be run by staff without laboratory training. They bring the lab to the patient instead of asking the patient to travel to the lab.
The thesis here is that the obvious answer is only half right. Point-of-care diagnostics fail in underserved regions far more often because of what happens after the result than because of the test itself. Programs that budget for devices and not for the pathway around them end up with expensive boxes in cupboards.
The HIV and malaria exception proves the rule
Notice the carve-out in the Commission’s finding: HIV and malaria. Rapid tests for those diseases are widely available at primary care level in many poor countries. Why those two?
Because they arrived with everything else attached. Donor programs for HIV and malaria funded not just the test, but the drugs, the supply chain, the training, the reporting forms and the supervision. A positive malaria rapid test leads to a treatment that is usually on the shelf. A positive HIV test leads into a treatment program with its own staff and funding.
For diabetes, hypertension, anaemia, syphilis in pregnancy and many other conditions, that surrounding scaffolding is thinner or missing. The test can be just as good. The pathway is not.
The mechanism is worth stating plainly. A diagnostic test has no value on its own. Its value is borrowed entirely from the decision it changes. If a positive result and a negative result lead to the same action, which in a health post without metformin is “go home,” the test has produced information and no benefit. HIV and malaria programs understood this intuitively because they were built backwards, from the treatment to the test. Most point-of-care procurement is built forwards, from the device to whatever happens next.
Three failure points after the result
When point-of-care programs disappoint, the problems tend to cluster in the same places.
The first is that treatment is not there. As in the scene above, a diagnosis without a medicine is at best a referral and at worst a burden. It can also erode trust. Communities learn quickly whether a test at the health post leads anywhere, and a test that leads nowhere teaches people not to come back, including for the conditions that are treatable.
The second is that consumables run out. Many point-of-care devices use proprietary cartridges or strips that only one company makes. When the donated supply runs out, the health system has to buy more, often at prices it did not plan for, through a procurement process that may take months. The device then sits idle. Buyers who choose platforms without asking what the cartridges will cost in year three are making a long-term commitment without reading the contract.
The third is that quality slips quietly. A laboratory has quality control routines. A health post often does not. Devices need calibration, reagents need to be stored correctly in hot climates, and staff need refresher training. Without that, results drift and nobody notices, because there is no reference to compare against. A glucose meter that reads consistently high will not raise an alarm. It will simply generate more diagnoses, each one looking perfectly plausible.
A back-of-envelope look at the real cost
Consider a hypothetical district that receives 20 donated analysers, each serving a health post that runs perhaps 10 tests a day on about 250 working days a year. That is 50,000 tests a year across the district. If a cartridge costs a few dollars, the recurring bill after the donation ends runs well into six figures annually, every year, for as long as the devices are used. The analysers themselves, the part that appears in the donation announcement, may end up being a minority of the ten-year cost.
Now add the pathway. If even a modest share of those tests come back positive for a chronic condition, each positive creates a patient who needs medicine every month for life, plus follow-up tests to check control. The diagnostic program has quietly created a pharmaceutical and monitoring budget that nobody costed. A ministry that cannot fund that downstream demand has not bought a diagnostics program. It has bought a waiting list.
The numbers here are illustrative, and real prices vary widely by platform and country. But the shape of the calculation holds everywhere: the device is the smallest and most visible line, and the recurring lines behind it are larger, longer and unowned.
An uncomfortable incentive
The global market for point-of-care diagnostics has a structure worth naming. Manufacturers make much of their money on consumables, not devices. That is a reasonable business model, but it means the cheapest device is not necessarily the cheapest option. Donors like to fund equipment, because equipment is visible and has a clear handover date. Recurrent costs like cartridges, maintenance and training are less photogenic and fall to ministries of health after the donor leaves.
The result is a predictable cycle: donation, enthusiasm, stock-out of consumables, idle device, new donation of a different device. Each cycle leaves a health post with another incompatible machine, and nurses with another set of procedures to remember.
No one in this cycle is acting in bad faith. The donor reports devices delivered. The manufacturer reports units placed. The ministry accepts a free gift. Each actor’s metric is satisfied, and the patient’s outcome sits outside all of them.
The strongest counterargument
A reasonable objection runs like this: diagnosis has value even without immediate treatment. Knowing prevalence helps ministries plan and argue for budgets. A confirmed diagnosis can prompt a patient to seek care elsewhere, change diet or monitor symptoms. And waiting until the whole pathway is perfect is a recipe for doing nothing, because the pathway is never perfect.
Much of this is right. Surveillance data do help, and some conditions, such as syphilis in pregnancy, have treatments cheap and simple enough that a test genuinely pulls the treatment behind it. There is also a political argument: a stack of documented diagnoses with no medicine is a powerful case for a treatment budget. Sometimes the test has to come first to create the demand.
But that argument works only if someone is collecting and using the data, and only if the patient is told honestly what happens next. A test run for surveillance should be designed as surveillance, with reporting and a plan. What does not hold up is the default: buying devices and hoping the rest follows. The objection defends deliberate sequencing, not the accidental kind.
Second-order effects
Stranded diagnostics do more damage than wasted money. Idle devices consume storage space and nurse attention. Parallel platforms from different donors fragment training and data, so a district may have three machines producing results in three formats that feed no common record. And every failed program makes the next one harder to sell, to communities and to finance ministries alike.
There is a positive second-order effect too, when programs work. A reliable test with a reliable treatment behind it makes the health post more credible, raises attendance and brings in patients earlier for other conditions. The payoff from a working pathway spreads well beyond the disease it was built for.
It also changes the nurse’s job in a way that matters for retention. A nurse who can diagnose and then act is practising medicine. A nurse who can only diagnose and apologise is delivering bad news all day, and that kind of work wears people down. It is hard to keep staff in a post where the tools lead nowhere.
What each actor should do differently
WHO’s Essential Diagnostics List, first published in 2018, gave countries a reference for which tests belong at which level of care. It is a useful tool. But a list tells you what to offer, not how to sustain it.
Ministries of health should refuse, or at least renegotiate, device donations that do not come with a costed plan for consumables and the treatment they imply. The simplest test is to ask whether the treatment is on the shelf, reliably, today. If it is not, fix that first or fund both together. Consumable costs belong in the recurring budget, not a project budget that expires.
Funders should fund pathways rather than products: the test, the medicine, the supervision and the data system as one grant with a multi-year horizon. They should also report outcomes such as patients started and kept on treatment, not devices delivered. That single change in metric would reshape what gets bought.
Procurement agencies and ministries should favour open or multi-disease platforms where they can. One device that runs several tests with competitively sourced reagents beats several single-purpose devices locked to one supplier.
Diagnostic companies and founders building for these markets should price for year five, not year one. A business model that depends on donor-funded cartridge sales is fragile, and the companies that design for local procurement and transparent consumable pricing will outlast those that do not.
Clinicians and programme managers can insist on the unglamorous basics: a logbook, a periodic external quality check, and a clear answer to where a positive result sends the patient. If the answer is a referral hospital two hours away, the program needs transport or a follow-up plan.
What to watch
Over the next year or two, the signal to watch is whether donors and ministries start announcing diagnostics and treatment together, with multi-year funding, rather than device handovers. Watch also whether national essential diagnostics lists begin to be tied explicitly to essential medicines lists and budgets, so that adding a test to a level of care automatically raises the question of its treatment. And watch procurement: pooled purchasing and open-platform tenders would be a sign that buyers have started reading the contract.
The takeaway
Point-of-care testing is one of the best tools available for closing the diagnostic gap, and the gap is enormous. But in underserved regions, the test is usually the cheapest and easiest part of the pathway. Diagnosis earns its keep only when the medicine, the cartridges and the follow-up arrive with it. Buy the pathway, not the box.
Have you seen a point-of-care program that stayed running after the donor left? What kept it alive? Share it below.
