Endoscopy and Its Alternatives in Resource-Limited Countries in Africa

Endoscopy service provision in low-income countries is sparse and inadequate to meet patient demands. Although novel endoscopic therapeutics have dramatically changed the way diseases are treated in the developed world, in low-resource countries, even basic services such as upper gastrointestinal (GI) endoscopy and colonoscopy are lacking. The need for endoscopy is apparent with high rates of upper GI bleeding from varices and peptic ulcers, and the rapidly growing rates of inflammatory bowel disease and GI cancers in these regions. There are limited alternatives to endoscopy available and are in general more risky and less efficacious. In Africa, the barriers to endoscopy service provision vary across the continent and serve as a model for challenges to overcome in providing health services in limited-resource environments. Although the clinical need for endoscopy grows, there has not been a parallel growth in the number of trained endoscopists with most regions having only one endoscopist for every 400,000 people. Many countries do not have a formal GI training program. Infrastructure investment remains insufficient, not fit-for-purpose, and endoscopy equipment is not consistently available in many regions. Nevertheless, some units continue to provide endoscopy services in challenging environments, modifying workflow to suit the limited structure, and adapting to local constraints while still trying to maintain endoscopy standards for their patients. The challenges are further amplified in bringing services to remote areas where, in some countries, more than 75% of the population resides, requiring innovative approaches such as mobile endoscopy units. Endoscopy is an essential life-saving medical service that is scarcely available in low-income countries. By examining the challenges to the development of endoscopy services throughout Africa, we hope to understand better the mechanisms by which GI medical services can be optimally delivered in low-and-middle–income countries.