This study describes the current geographic landscape of radiologic access in Rwanda. Despite most of the population living within a 25-km radius to a hospital with radiologic capability, there is significant disparity in access to certain imaging modalities, namely CT and MR, both of which are routinely used as first-line diagnostic imaging. Among the radiologic modalities included in this study, X-ray units were the most accessible, radiotherapy units were the least accessible, and PET units were inaccessible, reflective of the expense associated with purchasing, operating, and maintaining the equipment. Compared to Kenya, Tanzania, Zimbabwe, Zambia, and Uganda, Rwanda has the fewest radiologic facilities per million population [11]. Of these countries, the radiologic resources in Rwanda are most comparable to Tanzania, which has 0.4 CT units, 1.0 fluoroscopy units, 0.3 mammography units, and 0 PET units per one million people. The scarcity of Rwanda’s radiologic resources is further put into perspective once the comparative field is expanded internationally. For reference, according to Organization for Economic Co-operation and Development (OECD) countries, the United States has 38.0 MR units, 43 CT units, 70.7 mammography units, and 11.4 radiotherapy units per one million people [12,13,14].

Among the Rwanda population that live within a 25-km radius of a CT or MR scanner, there are further disparities to access depending on whether the equipment is located at a public or private hospital. Significantly, most of the higher-level and more expensive imaging equipment such as MR and CT scanners are private. This situation tends to pose barriers of higher cost of care, inconsistent health insurance coverage, and locations in urban centers. However, growth of private radiologic facilities may serve to reduce the burden on the public sector facilities.

There is, however, a pattern of progress in the radiologic landscape. In 2015, Rwanda had only two MR machines, both in the capital of Kigali, and five CT machines, three of which were in Kigali [10]. According to our study, there are now 3 additional MR units, one of which is in the city of Gisenyi, and 2 additional CT units, located in Kibuye and Kibungo. In contrast, there does not appear to have been any notable changes in the number of X-ray and fluoroscopy units, which perhaps alludes to an ongoing shift in the diagnostic paradigm.

Human resources are another integral piece to the radiologic landscape within Rwanda, which has been previously reported. In 2012, there were only 8 radiologists in Rwanda, with 87% (7) spending most of their time in Kigali hospitals [9]. Consequently, minimal radiologist coverage occurred at facilities outside of Kigali, where radiographic interpretation are performed predominantly by general practitioners. Much like that for radiologic equipment, there is also a growth trend for radiologists as the number of radiologists had increased from 8 in 2012 to 11 by 2014 [10]. Even so, there is still a clear deficiency of staffing for the 56 hospitals. As of 2015, there is an ongoing effort by the government to allocate resources toward a radiology residency program within Rwanda. Interestingly, in contrast to the scarcity of radiologists, there is an abundance of radiographers, averaging 10 at private hospitals and only 3 at public hospitals [9].

This study is limited by the exclusion of ultrasound as a radiologic modality due to the difficulty of obtaining accurate unit counts. However, it is known that ultrasounds are much more readily available compared to other imaging modalities in Rwanda. As a highly operator-dependent modality, ultrasound may accordingly have higher diagnostic utility in Rwanda than in more developed countries where radiologists have ready access to more advanced imaging modalities. We are therefore unable to comment on the relative diagnostic utility and necessity of the different radiologic modalities within Rwanda.

Future studies investigating the radiologic landscape in Rwanda would benefit from exploring the diagnostic utility and accuracy of the various imaging modalities, including ultrasound, as compared to more developed countries. This data would allow for realistic measures of health utility that can direct resource expansion. Additionally, data on human radiologic resources in Rwanda, including a tabulation of current technologists and radiologists, would direct further educational efforts. These studies, in conjunction with the current study, could be used to establish healthy, balanced growth of equipment and human resources.

While a comprehensive policy review is beyond the scope of this paper, the authors anticipate that improvements to the Rwandan radiologic landscape will likely take place in three areas: (1) increasing training of radiographers, (2) maximizing existing radiologic resources, and (3) expanding the repertoire of radiologic equipment. While ultrasound is the most accessible diagnostic imaging modality in Rwanda, it is arguably the most dependent on the skill of the radiographer. As radiographers gain more experience and access to subspecialty training, the diagnostic value of ultrasound is expected to increase, which may obviate the need for more advanced modalities in certain cases. Maximizing existing radiologic resources can be achieved by strengthening residency training programs and increasing the number of radiologists. Furthermore, the amount of physical radiologic equipment must be expanded, as access in Rwanda is largely limited by the scarcity of units. This ultimately will depend on the intentional allocation of health resources to equipment acquisition by the government. Overall, Rwanda has acknowledged the importance of radiologic resources in rebuilding their health care infrastructure and has made impressive strides within the past decade.