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The State of Pathology in Resource-Limited Countries: Part One

There’s no denying it: the need for pathologists is strong. If we want to treat cancer and beat cancer we need pathologists and pathology as a practice to make accurate diagnoses. Unfortunately, this need is unmet in low- and middle-income countries such as those in sub-Saharan Africa (SSA) where pathologists are not just scarce but non-existent in some areas. In this five-part series, we will cover what pathology scarcity looks like, what it means for patients and pathologists living in resource-limited areas and how cancer screening, detection and management efforts are greatly affected. So, let’s jump right in.

The facts are sobering. There is fewer than one pathologist per 500,000 people in SSA compared to one pathologist per 15,000 to 20,000 people in the United States and United Kingdom. An online survey of 34 unique institutions in SSA1 that assessed pathology capacity showed that in eight countries, there was not a single pathologist working within the public sector. In Tanzania, for example, there are only 22 pathologists in the public sector serving a population of 48 million.2

The scarcity of pathologists also means there is scarcity in pathology services—appropriate measures are not taken prior to treatment such as tumor staging or even tissue evaluation to make the correct diagnosis in the first place. The Kampala, Uganda Cancer Registry Report for 2007–2009 showed a tissue diagnosis rate of only 58.6%.3 Accurate data from pathology is the backbone of the cancer registry, which is critical to inform and influence the formulation of health policies at the national and regional level.4 In 2016, a retrospective assessment of reports of breast carcinoma in the university teaching hospital in Lagos, Nigeria, showed that 60% of the reports did not mention lymph node status and 50% did not mention excision margins. Hormone receptor was not stated in 74% cases. More concerning is that when the cases were examined by pathologists in the United Kingdom, there was a 46.9% discordance rate in the basic diagnosis, with failure to record the type of breast cancer in 72.2% reports.5

In addition to the issue of access to pathology and laboratory services, the issue of quality of these services remains of grave concern. Although there are sites in sub-Saharan Africa where regulation and resources yield services of high quality, this is not true in most areas. A paper on Turn Around Time (TAT)—time from biopsy till receipt of report by clinician—from Malawi showed that the median TAT for unpaid samples was 71 days, obviously making the report of limited or no value in patient diagnosis and treatment.6 In perhaps the best-studied area, Kampala, Uganda, the variability of quality in clinical laboratories is striking. In this study of clinical laboratories, the investigators identified and surveyed 954 laboratories, of which only 45 (5%) “met or surpassed the lowest quality standards defined by the World Health Organization African Regional Office-derived laboratory strengthening tool.”7

The combination of insufficient access to, and the variable quality of pathology in sub-Saharan Africa, undoubtedly means that a significant proportion of patients are receiving untimely and/or inaccurate diagnosis. This has important repercussions for the cancer patients and their families, not least in unnecessary prolongation of illness, or even unnecessary death.8 For example, the 5-year female breast cancer relative survival rates are 46% in Uganda and 12% in The Gambia, compared with 90% in the United States.9 These numbers are startling. With the United States having significantly more pathologists and high-quality laboratory services, one could argue that the lack of such resources contributes to the alarming mortality rates.

The shortage of pathologists is a global problem present on all continents; resource-limited areas exist even in the United States and United Kingdom. In our next blog post we’ll take a deeper dive into how the dire need for pathologists leads to additional gaps in healthcare like access to other specialists and a lack of resources for cancer screening, detection and management.

Built on the vision of better patient outcomes, Instapath was founded in 2017 by engineers and scientists to enable patients to immediately know their cancer diagnosis. Our team made it our mission to develop fast and easy digital pathology technology so diagnosis can be made in minutes instead of days. To learn more about Instapath and our technology, visit or contact us at


1 Adesina A, Chumba D, Nelson AM, et al. Improvement of pathology in sub-Saharan Africa Lancet Oncol 14:e152–e157,2013.

2 Sayed S, Lukande R, Fleming KA. Providing Pathology Support in Low-Income Countries. J Glob Oncol. 2015;1(1):3–6. Published 2015 Sep 23.

3 African Strategies for Advancing Pathology Group Members. Quality pathology and laboratory diagnostic services are key to improving global health outcomes: Improving global health outcomes is not possible without accurate disease diagnosis. Am J Clin Pathol. 2015;143:325–328.

4 Sayed S, Lukande R, Fleming KA. Providing Pathology Support in Low-Income Countries. J Glob Oncol. 2015;1(1):3–6. Published 2015 Sep 23.

5, 6 Fleming K. Pathology and cancer in Africa. Ecancermedicalscience. 2019;13:945. Published 2019 Jul 25.

7 Elbireer AM Jackson JB Sendagire H et al. The good, the bad, and the unknown: quality of clinical laboratories in Kampala, Uganda. PLoS One. 2013;8:e64661.

8 Fleming K. Pathology and cancer in Africa. Ecancermedicalscience. 2019;13:945. Published 2019 Jul 25.

9 Sankaranarayanan R, Swaminathan R, Brenner H, Chen K, Chia KS, Chen JG, et al. Cancer survival in Africa, Asia, and Central America: a population-based study. Lancet Oncol. 2010;11(2):165–73.

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