Article Research National inventory of authorized diagnostic imaging equipment in Ghana: data as of September 2020 Bright Kwadwo Bour, Edem Kwabla Sosu, Francis Hasford, Prince Kwabena Gyekye, Daniel Gyingiri Achel, Augustine Faanu, Joseph Kwabena Amoako, Richard Denys Pitcher Corresponding author: Francis Hasford, School of Nuclear and Allied Sciences, University of Ghana, Accra, Ghana. fhasford@ug.edu.gh Received: 02 Jul 2021 - Accepted: 03 Mar 2022 - Published: 14 Apr 2022 Keywords: Diagnostic radiology, medical imaging, equipment, population ratio, Ghana Copyright: Bright Kwadwo Bour et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Cite this article: Bright Kwadwo Bour et al. National inventory of authorized diagnostic imaging equipment in Ghana: data as of September 2020. Pan African Medical Journal. 2022;41(301). 10.11604/pamj.2022.41.301.30635 Available online at: https://www.panafrican-med-journal.com//content/article/41/301/full 4 National inventory of authorized diagnostic Authority, Accra, Ghana, Radiation Protection imaging equipment in Ghana: data as of Institute, Ghana Atomic Energy Commission, 5 September 2020 Accra, Ghana, Division of Radiodiagnosis, Faculty of Medicine and Health Sciences, Stellenbosch Bright Kwadwo Bour1, Edem Kwabla Sosu1,2, University, Cape Town, South Africa Francis Hasford1,2,&, Prince Kwabena Gyekye1,3, & Daniel Gyingiri Achel1,2, Augustine Faanu1,3, Joseph Corresponding author Kwabena Amoako1,4, Richard Denys Pitcher5 Francis Hasford, School of Nuclear and Allied Sciences, University of Ghana, Accra, Ghana 1School of Nuclear and Allied Sciences, University of Ghana, Accra, Ghana, 2Radiological and Medical Sciences Research Institute, Ghana Atomic Energy Commission, Accra, Ghana, 3Radiological and Non- Ionizing Radiation Directorate, Nuclear Regulatory Article Abstract distribution. A concerted national plan will be needed to address the disparity. Introduction: to address the challenge of inadequate and non-equitable distribution of Introduction diagnostic imaging equipment, countries are encouraged to evaluate the distribution of Diagnostic imaging has become an important installed systems and undertake adequate component of healthcare delivery and has monitoring to ensure equitability. Ghana´s medical impacted on life expectancy worldwide. In 2010, imaging resources have been analyzed in this study Welling et al. demonstrated the use of radiological and evaluated against the status in other services for the assessment, diagnosis and countries. Methods: data on registered medical monitoring of treatment of at least 30% of imaging equipment were retrieved from the patients with varied medical conditions [1]. Given database of the Nuclear Regulatory Authority and the increased popularity and usage of diagnostic analyzed. The equipment/population ratio was radiology across the world [2-4], there is growing mapped out graphically for the 16 regions of need to attach importance to the establishment of Ghana. Comparison of the equipment/population diagnostic imaging infrastructure to ensure ratio was made with the situation in other national and world-wide equitable access [5]. The countries. Results: six hundred and seventy-four World Health Organization (WHO) recommends diagnostic imaging equipment units from 266 one basic X-ray and one ultrasound unit for 50,000 medical imaging facilities (2.5 units/facility), people, which is expected to meet 90% of global comprising computed tomography (CT), general X- imaging needs [6]. The WHO and Organization for ray, dental X-ray, single-photon emission Economic Co-operation and Development (OECD) computed tomography (SPECT) gamma camera, have records on national estimates of high-end fluoroscopy, mammography and magnetic radiology equipment resources based on resonance imaging (MRI) were surveyed questionnaire surveys of member states [7,8]. nationally. None of the imaging systems measured above the Organization for Economic Co-operation Mollura and Lungren [9] estimated that two-thirds and Development (OECD) average imaging units of the world´s population have no access to basic per million populations (u/mp). The overall medical imaging services. The 60 th World Health equipment/population ratio estimated nationally Assembly of the United Nations held in May 2007, was 21.4 u/mp. Majority of the imaging systems adopted a resolution for member states to collect, were general X-ray, installed in the Greater Accra verify, update and exchange information on health and Ashanti regions. The regional estimates of technologies, with particular emphasis on medical equipment/population ratios were Greater Accra devices [10]. Ghana, being a United Nations (UN) (49.6 u/mp), Ashanti (22.4 u/mp), Western (21.4 member state, has taken some initiatives in this u/mp), Eastern (20.6 u/mp), Bono East (20.0 regard but is yet to take inventory of registered u/mp), Bono (19.2 u/mp), Volta (17.9 u/mp), diagnostic imaging equipment. Upper West (16.7 u/mp), Oti (12.5 u/mp), Central The scope of diagnostic imaging procedures in (11.9 u/mp), Northern (8.9 u/mp), Ahafo (8.9 Ghana covers general radiography (X-ray), dental u/mp), Upper East (6.9 u/mp), Western North (6.7 X-ray, mammography, computed tomography u/mp), Savannah (5.5 u/mp) and North-East (1.7 (CT), fluoroscopy, interventional radiology, u/mp). Conclusion: medical imaging equipment magnetic resonance imaging (MRI), ultrasound shortfall exist across all imaging modalities in and nuclear medicine. Studies which present Ghana. A wide inter-regional disparity in the picture of the distribution of the facilities across distribution of medical imaging equipment exists Ghana is lacking, unlike in other African countries contrary to WHO´s recommendation for equitable like South Africa [11], Zambia [12], Tanzania [13], Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 2 Article Zimbabwe [14] and Uganda [15] where this study Statistical analysis: the data were captured on has been conducted. This study aimed to analyze Microsoft Excel spreadsheet and analyzed based registered diagnostic imaging equipment units in on imaging modality types, regional distribution of Ghana and evaluate their distribution as well as equipment, equipment/population ratio (units per equipment/population ratios in all geographical million people (u/mp)) and ownership. The 2020 regions of the country. projected human population data used for the survey analysis was obtained from the website of Methods the Ghana statistical service [12], the body mandated to produce and disseminate official Study setting and period: Ghana is a lower-middle statistics in the country. The equipment density income country (LMIC) [16] and has population of was mapped out for each of the 16 regions of 31,478,523 and land area of 238,533 km2 as of Ghana and presented graphically to give a clear June 2021. The country is characterized by a picture of the distribution of available diagnostic population pyramid with a wide base, a population imaging facilities across the country. Comparative growth rate of 2.2% per annum and a life analysis of equipment/population ratios by expectancy of 66.6 years [17]. Diagnostic imaging imaging modality were also performed. infrastructure in Ghana is related to the country´s resources available to deal with the prevention, Results screening and early detection, diagnosis, treatment and palliative care for cancer control. Distribution of diagnostic imaging equipment in The public sector is responsible for 61% of health Ghana: there are 674 diagnostic imaging service provision, followed by private sector (31%) equipment units from 266 medical facilities in and faith-based organizations (7%). Forty-five Ghana, including the modalities general X-ray, percent of the population is covered under one dental X-ray, fluoroscopy, mammography, CT, MRI insurance or the other, with doctor-to-population and SPECT machines. Figure 1 presents number of ratio of 1: 8100 as of June 2021. Data for this the imaging equipment units in the country as of inventory study were collated from October 2019 September 2020, while Figure 2 shows their to September 2020 from the database of the regional distribution. The results indicate 58% Nuclear Regulatory Authority (NRA) of Ghana. The (n=674) of the imaging systems are concentrated NRA maintains updated database of all licensed in the Greater Accra and Ashanti regions of the diagnostic imaging equipment in the country and country, with majority (67% (n=674)) of them their regional and district locations. being general X-ray systems. Number of the diagnostic healthcare centres in private ownership Data source: data on ionizing radiation equipment (52% (n=266)) are more than in state/public (general X-ray, dental X-ray, fluoroscopy, ownership (48% (n=266)). Greater Accra, among mammography, CT and Single Photon Emission 15 other geographical regions of the country, is Computed Tomography (SPECT) gamma camera) the only region with full spectrum of diagnostic were retrieved from the Regulatory Authority imaging modalities considered under this survey. Information System (RAIS) of the Three regions with more numbers of imaging units Nuclear Regulatory Authority (NRA), while data on per centre than the national average of MRI systems were obtained from the published 2.5 (Table 1) are the Greater Accra, Eastern and research of Ofori et al. (2020) [18]. Ultrasound Bono. equipment was excluded, due to the absence of a national database and no published data on Equipment to population ratios: the ultrasound units in the country. equipment/population ratios (units per million people) by imaging modality and geographical region are presented in Figure 3 and Figure 4 Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 3 Article respectively. General X-ray, dental, CT, representing 67% of the surveyed systems and fluoroscopy, mammography, MRI and SPECT 14.4 u/mp. Each of the regions in Ghana has systems have population ratios of 14.41, 2.51, installed X-ray systems and these are routinely 1.46, 1.24, 1.17, 0.57 and 0.03 respectively. The used as a common diagnostic imaging tool to Greater Accra with imaging units/population ratio support healthcare delivery in clinical cases such of 49.6 u/mp and Ashanti with 22.4 u/mp are the as bone fractures, arthritis in joints and chest two most dense equipment distribution regions in conditions like tuberculosis. General X-ray systems the country. Detailed data are presented in are common in the country due to their ease of Table 2. The study reveals that, general X-ray use, low cost, minimal maintenance as well as the equipment is the most common medical imaging relatively low-level radiation exposure associated device in use locally while SPECT gamma camera with the procedure [21]. As part of a national system is the least popular. programme for detection of tuberculosis (TB) cases in Ghana, the government in 2016 installed Comparative equipment/population ratios from 52 X-ray systems across the country [22]. In this study and published international data from addition to TB diagnosis, these systems have Africa [11-15] and OECD [19,20] countries are found use for a variety of other health needs and presented in Table 3. South Africa largely contributed to strengthening the Ghanaian (5.03 u/mp) and Zimbabwe (1.50 u/mp) are the healthcare system. countries with better distribution of CT systems per million population relative to Ghana. The private sector, constituting 52% of the medical South Africa consistently produced better imaging centres in Ghana (Table 1), has made equipment/population distribution of 4.96, 2.9, immense contribution to diagnostic imaging 34.8 and 6.60 for mammography, MRI, X-ray, healthcare delivery. This is perceived to be fluoroscopy. laudable in healthcare provision in a country that sees the private sector as the engine of growth. Discussion The Greater Accra, Eastern and Bono regions, with imaging units per medical centre ratios of 3.0, 3.0 As a country, Ghana needs quality data on and 3.3 respectively, were found greater than the available medical imaging systems to inform the national average of 2.5. The ratios of Eastern and radiological healthcare needs of its inhabitants. Bono regions are found to be high due to low This study provides a clear picture of the regional numbers of diagnostic medical facilities in these distribution of available diagnostic imaging regions in relation to the corresponding installed systems in the country and their comparison, imaging equipment. relative to recommendations of the WHO. The study provides analysis of the diagnostic imaging As presented in Table 3, the national estimates for capacity in Ghana and as such adds significant new equipment/population ratios ranged from 14.4 insights into the provision of radiological u/mp for general X-rays to 0.03 u/mp for SPECT healthcare services in the country. Five of the gamma camera. None of the available imaging regions (Greater Accra, Ashanti, Western, Eastern systems measure above WHO´s recommended and Bono East) recorded equipment/population equipment units per million population. Coupled ratios exceeding 20 units per million people. with this observation is the skewness in regional However, on the national scale, distribution of the installed imaging equipment equipment/population ratios are much lower than towards the Greater Accra and Ashanti regions OECD averages for respective imaging modalities. which accounts for 58% of all imaging systems Of the installed medical imaging equipment in the nationally. The two regions, being the most country (excluding ultrasound systems) this study populous and highly cosmopolitan in nature, found general X-ray as the most dominant, naturally attract a lot more of national Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 4 Article infrastructure and businesses from both public OECD-level imaging capacity in Ghana and other and the private sector. A great deal of effort is African countries is the huge discrepancy in health anticipated from government to put in required expenditure per capita between countries in the measures to bridge the gap by increasing OECD region and those in Africa. OECD countries availability of radiological health services in other have always had a culture of investing more parts of the country and promote equitability in resources to cater for radiology services for their medical imaging infrastructure at the regional population. level. Published data on radiological health facilities in The regional estimates of equipment/population Ghana has been scanty. With the few available ratios in decreasing order per this study is Greater data, much of the information is largely out-of- Accra (49.6 u/mp), Ashanti (22.4 u/mp), Western date. Schandorf and Tetteh [23] and RAD-AID [21] (21.4 u/mp), Eastern (20.6 u/mp), Bono East (20.0 highlight the structure of radiology services in u/mp), Bono (19.2 u/mp), Volta (17.9 u/mp), Ghana, as pertaining in the late 1990s, as follows: Upper West (16.7 u/mp), Oti (12.5 u/mp), Central 1) University teaching hospitals, with specialist (11.9 u/mp), Northern (8.9 u/mp), Ahafo (8.9 radiologists and radiographers, and operate u/mp), Upper East (6.9 u/mp), Western North (6.7 radiology departments in conjunction with the u/mp), Savannah (5.5 u/mp) and North-East (1.7 medical schools. All medical imaging equipment u/mp). The regions with equipment/population including general X-rays, CT, dental X-rays, density above 20 u/mp are in line with the fluoroscopy, angiography, MRI, etc. are available; urbanized and cosmopolitan nature of such places. 2) regional hospitals, with radiological services On the national scale, the imaging modalities did operated by radiographers under the supervision not meet their corresponding OECD average of senior medical officers in charge of the hospital. equipment/population ratios for CT (25.72), Basic equipment is mostly available for radiological mammography (24.34) and MRI (15.94). examinations; 3) district hospitals, with about 60% having basic radiological equipment available for Ghana´s equipment/population ratio relative to conventional radiography operated by trained South Africa indicates a better medical imaging senior technical officers under the supervision of infrastructure per unit population in the latter, senior medical officers in charge; 4) district health primarily as a result of its higher economic posts and centres, mostly with no imaging strength. South Africa´s gross domestic product services; 5) service agency hospitals, established (GDP) per capita of 5,067 USD is three-fold that of by agencies like the police, military and social Ghana (1,700 USD) and this is known to have a security agencies. Such facilities offer conventional direct correlation on health infrastructure. radiography and fluoroscopy. Relatively, Ghana is also seen to perform better in equipment/population ratio compared to In recent times, the categories of health facilities countries like Kenya, Tanzania, Uganda, Zambia have seen sophistication in diagnostic equipment, and Zimbabwe, however, the country falls below with district, regional and some private hospitals the recommended WHO target and OECD and imaging centres installing systems such as CT, averages [19,20]. A major challenge in each of the MRI and fluoroscopy. Ghana health service, the African countries will be to address the technical wing of the ministry of health, has geographical discrepancies in distribution of introduced telemedicine schemes, but currently imaging equipment [13-17]. If Ghana is to achieve do not include diagnostic radiology reporting due equitable access to diagnostic imaging, the least- to limited availability of Picture Archiving resourced regions of the country will have to be Communication Systems (PACS) in the health afforded priority when allocating future facilities. Only a few of the radiology centres have equipment resources. A constraint to achieving installed PACS systems, permitting intra- and inter- Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 5 Article facility telemedicine procedures. The country also  There exists a wide disparity in the lacks local manufacturing of radiology equipment distribution of medical imaging equipment and parts, a cause for delay in importation of parts between different geographical regions of for broken equipment and high maintenance Ghana; costs.  Ghana´s diagnostic unit/population ratio is below the OECD average and WHO´s The strength of this study has been the recommendation. identification of gap in diagnostic imaging infrastructure in Ghana, which directly translates Competing interests into geographical access to radiological services. This study would inform government in terms of The authors declare no competing interest. future planning of budget for healthcare delivery in the country. The study is however limited in its exclusion of diagnostic ultrasound data. Authors' contributions RDP and DGA conceived the project idea; all Conclusion authors (RDP, DGA, AF, EKS, FH, JKA, PKG, BKB) contributed to development of methodology for This paper has outlined radiological imaging the study; BKB collected and collated the data; equipment availability in Ghana in all its 16 BKB, EKS and FH conducted the data analysis; BKB regions. Disparities in the distribution of medical and FH drafted the initial manuscript. All the imaging equipment in the country is glaringly authors reviewed, read and agreed to the final projected by this study and a call for steps by manuscript. government to homogenize the distribution and to bridge the gap, as per WHO recommendation, thereby creating equitable access to radiological Acknowledgments services nationally. The private sector´s The authors acknowledge the support of the contribution to diagnostic imaging services is Nuclear Regulatory Authority (NRA) of Ghana for laudable and should be further encouraged. granting access to the data used for the study. What is known about this topic They also acknowledge the support of Ghana  Audit of registered diagnostic radiology Atomic Energy Commission, School of Nuclear and equipment resources have already been Allied Sciences of the University of Ghana and the conducted in at least five African countries Department of Medical Imaging and Clinical (South Africa, Tanzania, Uganda, Zambia, Oncology of the Stellenbosch University. Zimbabwe);  The WHO recommends equitable Tables and figures distribution of diagnostic imaging equipment nationally and at the global Table 1: equipment/diagnostic centre ratios level for improved healthcare delivery. Table 2: regional breakdown of diagnostic imaging equipment per million population What this study adds Table 3: equipment/population ratio comparisons  The study is the foremost comprehensive Figure 1: number of imaging equipment units in audit of diagnostic imaging equipment Ghana resources conducted in Ghana; Figure 2: distribution of diagnostic imaging equipment in the 16 regions of Ghana Figure 3: units per million people by imaging modality in Ghana Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 6 Article Figure 4: geographical regional map of Ghana 9. Mollura DJ, Lungren MP. Radiology in global showing imaging equipment/population ratios health. New York, Springer-Verlag. 2014. Google Scholar References 10. World Health Organization. Global health risks: mortality and burden of disease 1. Welling RD, Azene EM, Kalia V, Pongpirul K, attributable to selected major risks. 2009. th Starikovsky A, Sydnor R et al. 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Table 1: equipment/diagnostic centre ratios Region Number of imaging Number of diagnostic medical Unit(s) per centre units centres ratio Public Private Total Greater Accra 253 26 59 85 3.0 Ashanti 132 20 35 55 2.4 Western 47 13 7 20 2.4 Eastern 68 14 9 23 3.0 Bono East 12 5 0 5 2.4 Bono 23 4 3 7 3.3 Volta 34 9 8 17 2.0 Upper West 15 4 2 6 2.5 Oti 10 5 1 6 1.7 Central 31 8 7 15 2.1 Northern 17 6 3 9 1.9 Ahafo 8 2 2 4 2.0 Upper East 9 3 1 4 2.3 Western North 8 5 1 6 1.3 Savannah 6 3 0 3 2.0 North-East 1 1 0 1 1.0 Total 674 128 138 266 2.5 (national) Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 8 Article Table 2: regional breakdown of diagnostic imaging equipment per million population Regio Populat Are Populati General Dental 1CT Fluorosc Mammogra 2 3 MRI SPECT Total n ion a on X-ray X-ray opy phy gamma (X106) (X1 density camera 03 (X103 2 n u/ n u/ n u/ n u/m n u/mp n u/ n u/ n u/ km people/ 2 mp mp mp p mp mp mp ) km ) Great 5.1 3.2 1594 13 27. 4 8.8 2 4.9 1 2.0 21 4.1 1 2.4 1 0.2 25 49. er 9 3 5 5 0 2 3 6 Accra Ashan 5.9 24. 242 79 13. 1 2.9 1 2.0 1 2.0 9 1.5 3 0.5 0 - 13 22. ti 4 4 7 2 2 2 4 Weste 2.2 13. 159 40 18. 2 0.9 3 1.4 1 0.5 1 0.5 0 - 0 - 47 21. rn 8 2 4 Easter 3.3 19. 171 52 15. 8 2.4 1 0.3 6 1.8 1 0.3 0 - 0 - 68 20. n 3 8 6 Bono 0.6 23. 26 10 16. 0 - 1 1.7 1 1.7 0 - 0 - 0 - 12 20. East 3 7 0 Bono 1.2 11. 108 16 13. 3 2.5 1 0.8 2 1.7 1 0.8 0 - 0 - 23 19. 1 3 2 Volta 1.9 9.5 200 30 15. 0 - 0 - 2 1.1 1 0.5 1 0.5 0 - 34 17. 8 9 Upper 0.9 18. 49 13 14. 0 - 0 - 1 1.1 1 1.1 0 - 0 - 15 16. West 5 4 7 Oti 0.8 11. 72 9 11. 1 1.3 0 - 0 - 0 - 0 - 0 - 10 12. 1 3 5 Centr 2.6 9.8 265 23 8.8 2 0.8 1 0.4 3 1.2 1 0.4 1 0.4 0 - 31 11. al 9 North 1.9 25. 75 12 6.3 0 - 2 1.1 1 0.5 1 0.5 1 0.5 0 - 17 8.9 ern 4 Ahafo 0.9 5.2 173 8 8.9 0 - 0 - 0 - 0 - 0 - 0 - 8 8.9 Upper 1.3 8.8 148 8 6.2 1 0.8 0 - 0 - 0 - 0 - 0 - 9 6.9 East Weste 1.2 10. 119 8 6.7 0 - 0 - 0 - 0 - 0 - 0 - 8 6.7 rn 1 North Savan 1.1 35. 31 6 5.5 0 - 0 - 0 - 0 - 0 - 0 - 6 5.5 na 9 North- 0.6 9.1 66 1 1.7 0 - 0 - 0 - 0 - 0 - 0 - 1 1.7 East Total 31.5 238 132 45 14. 7 2.5 4 1.4 3 1.24 37 1.17 1 0.5 1 0.0 67 21. .5 4 41 9 1 6 6 9 8 7 3 4 40 1 2 N: number of diagnostic imaging equipment; u/mp: units per million population; computed tomography; magnetic resonance 3 imaging; single photon emission computed tomography Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 9 Article Table 3: equipment/population ratio comparisons Units per million people CT Mammography MRI General Fluoroscopy SPECT X-ray gamma camera Ghana (this study) 1.46 1.17 0.57 14.41 1.24 0.03 Other African Egypt 2.00 countries Kenya 0.80 0.50 South Africa 5.03 4.96 2.90 34.80 6.60 Tanzania 0.42 0.31 0.09 9.02 1.00 Uganda 0.60 0.50 9.60 0.80 Zambia 0.79 1.22 0.24 14.30 0.55 0.06 Zimbabwe 1.50 0.80 0.50 26.00 0.80 OECD data, Belgium 36.57 2015 or Brazil 15.34 6.76 nearest year Canada 15.01 18.05 9.48 Germany 35.09 33.63 Greece 65.97 Iceland 39.30 16.81 21.16 Israel 9.79 4.06 Italy 33.31 33.83 28.24 Japan 107.17 34.32 51.69 Korea 37.03 61.57 26.27 Lithuania 21.00 15.75 11.02 Mexico 5.92 9.73 2.39 New Zealand 17.84 19.70 13.27 United 9.46 7.23 Kingdom United States 40.98 65.26 39.00 of America OECD average 25.72 24.34 15.94 CT: computed tomography; MRI: magnetic resonance imaging; SPECT: single-photon emission computed tomography; OECD: organization for economic co-operation and development Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 10 Article Figure 1: number of imaging equipment units in Ghana Figure 2: distribution of diagnostic imaging equipment in the 16 regions of Ghana Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 11 Article Figure 3: units per million people by imaging modality in Ghana Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 12 Article Figure 4: geographical regional map of Ghana showing imaging equipment/population ratios Bright Kwadwo Bour et al. PAMJ - 41(301). 14 Apr 2022. - Page numbers not for citation purposes. 13