title: Point-of-care testing in India: missed opportunities to realize the true potential of point-of-care testing programs.
abstract: BACKGROUND
  The core objective of any point-of-care (POC) testing program is to ensure that testing will result in an actionable management decision (e.g. referral, confirmatory test, treatment), within the same clinical encounter (e.g. POC continuum). This can but does not have to involve rapid tests. Most studies on POC testing focus on one specific test and disease in a particular healthcare setting. This paper describes the actors, technologies and practices involved in diagnosing major diseases in five Indian settings - the home, community, clinics, peripheral laboratories and hospitals. The aim was to understand how tests are used and fit into the health system and with what implications for the POC continuum.
  
  
  METHODS
  The paper reports on a qualitative study including 78 semi-structured interviews and 13 focus group discussions with doctors, nurses, patients, lab technicians, program officers and informal providers, conducted between January and June 2013 in rural and urban Karnataka, South India. Actors, diseases, tests and diagnostic processes were mapped for each of the five settings and analyzed with regard to whether and how POC continuums are being ensured.
  
  
  RESULTS
  Successful POC testing hardly occurs in any of the five settings. In hospitals and public clinics, most of the rapid tests are used in laboratories where either the single patient encounter advantage is not realized or the rapidity is compromised. Lab-based testing in a context of manpower and equipment shortages leads to delays. In smaller peripheral laboratories and private clinics with shorter turn-around-times, rapid tests are unavailable or too costly. Here providers find alternative measures to ensure the POC continuum. In the home setting, patients who can afford a test are not/do not feel empowered to use those devices.
  
  
  CONCLUSIONS
  These results show that there is much diagnostic delay that deters the POC continuum. Existing rapid tests are currently not translated into treatment decisions rapidly or are not available where they could ensure shorter turn-around times, thus undermining their full potential. To ensure the success of POC testing programs, test developers, decision-makers and funders need to account for such ground realities and overcome barriers to POC testing programs.
authors.affiliation: Department of Health, Ethics & Society, Research School for Public Health and Primary Care, Maastricht University, Postbus 616, Maastricht, MD, NL - 6200, The Netherlands. n.engel@maastrichtuniversity.nl.
authors.forename: Nora
authors.initials: N
authors.lastname: Engel
authors.affiliation: Institute of Public Health, #250, 2nd C Main, 2nd C Cross, Girinagar I Phase, Bangalore, 560 085, India. gayatriganesh@yahoo.com.
authors.forename: Gayatri
authors.initials: G
authors.lastname: Ganesh
authors.affiliation: Institute of Public Health, #250, 2nd C Main, 2nd C Cross, Girinagar I Phase, Bangalore, 560 085, India. drmamatap@gmail.com.
authors.forename: Mamata
authors.initials: M
authors.lastname: Patil
authors.affiliation: Institute of Public Health, #250, 2nd C Main, 2nd C Cross, Girinagar I Phase, Bangalore, 560 085, India. vijayashree@iphindia.org.
authors.forename: Vijayashree
authors.initials: V
authors.lastname: Yellappa
authors.affiliation: Department of Epidemiology & Biostatistics, McGill International TB Centre, McGill University, 1020 Pine Ave West, Montreal, QC, H3A 1A2, Canada. caroline.vadnais@mail.mcgill.ca.
authors.forename: Caroline
authors.initials: C
authors.lastname: Vadnais
authors.affiliation: Division of Clinical Epidemiology, Department of Medicine, McGill University and McGill University Health Centre, V Building, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, H3A1A1, Canada. nitika.pai@mcgill.ca.
authors.forename: Nitika Pant
authors.initials: NP
authors.lastname: Pai
authors.affiliation: Department of Epidemiology & Biostatistics, McGill International TB Centre, McGill University, 1020 Pine Ave West, Montreal, QC, H3A 1A2, Canada. madhukar.pai@mcgill.ca.
authors.forename: Madhukar
authors.initials: M
authors.lastname: Pai
mesh_terms: D000328:Adult; D057210:Delayed Diagnosis / Q000517:prevention & control*; D003695:Delivery of Health Care / Q000592:standards*; D005260:Female; D017144:Focus Groups / Q000379:methods*; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D000067716:Point-of-Care Testing / Q000458:organization & administration / Q000706:statistics & numerical data*; D036301:Qualitative Research; D012017:Referral and Consultation; D012424:Rural Population