9.1 Introduction

The incidence and mortality associated with non-communicable diseases (NCDs) is on the rise globally. There has been a significant shift in the global disease burden in the past decades from communicable infectious diseases to non-communicable diseases, especially evident in low- and middle-income countries (LMICs). According to the World Health Organization (WHO), more than 38 million people die each year as a consequence of NCDs. It is expected that in the next 25 years the majority of new NCD cases and associated deaths will occur in LMICs. The increase in NCDs is related to several factors, including population growth, increased life expectancy and changes in lifestyle. The most frequent NCDs are cardiovascular diseases, cancer, chronic respiratory diseases and diabetes.

Medical imaging has revolutionized healthcare in the past decades as it has enabled the delivery of individual, patient-tailored disease management. Nuclear medicine (NM) techniques have become of paramount importance for the diagnosis and treatment of a wide range of health conditions, in particular NCDs.

For over 50 years, the International Atomic Energy Association (IAEA), an independent international organization related to the United Nations system, with a long history of promoting the safe, secure and peaceful uses of nuclear science and technology in its Member States (MS) provides assistance in building sustainable capacities in the use of medical use of radiation and radionuclides, including NM. The IAEA’s Human Health program includes the Nuclear Medicine and Diagnostic Imaging (NMDI) sub-program which takes care of numerous initiatives aimed at fostering the integration of NM practice both in imaging and therapeutic applications into MS’ healthcare systems.

On 25 September 2015, at the Summit on Sustainable Development, the 193 MS of the United Nations unanimously adopted the Sustainable Development Goals (SDGs), to improve the health status of vulnerable populations by ensuring universal and equitable access to quality healthcare, emphasizing their intention to significantly reduce the incidence of both communicable and non-communicable diseases. One target outlined in the agenda (target 3.4) aims “to reduce premature mortality from NCDs by one-third through prevention and treatment by 2030”.

NM techniques can make significant contributions to the achievement of this SDG target. They evolved to allow for personalized healthcare, and they represent now an indispensable part of modern-day clinical practice. NM diagnostic and therapeutic applications are very useful in addressing both NCDs and infectious diseases.

Despite the evident usefulness of NM techniques, in most MS, NM services are inadequate. The main factors affecting the expansion and sustainability of NM include high investment, operation and maintenance costs, inadequate qualified personnel and limited suppliers of radiopharmaceuticals [1,2,3,4,5,6,7,8,9].

9.2 Key Challenges

The routine use of NM might be impeded by significant obstacles. Limited infrastructure prevents countries from offering NM services to meet rising demand, especially for the management of cancer, CVDs and other NCDs [10,11,12]. The main constraints are:

Acquisition and Operation and Maintenance Costs

The cost of establishing a nuclear medicine facility (including buildings and equipment) deters many MS. For countries with existing NM facilities, maintaining functional equipment is an issue. Countries who acquired their NM equipment through the IAEA technical cooperation programme, due to conflicting priorities (especially the need for response to communicable diseases) and limited financial resources, do not have adequate capacity for sustainable operation and maintenance, which include the cost of radiopharmaceuticals and equipment repairs. In addition, some countries are not able to replace the obsolete equipment without additional support from the IAEA.

Affordability

NM is a relatively expensive tool. With limited or no health insurance, many patients cannot afford nuclear medicine procedures. The current global economic situation has kept health expenditure growth to almost zero in many low-income countries.

Awareness of the Role of Nuclear Medicine

Although NM plays a key role in the current diagnostic imaging revolution, there is still a lack of knowledge among different stakeholders of the benefits and usefulness of the clinical applications of NM techniques. These need to be adequately explained. Most referring clinicians are not adequately informed about the NM discipline, as can be seen in inappropriate referrals. There is a stigma associated with the word ‘nuclear’ that may deter stakeholders from learning more about nuclear medicine, despite the high potential of radiolabelled molecules in diagnostic and therapeutic applications.

Human Resources

To reach the full potential of nuclear medicine, there is a need to train the involved professionals throughout their careers. However, clinical and research personnel are scarce in all the disciplines involved in the practice of NM (i.e., chemists, radiopharmacists, physicians, physicists, clinician-scientists, technologists, etc.). This is, in many cases, due to a lack of specific training programmes that emphasize clinical applications, as well as a limited number of adequately equipped and well-staffed institutions capable of providing both academic and clinical trainings. Training in universities, medical institutions and industry has not been able to keep up with current demands. Furthermore, there is an impending leadership gap in the field. Nuclear medicine research requires a multidisciplinary team of individuals with extremely varied education and training. Only by training an adequate number of individuals in these various disciplines will nuclear medicine and molecular imaging reach its potential. Furthermore, there is a need to harmonize the training programs, in order to raise the level of knowledge and competencies of nuclear medicine specialists worldwide. Trainees come from diverse backgrounds and possess different knowledge and experience; hence, the training program requires an active and standardized approach to ensure compliance with at least the minimum standards needed to provide an optimal clinical nuclear medicine care.

Customs Practices

Short half-lives radiopharmaceuticals need to be frequently imported. They must be cleared by customs upon arrival and delivered to the nuclear medicine centre immediately thereafter. However, in some countries, customs regulations are so cumbersome that clearing radiopharmaceuticals in time represents a real challenge.

Limited Suppliers of Radiopharmaceuticals

Currently, the most important isotope used in nuclear medicine is metastable technetium-99 (Tc-99m). This radioisotope is produced from molybdenum-99 (Mo-99) in nuclear reactors that use highly enriched uranium (HEU) targets. There are only four producers of Tc-99m worldwide. Any interruption in production in one or more of these reactors results in a decrease of supply. This affects the accessibility of NM services and thus lifesaving treatment.

Inadequate Quality Assurance (QA) and Quality Control (QC)

In LMIC, the limited availability of basic equipment used for QC, radiation protection and in medical physics research facilities, such as phantoms and certain radiation sources, poses another challenge to the practice of nuclear medicine.

Radiation Safety

Radiation safety is a challenge for the practice of nuclear medicine. Each professional working with ionizing radiation should undergo compulsory monitoring for occupational radiation exposure. In countries, monitoring services for personnel are often provided by government agencies, such as radiation regulatory bodies. These services may also be provided by licensed, for-profit companies which charge more for the same services.

9.3 Interventions

The establishment, expansion and strengthening of NM services will contribute to reducing the incidence and impact of NCDs through early diagnosis, treatment and palliative care for the improved well-being of the population. The IAEA proposed several strategic interventions to be implemented concurrently for effective and sustainable NM services. The intention is to incorporate best practices for the establishment, operation and maintenance of NM facilities and services, as well as for cost-recovery, expansion, human resource capacity building, and recruitment and retention of staff [10].

  1. 1.

    To increase the total number of NM centres

    1. (a)

      Prioritize NM in national health policy and budget through conducting national needs assessments and/or feasibility studies for nuclear medicine.

    2. (b)

      Establish domestic funding mechanisms, such as trust funds, for costly but essential medical services and facilities such as radiotherapy and nuclear medicine.

    3. (c)

      Formulate and implement national IAEA technical cooperation (TC) projects for the establishment of NM facilities.

    4. (d)

      Build and strengthen strategic partnerships.

  2. 2.

    To continuously educate the public and other stakeholders on the benefits and usefulness of the clinical applications of NM.

    1. (a)

      Publish and disseminate awareness-raising materials on the benefits of NM procedures and its critical diagnostic and therapeutic roles in a variety of clinical areas, including cardiology, oncology, paediatrics, neurology, endocrinology, infection, inflammation and pulmonology, to referring physicians and hospital managers.

    2. (b)

      Organizing NM events at national and regional levels.

    3. (c)

      Include introduction courses to NM in undergraduate medical degrees.

    4. (d)

      Educate customs officials and clearing and forwarding agents about the short half-life of radiopharmaceuticals and the need for urgent clearance.

  3. 3.

    To ensure that NM is recognized as a medical specialty in all MS.

    1. (a)

      Incorporate NM into national health policy frameworks, recognizing it as a medical speciality.

    2. (b)

      Strengthen the collaboration between existing NM professional societies and establish new ones, if absent, at national, regional, and international levels.

  4. 4.

    To have an adequate number of qualified NM professionals (including physicians, radiopharmacists, physicists, technologists and nurses) available in the NM centres.

    1. (a)

      Create a public structure and career ladder for NM.

    2. (b)

      Assess training needs, establish appropriate training curriculum and implement appropriate training programme, including continuous professional development programmes.

    3. (c)

      Recruit staff and create incentives for staff retention.

  5. 5.

    To establish appropriate cost recovery programmes to ensure a sustainable supply of radiopharmaceuticals, the operation and maintenance of equipment, and the replacement of ageing equipment.

    1. (a)

      Negotiate and conclude suitable contracts for the regular supply of radiopharmaceuticals with suppliers.

    2. (b)

      Negotiate and settle appropriate maintenance contracts for NM equipment that ensure that the warranty starts following proper installation and includes servicing and the replacement of parts.

    3. (c)

      Put in place long-term plans for the replacement of obsolete/ageing equipment as well as for the expansion and upgrading of NM services.

    4. (d)

      Produce locally radiopharmaceutical.

    5. (e)

      Provide financial autonomy or a dedicated operational budget for NM in order to maximize efficiency and flexibility.

  6. 6.

    To make NM more affordable.

    1. (a)

      Mobilize NGOs, local companies and philanthropists to support NM.

    2. (b)

      Establish schemes to help patients who cannot afford NM services.

    3. (c)

      Make NM consumables tax exempt since they are health related.

  7. 7.

    To increase the number of NM research studies, especially in the main clinical areas such as cardiology, oncology, paediatrics, neurology and endocrinology.

    1. (a)

      Mobilize resources to support the utilization of NM in clinical research.

    2. (b)

      Encourage NM professionals to actively participate in coordinated research activities in NM.

    3. (c)

      Promote the sharing and utilization of NM research findings with other stakeholders at national, regional, and international levels, and at NM conferences.

    4. (d)

      Collaborate with other national or international research institutes.

  8. 8.

    To enhance the safety of NM practice for both patients and physicians.

    1. (a)

      Establish and enforce safety regulations and guidelines.

    2. (b)

      Train qualified professionals in methods to enhance safety.

    3. (c)

      Promote quality assurance procedures.

    4. (d)

      Establish or strengthen occupational exposure control programmes.

While recognizing the need for continuity of support from the IAEA and other partners, the above-proposed interventions cannot be achieved without national ownership and leadership by individual governments. Each government is expected to provide equitable universal access to healthcare services, including NM.

9.4 Results

9.4.1 Technical Cooperation Programme

The technical cooperation (TC) programme is one of the mechanisms through which the IAEA directly helps its Member States to build, strengthen and maintain capacities for the safe, peaceful and secure use of nuclear technology in support of sustainable socioeconomic development. The TC programme addresses wide-ranging development objectives which include greater food productivity, better health and nutrition services, improved energy development, and sustainable energy production.

TC projects can be national, driven by the development priorities of a single Member State, or regional, when a group of Member States belonging to the same geographical area cooperate to create regional sustainability and self-reliance in the effective use of nuclear technologies. All Member States are eligible for support through TC projects, although in practice technical cooperation activities are focused on the needs and priorities of low-and-middle-income countries.

Through TC projects, the IAEA supports Member States by coordinating several activities aiming to build human resource capacity, and transfer know-how and technology. These activities include fellowships for individuals, scientific visit opportunities for more experienced professionals, training courses, meetings, missions of experts in the field, as well as procurement of technology and equipment.

TC projects related to nuclear medicine focus on the establishment of a nuclear medicine service (often the first in the country), the upgrade of existing departments with newer hybrid imaging modalities such as SPECT/CT or PET/CT, the enhancement of the clinical practice or the introduction of new diagnostic or therapeutic methodologies. Because of the multidisciplinarity of nuclear medicine, these projects usually include other components related to radiopharmacy, medical physics and safety.

Within a TC project fellowships are granted to health professionals to foster capacity building. These candidates are supported to spend an adequate period of time, in a well-established nuclear medicine service, for specialized and supervised hands-on training. The training programme is agreed with the hosting institute and is usually focused on a specific topic, for example, on the establishment and standardization of clinical protocols, the use of SPECT for cardiological and oncological studies, the therapeutic use of a certain radiopharmaceutical, the practical aspects of QA/QC of instrumentation and radioprotection, or the preparation of radiopharmaceuticals.

Education and training activities are a key component of TC projects and training courses are often included in the workplan to reach out to a larger number of health professionals. The use of international experts is another very effective mean for the transfer of know-how. These experts are recruited by the IAEA and asked to support the project’s counterparts on a specific aspect of the project. Being delivered locally, this kind of support is particularly important for solving specific issues and therefore for achieving the project’s objectives. Finally, as one of the means for achieving their objectives, TC projects often include the procurement of important equipment or services based on the general aspects of sustainability and ownership [13].

9.4.2 Quality Assurance

In 2006, NMDI Section of the IAEA launched an initiative to design a program to help its constituency in MSs to self-assess the standard of their NM clinical practices and, if necessary, raise them up to accepted international standards. The output of that initiative has been a program called Quality Management Audits in Nuclear Medicine (QUANUM), based on comprehensive auditing missions of multidisciplinary teams.

The aim of the QUANUM program is threefold: in the first place to encourage the introduction of a routine process of conducting annual systematic audits in the clinical arena; secondly, to encourage the adoption of a culture of regular analyses and reviews of internal processes, both of them essential for positive growth in medical services and, third and even more important, to introduce the entire quality audit process, patient oriented, systematic and outcome based.

The QUANUM program proved to be applicable to a wide variety of institutions, from small practices to larger centres with PET/CT and cyclotrons. Clinical services rendered to patients showed a good compliance with international standards, while issues related to radiation protection of both staff and patients require a higher degree of attention. This should be considered as relevant feedback for the IAEA with regard to the effective translation of safety recommendations into routine practice. Training on drafting and application of Standard Operating Procedures (SOPs) should also be considered a priority [10,11,12].

9.4.3 Procurement

Over the years, NMDI Section of the IAEA has assisted over hundred low- and middle-income MS to acquire or strengthen their NM services. The Nuclear Medicine Resources Manual, for example, provides guidance to decision-makers on the different applications of nuclear medicine and on the prerequisites and resources needed to establish this service.

9.4.4 Education

Training in nuclear medicine is vital for the development of adequate capacities in MS. NMDI Section of the IAEA provided education and training opportunities to professionals throughout their careers, as part of a lifelong learning process.

As a promoter of optimal nuclear medicine practice, the IAEA published a Training Curriculum for Nuclear Medicine Physicians, which offers guidelines that are based on various publications, international recommendations as well as expert advice. The objective of this publication is to recommend a harmonized training programme for nuclear medicine physicians, allow trainees to develop the necessary knowledge, competencies and skills to practice this medical speciality and to ensure a safe and quality level of clinical nuclear medicine [7].

9.4.5 Coordinated Research Activities

The IAEA Coordinated Research Projects (CRPs) bring together research institutions throughout the world to collaborate on a well-defined research topic related to the acquisition and dissemination of new knowledge and technology in the various fields related to the peaceful use of atomic energy. Institutions and scientists from all around the world are selected to exchange information and work together on some relevant aspects related to the main topic, thus creating international scientific networks and enhancing the capabilities of participating countries to be involved in state-of-the-art scientific research. The results are made freely available to the MS and the scientific community usually through IAEA publications, training material, or articles published in peer-reviewed journals [9].

9.5 Conclusion

The IAEA has a long tradition in assisting its Member States in the field of nuclear medicine. The main activities in this field are the production of guidance documents, the establishment of educational and training, the coordination of research activities and the support to Member States for establishing and safely operating nuclear medicine facilities through the technical cooperation programme. But enormous efforts are still needed, not only to ensure universal access to NM services, but also to make these services affordable and reliable.