Point of care ultrasound (PoCUS) in low- and middle-income countries

Abstract

Point-of-Care Ultrasound (PoCUS) is a portable, affordable, and versatile diagnostic and procedural tool that enhances bedside decision-making. Its simplicity and safety make it especially valuable in low- and middle-income countries (LMICs), where access to advanced imaging is limited. PoCUS helps bridge diagnostic gaps by enabling real-time, noninvasive assessment and procedural guidance across anesthesiology, perioperative care, critical care, and emergency-medicine. However, implementation in LMICs faces barriers such as limited device availability, high costs, maintenance difficulties, and insufficient training. Equipment availability, accessibility and structured education remain key determinants of adoption. Training programs are often short-term and externally led, with limited long-term integration into local systems. Emerging strategies including “train-the-trainer” approaches, blended learning, and tele-mentoring—offer scalable solutions. Coordinated efforts across access, education, and sustainability—supported by mentorship and standardized credentialing—are essential. Ultimately, PoCUS represents more than a diagnostic tool; it is a driver of equity, safety, and empowerment in global health.

Graphical abstract

1 Introduction

Point of Care Ultrasound (PoCUS) involves the use of ultrasound (US) at the patient’s bedside to answer specific diagnostic questions and to visualize real-time physiological responses to various treatments or medical interventions. PoCUS can be viewed as an extension of the traditional physical examination and standard monitoring practices—an evolutionary step that provides a rapid, noninvasive alternative to more complex imaging modalities ^,. Over time, it has evolved into an indispensable tool in bedside assessment, with expanding applications across multiple medical specialties, including perioperative care. PoCUS evaluations of the heart, airway, lungs, abdomen, and head are considered safe, straightforward to learn, and highly reproducible, demonstrating strong sensitivity and specificity. The technique has virtually no contraindications, and complications are exceedingly rare . Additionally, PoCUS has a valuable procedural role by providing real-time visualization of anatomical landmarks, needle and catheter positioning, and even the spread of injected medications, thereby enhancing the safety and precision of interventions. Through this review we will discuss the current role, challenges, and opportunities for implementing PoCUS in low- and middle-income countries (LMICs), with a focus on anesthesiology training and practice.

2 PoCUS in LMICs (importance and role)

2.1 Importance and Role

Despite the limitations and criticism of the term “Low- and Middle-income countries” defined by a specific range of Gross National Income (GNI) per capita (The World Bank) , it is pragmatically useful to signal the pressing challenges faced by healthcare systems serving approximately 60 % of the global population. These systems often experience severe constraints in financial, human, structural, and social resources; limited training opportunities; as well as significant geographical and environmental barriers . Such limitations translate into restricted access and low-quality healthcare, contributing to a substantial burden of preventable deaths each year . Among the key deficiencies underpinning low-quality healthcare is the lack- or delayed availability-of appropriate imaging tools for diagnostic purposes, clinical decision-making, and procedural guidance.

PoCUS represents a crucial and transformative solution to various healthcare challenges . It is a practical option, being affordable, portable, and readily available at the bedside . Compact, battery-powered, handheld devices that connect to smartphones or tablets now offer image quality comparable to the traditional cart-based systems, but at a fraction of the cost of CT or MRI machines . As a noninvasive and cost-effective diagnostic tool, PoCUS has the potential to bridge the “diagnostic gap” that often defines healthcare delivery in resource-limited settings .

The importance of PoCUS extends to its broad clinical applicability and its capacity to enhance real-time clinical decision-making. As an adjunct to clinical evaluation, PoCUS improves the quality and safety of patient care by reducing time to diagnosis, improving diagnostic accuracy, and maximizing procedural safety. In anesthesiology, PoCUS supports perioperative evaluation, airway assessment, hemodynamic monitoring, and emergency interventions. It facilitates critical procedures such as central venous and arterial catheter placement and peripheral nerve blocks, improving success rates while minimizing procedural risks. Moreover, it enables rapid bedside diagnosis of life-threatening conditions such as pneumothorax, pleural effusion, cardiac tamponade, and pericardial effusion, conditions where timely imaging may determine survival. It also aids in distinguishing cardiogenic shock from severe hypovolemia in perioperative trauma settings and plays an essential role in focused protocols such as FAST (Focused Assessment with Sonography for Trauma) and FASH (Focused Assessment with Sonography for HIV/TB), which are particularly relevant for diagnosing trauma and infectious diseases prevalent in LMICs. Importantly, PoCUS does not involve exposure to ionizing radiation, making it safer for both patients and healthcare providers than other imaging modalities ^,.

The applications of PoCUS may differ substantially between high-income countries and LMICs mainly due to differences in infrastructure, clinical context, and resource availability . In well-resourced environments, PoCUS often complements existing diagnostic and monitoring systems, whereas in resource-limited settings it frequently serves as the primary imaging modality, functioning as a critical diagnostic and monitoring tool rather than a complementary one.

In many LMIC hospitals, reliance on PoCUS enhances the rapid assessment of hemodynamic status, airway management, and procedural guidance. Additionally, US-guided regional anesthesia (RA) can reduce the need for general anesthesia when ventilators or recovery resources are scarce, while assessment of volume status or cardiac function helps optimize fluid therapy where invasive monitoring is unavailable. As a matter of fact, reports have highlighted a greater preference for the use of RA in low-income countries compared with practices of the same anesthesia providers in their countries of origin . Moreover, RA has been associated with lower odds of perioperative mortality in resource-limited settings compared with general anesthesia .

Moreover, perioperative PoCUS in LMICs frequently extends beyond the operating room, supporting triage and management in emergency, obstetric, and critical care settings . These contextual differences mean that PoCUS in LMICs is not merely a tool for precision, but often a substitute for otherwise inaccessible diagnostics. Consequently, its educational priorities, implementation strategies, and safety frameworks must be adapted to local realities—emphasizing portability, cost-effectiveness, and task-shifting rather than technological sophistication.

2.2 PoCUS in LMICs (limitations and barriers)

Despite its clear benefits, PoCUS implementation in LMICs faces persistent barriers. In 2023, a global, anonymous online survery by Ginsburg et al. explored the current use, barriers, facilitators, perceptions, and practices related to PoCUS in LMICs. A total of 241 respondents from 62 countries participated in the survey, 70 % of whom reported direct experience working in LMICs. Most participants were physicians (82 %) employed in urban tertiary or academic hospitals (88 %) that were predominantly publicly funded (62 %). Notably, the majority of respondents had already received US training (78 %) and reported having both experience (65 %) and confidence (90 %) in its use .

While 96 % agreed that PoCUS improves care quality and outcomes, and 80 % indicated that it is important for patient management, access to machines remained the main determinant of adoption: 17 % identified limited equipment as the leading barrier, while 53 % considered its availability as the primary facilitator. Other obstacles included device cost and maintenance (83 %), limited training, and competition for machine use among different providers or departments. Finally, a minority of respondents (18 %) expressed concerns or reservations regarding PoCUS use, with fear of misdiagnosis being the most frequently cited concern (71.4 %). The most reported uses of US were procedural guidance (e.g., intravenous line placement, thoracentesis, paracentesis) and diagnostic evaluations of the lungs, heart (echocardiography), and trauma (FAST). Specific obstacles and barriers described in this study are presented in Table 1 .

Table 1

Main barriers to PoCUS implementation in LMICs .

Barrier Category	Specific Obstacle
Access to Equipment and Supplies	Limited access to or availability of PoCUS machines and probes.
	High cost of PoCUS devices—although less expensive than CT or MRI, the price of machines, probes, and maintenance remains a significant financial challenge.
	Lack or absence of reliable local maintenance and repair services for PoCUS machines and probes.
	Limited availability or insecure storage of devices, resulting in machines being locked away and underused.
	Limited supply of essential consumables such as ultrasound gel and probe covers.
	Competition for PoCUS use among different providers or departments.
Infrastructure and Environmental Context	Unreliable electrical grid with frequent power outages, limiting scanning time, image display options, and opportunities for tele-mentoring.
	Limited internet connectivity (Wi-Fi or cellular networks) with low bandwidth, poor coverage, and high mobile data costs, impeding access to online educational resources, image transfer, and remote feedback.
	Physical space limitations for performing PoCUS (e.g., overcrowded emergency settings) or for housing larger machines.
	Dispersed hospital layout requiring long travel distances between departments.
	Harsh environmental conditions such as humidity, heat, and dust, posing challenges to both operators and machines.
Education and Training	Lack of high-quality, contextually relevant training opportunities.
	Shortage of adequately trained providers and local mentors.
	Limited training time for mastering a complex psychomotor skill, often constrained by concurrent clinical duties.
	High learner-to-instructor and learner-to-device ratios, resulting in insufficient scanning time per participant.
	Trainees’ limited familiarity with computers or digital devices, requiring additional time for adaptation.
	Training materials that are overly comprehensive or overwhelming rather than concise and context-focused.
	Absence of formal quality assurance systems, assessment frameworks, and continuous reflection on PoCUS practice.
Operational and Systemic Factors	Resistance or negative perceptions toward PoCUS from other departments and hospital administration.
	Curricula that are poorly adapted to local context or prevalent diseases, or insufficiently comprehensive to meet clinical needs.
	Frequent staff turnover and learner attrition.
	Challenges in maintaining sterile technique and patient privacy in busy clinical environments.
	Lack of standardized documentation for ultrasound reports, leading to miscommunication or errors.
	Fear of misdiagnosis associated with PoCUS use (reported by 71.4 % of respondents expressing concerns).
	High cost of alternative diagnostic tests (CT, MRI, X-ray), leaving patients unable to afford PoCUS without diagnostic options—an economic barrier at the patient level.

Consistent with these findings, a national survey conducted among Colombian anesthesiologists reported equipment availability as the strongest predictor of US use, while lack of access to devices remained the primary barrier . This underscores that across different settings, from national to global contexts, the accessibility of US equipment continues to be the most decisive factor determining its clinical adoption.

Medical equipment licensing represents another barrier to the implementation of PoCUS, as multiple regulatory requirements must be fulfilled before devices can be marketed within a given region. In contrast to high-income countries, where regulatory approval is typically secured prior to market entry, the absence or delay of such approval in many LMICs restricts the availability of US equipment to healthcare institutions. Consequently, device selection is often determined by regulatory authorization rather than by technical performance or clinical suitability .

Infrastructural and environmental constraints further challenge PoCUS adoption. Unreliable electricity, poor internet connectivity, space limitations, dispersed hospital layouts, and harsh conditions such as heat, humidity, and dust impede both device function and operator performance. Consumables like gel and probe covers are often scarce, and frequent staff turnover disrupts continuity of care and training.

Education and training represent another major barrier. Most PoCUS programs in LMICs are short workshops, often externally led, and rarely support long-term skill retention. . Curriculum relevance is also an issue. Courses designed for high-income contexts often emphasize conditions less common in LMICs. A rural hospital in Malawi, for example, may need more training in obstetric scanning and trauma evaluation than in echocardiography. Tailoring training to local needs is therefore crucial.

Operational and systemic factors also impede PoCUS use. Resistance from other departments, poorly adapted curricula, lack of standardized documentation, and insufficient protected training time further constrain integration.

3 Education and training

Despite being an invaluable tool, PoCUS carries risks. The rapid increase in its use may outpace the development of best practices for patients and providers. Training availability and quality are significant barriers to the sustainable use of PoCUS in LMICs. Most training initiatives are short workshops or brief courses, typically organized by Non-Governmental Organizations, academic partnerships, or medical societies, combining brief classroom sessions with supervised scanning on patients or volunteers. In our experience with humanitarian work for the Médecins Sans Frontières and ICRC (International committee of the Red Cross), these organizations have been a pioneers in delivering targeted US training to field clinicians, focusing on high-yield applications like obstetric imaging, trauma (FAST), and abdominal emergencies . However, they only provide initial exposure but rarely promote long-term retention of skills.

A recent scoping review in 2025, encompassing 53 studies, highlighted the magnitude of these challenges . More than 80 % of the reported programs consisted of short courses, with about 40 % delivered as single stand-alone sessions and 60 % offering only limited follow-up. Only a small minority (13 %) described longitudinal programs with repeated sessions or sustained mentorship extending beyond one month. Furthermore, the training content was narrow in scope, emphasizing organ- or syndrome-focused applications, most commonly lung (55 %), cardiac (53 %), and basic obstetric (43 %) US. By contrast, applications highly relevant to anesthesiology—such as regional anesthesia, airway assessment, and hemodynamic monitoring—were rarely included. Reflecting this imbalance, the distribution of specialties favored emergency medicine, primary care, and obstetrics, which accounted for 76 % of publications, while only a single study included anesthesiologists . Additionally, trainees were predominantly medical doctors and clinical officers with little or no prior US experience, and training was usually delivered by external faculty, half of whom were emergency physicians. Importantly, most programs (55 %) were not embedded in local curricula, raising concerns about long-term sustainability.

The lack of anesthesiology involvement in PoCUS training literature from LMICs has significant implications for education and clinical implementation. In many LMICs, anesthesiologists provide perioperative and critical care, often with limited diagnostic resources. PoCUS could transform perioperative safety, guide airway and vascular management, and support hemodynamic monitoring. However, without structured training, anesthesiologists cannot fully leverage these benefits. This gap leaves patients, already burdened by high disease prevalence, at risk of delayed or suboptimal care. Integrating PoCUS into anesthesiology through standardized, high-quality training and certification could improve scalability, build local capacity, and strengthen perioperative and critical care services.

Recent studies conducted in LMICs to evaluate the feasibility, effectiveness, and sustainability of PoCUS training initiatives across various clinical contexts are summarized in Table 2 .

Table 2

Characteristics and outcomes of recent PoCUS training studies in LMICs.

Author & Year	Title	Objective	Method	Main Findings
Weimer, J. M. et al. (2024)	Effectiveness of an ultrasound basic cancer training program through on-site training and virtual case discussions in rural Tanzania: a proof-of-concept study	To assess the feasibility of an ultrasound training program for cancer diagnosis, screening, and staging in a low-resource setting, aiming to accelerate patient referrals to specialized centers.	Proof-of-concept observational study with 16 participants (medical and clinical officers) in Tanzania. The curriculum followed the WHO Diagnostic Ultrasound Manual and included a 5-day (24-h) on-site training plus biweekly virtual tumor boards. Knowledge was assessed before and after training.	Demonstrated a significant increase in knowledge and continuous improvement in image acquisition quality during virtual follow-up. The program was highly rated by participants, confirming feasibility and acceptability.
Nadimpalli, A. et al. (2019)	Feasibility of Training Clinical Officers in Point-of-Care Ultrasound for Pediatric Respiratory Diseases in Aweil, South Sudan	To examine the feasibility of training Clinical Officers (COs) to use a PoCUS algorithm to differentiate causes of lower respiratory tract infections (LRTI) in children under 5 years.	Feasibility study involving six COs without prior ultrasound experience who received 12 h of field-based training and performed 360 pediatric lung scans. Image quality and interpretation were reviewed by blind experts.	Training was feasible and effective: 99.1 % of images were acceptable, and 86 % of interpretations were appropriate. Interrater agreement was very good for viral LRTI and good for bacterial pneumonia.
Terry, B. et al. (2019)	Rapid, remote education for point-of-care ultrasound among non-physician emergency care providers in a resource-limited setting	To evaluate the impact of remote feedback on PoCUS image quality and utilization among non-physician emergency care providers (ECPs).	Prospective observational evaluation in Uganda (10 ECPs) over 11 months across four phases: initial in-person training, two independent practice phases, and a final phase with remote feedback. Image quality was scored on an 8-point scale.	Remote quality-assurance feedback effectively improved skills and sustained ultrasound use. Image quality improved from 3.82 to 4.68. Monthly ultrasound utilization dropped by 61 % post-training but increased by 240 % after feedback. FAST exam sensitivity improved by 88 %.
Wachira, J. et al. (2023)	A training program for obstetrics point-of-care ultrasound to 514 rural healthcare providers in Kenya	To assess the feasibility of implementing large-scale OB PoCUS training for high-risk obstetric conditions in rural Kenyan public health facilities.	Large-scale training program involving 514 mid-level healthcare providers across multiple 5-day intensive workshops (instructor: trainee ratio 1:5). Pre/posttests and OSCE were used for evaluation.	Demonstrated the feasibility of rapidly building OB PoCUS skills. Post-test scores improved from 52.8 % to 90.6 %, and 99 % passed the OSCE (mean score 87.3 %). The program proved scalable and effective.
Pathak, A. et al. (2024)	Physicians’ clinical experience and perspectives following a pilot, blended learning, point of care ultrasound course in Ghana: a mixed methods analysis	To explore real-world experiences, barriers, and facilitators among physicians applying PoCUS in clinical practice after a blended learning course.	Mixed-methods retrospective study with eight physicians (specialists and residents) in Ghana. The 7-month pilot course combines online and practical components. Frequency of PoCUS use and perceptions were assessed using the CFIR framework.	PoCUS was used 3–6 times per week (cardiac, IVC, DVT, lung/pleura, vascular access). About 40 % of patients could not afford alternative diagnostics, and PoCUS findings were confirmed in 60–78 % of second opinions. The perceived advantage was the strongest facilitator; equipment and maintenance were key barriers.