It is imperative to protect both patients and health workers from the dangerous risks of excess radiation exposure. Although radiation doses to patients in radiographic examinations are generally considered to be small in comparison with the immense benefits derived from these examinations, it is appropriate to reduce the dose to the lowest amount that is necessary to produce the image quality required for a diagnosis [34]. Poor-quality images result in unnecessary radiation exposure to patients through repeated radiographic examinations, loss of diagnostic information, and increased costs of health care [35].

The lack of appropriate infrastructure, well-maintained equipment, trained staff, governmental regulations, among other factors, threatens the safety of patients, workers, and the environment. About 40 % of low-income countries lack an expert responsible for implementing and enforcing regulations that ensure the safety of the device for the medical professional and the patient [32].

Quality assurance (QA) is a management tool, which aims to ensure that every exam or treatment in a radiology department is necessary and appropriate to the medical problem, and performed with the utmost level of quality and safety for the patient. These procedures should be performed according to previously accepted clinical protocols, by adequate trained personnel, with properly selected and functioning equipment, to the satisfaction of patients and referring physicians, in safe conditions and at minimum cost. Thus, a QA program should include periodic reviews of referral patterns, clinical protocols, continuing education opportunities for staff, facility inspections, equipment testing, and administrative procedures related to the purchase of supplies and billing. The ultimate goal of QA is to improve patient care.

Implementation of quality assurance programs is essential for obtaining accurate diagnoses. A PAHO assessment of imaging services conducted in public and private hospitals of five Latin American countries showed that very few services had implemented periodic quality control programs. As a result, more than 30 % of the clinical images from gastrointestinal tract exams and more than 50 % of lumbar spinal studies were not of diagnostic quality [36].

Accreditation programs represent a method for establishing and monitoring a set of quality standards. Regardless of the limitations that developing countries face, they can benefit from accreditation programs if they are to be tailored to the country’s specific needs, in order to meet the demands of the population. With this in mind, PAHO developed a model of accreditation programs for imaging services in Latin American and the Caribbean countries, based on the experiences of the ACR program [37].

In some countries, the low demand for medical technology often derives from deep-rooted culture and social norms. At the beginning of the symptoms, persons tend to solve their problems with traditional medical services, or via regional religious or folk-healing practitioners. Often when expected results are not produced with local folk medicine, the patient then seeks modern medicine. Although the introduction of new technologies and techniques in some countries is necessary, awareness of the traditions and beliefs may be crucial to the success of any project. Some cultural beliefs can affect medical imaging’s acceptability and accessibility. For example, in Bangladesh, women are considered expendable and one with cancer is viewed as “bringing a curse to the family,” and often leading to separation or divorce. They are therefore less likely to seek care or screening [38].

Access to appropriate healthcare services is very limited in rural areas, where approximately one-half of the global population lives and heavily depends on the numbers and types of qualified workers available. Only 38 % of the total nursing workforce and by less than a quarter of the total physician workforce practice in rural areas. For 57 countries, the critical shortage of trained health workers means an estimated one billion people without access to essential healthcare services. In Bangladesh for instance, 30 % of nurses are situated in four metropolitan districts where only 15 % of the population lives. In South Africa, 46 % of the population lives in rural areas, but only 12 % of doctors and 19 % of nurses are working there [39].