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176 Chapter 9 fewer resources for autopsy. On top of that, this MIA method may unnecessarily be an overly extensive approach, considering that the leading causes of death in low-income countries are lower respiratory tract infections and diarrheal diseases. 142 Therefore, in Mozambique the MIA was reduced to only tissue biopsies (without any guidance) according to a fixed protocol, and blood and cerebrospinal fluid sampling for histological and microbiological examination. 275 This method sufficed to detect infectious diseases and malignancies in around 80% of the cases. In our study cohort, a preliminary calculation of the costs of a complete MIA gave the amount of €1,300. This includes all personnel time (e.g. preparation of the body, and the time spent by the involved radiologists, pathologists and neurosurgeons), technique costs (e.g. imaging modalities; histological slides and immunohistochemistry) and, in our cohort, brain biopsies in a quarter of the cases. Even though we performed CT (and stereotactic) guided biopsies, explaining the higher costs of MIA than in our pilot, 57 we were able to prevent an excessive increase of costs, by employing medical students to assist with MIA instead of the more expensive radiologic technologists. The costs of imaging equipment are low in this study because the scanners are fully utilized in the clinical program. Dedicated scanners for MIA, e.g. installed at the morgue, would probably be underutilized, making the procedure more expensive to compensate for the higher depreciation and running costs of the equipment. However, if ‘second-hand’ scanners would be made available for post-mortems only, WKH PDLQ ILQDQFLDO DQG ORJLVWLF LPSHGLPHQWV ZLOO EH VROYHG 7KHQ PLQLPDOO\ LQYDVLYH autopsies can readily be performed shortly after death, and more frequently once its workflow has become a routine. With the improved efficiency, there will be a low- threshold for general practitioners to request autopsy for out-of-hospital deceased, and eventually, MIA may become less expensive. Another way to reduce the costs of MIA in the future would be to shorten the most time consuming step, which is the biopsy needle placement for tissue sampling. This is being explored in forensics, where a robotic system is under development that permits automated needle placement, thereby shortening procedure time. 96 Another approach would be stereotactic guidance of the biopsies, similar to the technique we used for our brain biopsies. This way, it will no longer be necessary to check the needle position for each biopsy by performing new scans. Inevitably, the more advanced an alternative autopsy technique is, the higher its price, but, in general, the better its diagnostic capabilities. Future studies are needed to explore possibilities to tailor the MIA technically without reducing its diagnostic performance.