Underdeveloped and underused medical laboratories in sub-Saharan Africa negatively affect the diagnosis and appropriate treatment of ailments.
We identified political, disease-related and socio-economic factors that have shaped the laboratory sector in Senegal, Mali and Burkina Faso to inform laboratory-strengthening programmes.
We searched peer-reviewed and grey literature from February 2015 to December 2018 on laboratory and health systems development from colonial times to the present and conducted in-depth interviews with 73 key informants involved in (inter)national health or laboratory policy, organisation, practice or training. This article depended on the key informants’ accounts due to the paucity of literature on laboratory development in francophone West African countries. Literature and interview findings were triangulated and are presented chronologically.
Until around 1990 there were a few disease-specific research laboratories; only the larger hospitals and district health facilities housed a rudimentary laboratory. The 1990s brought the advent of donor-dictated, vertical, endemic and epidemic disease programmes and laboratories. Despite decentralising from the national level to the regional and district levels, these vertical laboratory programmes biased national health resource allocation deleteriously neglecting the development of the horizontal, general-health laboratory. After the year 2000, the general-health laboratory system received more attention when, influenced by the World Health Organization, national networks and (sub-)directorates of laboratories were installed.
To advance national general healthcare, as opposed to disease-specific healthcare, national laboratory directors and experts in general laboratory development should be consulted when national policies are made with potential laboratory donors.
Underdeveloped and underused medical laboratories in sub-Saharan Africa hamper the diagnosis and management of potentially epidemic infectious diseases as well as general public health conditions.
Identifying the historical developments that have shaped the laboratory sector could help to understand the gaps and provide lessons for laboratory-strengthening programmes. As far as we know, this is the first study on this topic. The guiding question of our study was: what political, socio-economic, and disease-related factors have influenced the current status of medical laboratories in Senegal, Mali and Burkina Faso?
The development of medical laboratories in Africa cannot be dissociated from the development of the healthcare sector at large.
Our article progresses chronologically: it begins in late colonial times, goes on to the post-independence period, followed by the time of structural adjustment, and ends with the emergence of global health. In each period, we describe the developments in the laboratory sector and the influencing factors.
The objectives of the study were explained to all key informants; all gave verbal consent to be interviewed and recorded, as can be proven by the audio recordings.
The data for this qualitative descriptive study are derived primarily from in-depth key informant interviews and a literature review. The study proposal identified themes in the interrelated factors influencing laboratory development. Themes explored were: organisation of services, regulations, health policies and plans; economic conditions and by extension personnel, equipment, training and infrastructure development; endemic and epidemic disease contexts; and lastly, funding by national governments and (inter)national donors.
Between February 2015 and February 2016, three country teams of three to six social science researchers and laboratory professionals searched for peer-reviewed and grey literature on the study’s themes and identified factors in local libraries, organisations and government departments (Online Supplementary Document – Table 1), and freely accessible websites (Online Supplementary Document – List 1).
Key informants, selected by the country team members, were in 2015 interviewed for 30 min to 3 h, mainly at their workplace. Selection criteria were having an active role in the (inter)national health or laboratory policy, organisation, practice or training (past and present). For every key informant, a personalised question guide was prepared, considering their professional background, the period of their professional work and their involvement with laboratories.
A summary of the 73 key informants’ background characteristics is presented in
Background of the 73 key informants, francophone Africa, February 2015 – February 2016.
| Variable | % | |
|---|---|---|
| Male | 49 | 67 |
| Female | 24 | 33 |
| Senegal | 20 | 27 |
| Burkina Faso | 24 | 33 |
| Mali | 29 | 40 |
| Laboratory (assistant, technician, pharmacist, biologist) | 40 | 55 |
| Clinical (nurse, midwife, medical doctor, gynaecologist) | 32 | 44 |
| Other | 1 | 1 |
| Colonial | 1 | 1 |
| 1960–1979 | 9 | 12 |
| 1980–1999 | 48 | 66 |
| 2000–2014 | 15 | 21 |
| At training institute (university, training school for laboratory technicians, midwives) | 19 | 26 |
| At Ministry of Health (division or [sub-] directorate laboratories, other directorates) | 16 | 22 |
| Private practice (laboratory, maternity) | 12 | 16 |
| Laboratory practice | 10 | 14 |
| Clinical practice | 9 | 12 |
| Research institute | 7 | 9 |
| International organisation | 6 | 8 |
| Retired | 8 | 11 |
The audio-recorded key informant interviews (in French) were transcribed verbatim. NVivo qualitative data analysis software, version 10 (QSR International, Melbourne, Australia), was used for the thematic analysis of the interviews and a timeline was constructed for each country. Each country team summarised their literature findings thematically and chronologically. In this article, the findings derived from the two data collection methods have been triangulated and are presented for the three countries combined. Occasionally, differences and specificities across countries are pointed out. It should be noted that when the article refers to literature, the same information was usually corroborated by key informants. All quotations in the text are English translations of the French citations.
The study’s primary finding and challenge was the scarcity of written sources on laboratories; consequently, this history of laboratory development mainly hinges on the accounts of key informants, all of whom willingly recounted their experiences. Notably, those involved in laboratory practice or policy welcomed the attention; as a Senegalese biologist involved in laboratories since 1982 expressed: ‘The laboratory has habitually been the forgotten part of medicine, meaning one thinks of everything, and of the laboratory only after that’ (Key informant 62, male, Interview date 11 March 2015, Dakar). Descriptions of developments for colonial times and during the first decades after independence are briefer than for the periods afterwards because most of the key informants commenced their laboratory experience after these two periods.
In colonial times, all three countries housed renowned research laboratories, including
After independence, the colonial research laboratories remained – although some under another name (the Malian
Laboratory diagnostic tests were limited and aimed mainly at detecting parasites and measuring glycosuria. Even in larger public hospitals, laboratory services were embryonic and only a few laboratory training programmes existed. In Burkina Faso, nurses could specialise in laboratory technology at
The national MoH in Senegal and Burkina Faso did not prioritise laboratories, resulting in a lack of equipment and supplies for the few existing public facilities. In Mali, however, the Minister of Health acknowledged the importance of laboratories relatively early; he created the national research laboratory INRSP in 1973
This period saw the implementation of two global strategies for health systems development: the 1978 Alma Ata Primary Health Care Declaration and the 1988 Bamako Initiative. These called for the decentralisation of basic health services, a focus on clinical diagnosis and the supply of essential drugs and equipment. However, structural adjustment programmes, with their efficiency-driven economic reforms, implied less state involvement, public spending cuts and privatisation of healthcare services.
In the three countries, health centres at (sub-)district level were built, usually with a supporting laboratory to provide the stipulated minimum of primary healthcare diagnostic tests.
Medical doctors and laboratory personnel working at district level narrated that at this time if there was a laboratory at all, it was rudimentary and very few types of tests were done, usually in a room not designed to house a laboratory. A Burkinabé laboratory technician depicted how, in the 1980s, a typical health centre laboratory was just a small room with a microscope, a manual centrifuge and a fridge with some reagents. ‘Community people called us “stool doctors” because they only saw us examining stools’ (Key informant 35, male, interview date 06 May 2015, Ouagadougou), recounted the lecturer for laboratory technicians at
‘During the years 1984–1990, it was challenging. It was apparent that when you were in a place without electricity you could use very little equipment. Only those working in private laboratories had solar microscopes. Thus, we had to seek a window and work with sunlight; in that way, we could only do parasitology tests’. (Key informant 46, male, interview date 04 May 2015, Ouagadougou)
He concluded: ‘Sophisticated laboratory development followed electrification’. His midwife colleague at
Key informants in Mali and Burkina Faso reported that structural adjustment programmes had stimulated private practice; this was supported by government laws authorising private medical practice.
Training opportunities at this time increased. The University of Mali (founded in 1993) offered pharmacists and medical doctors additional training options in medical biology. Cheikh Anta Diop University in Dakar offered training for senior laboratory technicians. In Burkina Faso, a three-year training programme for laboratory technicians started in 1985 at the
Insufficient local training opportunities persisted for assistant and specialisation levels. Also, no formal training existed for laboratory assistants and nurses trained on-the-job, who still formed a large portion of laboratory personnel.
The first national Demographic and Health Surveys were conducted in the mid-1980s. National health plans focused on equity in service access through primary healthcare, the reduction of infant, child and maternal mortality, and family planning.
No national funds were dedicated to laboratories, and therefore laboratory operations relied on budgetary allocations from health facility management. In those periods of economic austerity, the management of health facilities struggled to maintain all services, including laboratory services. Limited budgets and the consequently erratic reagent availability made it difficult for laboratories to function well.
Laboratories became more visible in Senegal in 1990 as part of the
Many informants pointed out that the rapid development of laboratories from the 1990s onwards was mainly linked to AIDS control programmes which, compared to tuberculosis and malaria control programmes, required more than reagents and microscopes. Once HIV cases were discovered in the mid-1980s, national AIDS programmes were set up with large international donor support to gather epidemiological data. Until the mid-1990s, HIV testing was centralised – either the suspected HIV-positive individuals had to go to central laboratories or the laboratory staff went to the regions. A director of the Senegalese
HIV serology and immunology tests were gradually decentralised to the regional hospital level. Donors supported regional hospitals and selected district health centre laboratories with equipment and supplies and by training laboratory staff – often assistants – to execute specific tests. The president of the Burkinabé association of technicians explained that in 1999 the entrance qualifications for laboratory technician training at the
Two important drivers for laboratory development were the 1996 World Health Organization (WHO) meeting in Ouagadougou and the 1998 meeting in Bamako on epidemic preparedness and the vital role of laboratories. Ministry of Health representatives from 16 West African countries participated. Key informants who attended these meetings remembered that the WHO stressed laboratory development, training of laboratory staff for early diagnosis of epidemic diseases, and setting up of national laboratory networks. Some few years later, all MoHs agreed to support medical laboratories to prevent and fight epidemic diseases.
In all three countries, more public regional hospitals and health centres were built from the late 1990s onwards, which included buildings or rooms dedicated to laboratory services.
With the arrival of more equipment and machines, the array of tests that laboratories could process increased.
If the person [clinician] knows he can have a haemoglobin count, he does not bother to check the eyes or tongue of the patient, because that would take him more time than to write a test request. (Key informant 47, female, interview date 04 May 2015, Ouagadougou)
Medical laboratories exist from the health centre level. However, many (public) laboratories are often substandard. They have inadequate qualified human resources, often face stock-outs of rapid tests, encounter recurrent machine maintenance problems and non-availability of supplies and reagents, and have inadequate laboratory space. The latter was particularly true in Mali. A Malian biological pharmacist described how a health centre would find a laboratory space: ‘Here there is a spare storeroom that only has to be transformed to be a laboratory’ (Key informant 28, male, interview date 14 August 2015, Bamako). Laboratory staff worried that working in a non-dedicated room compromises safety and biosecurity. For instance, a laboratory technician in a Malian health centre complained that laboratory training was not practicable in these settings. For instance little space means that equipment is sometimes placed too close to the wall, or on top of each other.
Some health centre laboratories are still headed by inadequately trained staff. Mali has a shortage of clinical biologists due to the lack of training opportunities. In Burkina Faso, biological pharmacists are available, but many opt to work in private pharmacies, so they are ‘lost for the [public] laboratory’. In Senegal, the bottleneck is the result of an insufficient budget to recruit the many required trained laboratory technicians.
The three countries’ MoHs realised the need to prepare and enable health facility laboratories to quickly respond to epidemic threats and to be less dependent on specialised research laboratories. National plans began to increasingly include laboratory services: national laboratory networks, directorates and sub-directorates. Interestingly, an outbreak of meningitis in Burkina Faso in 2002 led directly to the installation of the
In Mali, the national network of laboratories was created in 2004, consisting of specialised laboratories, hospital and
A public health medical doctor at WHO Dakar explained that the advantage of being a stand-alone directorate is visibility at the ministry level, which goes with resource allocations. The problem of not having a budget for the sub-directorate in Burkina Faso was explicated by its former director: ‘I was appointed director without materials, without anything. It is with my car that I visited all the laboratories in the country [for quality assessment]’ (Key informant 30, male, interview date 04 May 2015, Ouagadougou). The director of the Division of Laboratories in Mali noted that the division still struggles to function well because of a lack of resources for personnel.
The national laboratory networks, the (sub-)directorate and division depend heavily on donor funds for their outreach activities such as general supervision and quality control. However, these donors mainly support disease-focused programmes and outreach stops when the programme ends. For example, laboratory supervision activities in Mali no longer take place since money from the Global Fund to fight AIDS, tuberculosis and malaria stopped.
To improve organisation and monitoring, the
The WHO guided the three MoHs in developing national laboratory policies and strategic plans. The first step was to conduct a countrywide inventory and evaluation of the status of laboratories. The United States Centres for Disease Control and Prevention (CDC) funded this exercise in Mali in 2012, and the Malian national laboratory policy was accepted in the same year. In Burkina Faso, the national laboratory policy was endorsed by the government in 2007, including the first five-year strategic plan.
In-country training opportunities for all levels of laboratory personnel have increased since the late 1990s, and medical staff could specialise in laboratory sciences. Public and some private schools (the latter more prevalent in Senegal) were opened and existing schools or universities offered new curricula. Since 2007, laboratory technicians can upgrade their qualification through the Bachelor in Applied Medical Biology (
A general problem reported for many laboratory training programmes is the scarcity of equipment and supplies for hands-on practice. A lecturer in Dakar explained how lecturers have to buy equipment and reagents for the students’ practical work because since 2008 or 2009 the university does not receive government funding for research: ‘We do not even have a bottle of reagent for the practical work. The state has no money’ (Key informant 60, male, interview date 10 March 2015, Dakar). To tackle this problem, Senegalese university and training school laboratories have been allowed to generate money by offering paid services to the public.
Donors have continued to support specific laboratories with training and equipment for the disease they focus on. HIV programmes have greatly increased the availability and level of laboratory services for diagnosis and treatment follow-up. International donors, including the United States CDC, the Bill and Melinda Gates Foundation, the Clinton Health Access Initiative, the World Bank and the Global Fund, have financially supported or provided equipment, supplies and staff training. The Global Fund and World Bank financially supported infrastructure, surveillance, and supervision of HIV programmes. The United States CDC gave technical and financial support for sentinel site surveillance of HIV and syphilis among pregnant women, while providing quality controls for the testing services. The WHO provided financial and technical support for laboratory services to fight (other) epidemic-threat diseases, focusing on bacterial meningitis, bacterial diarrhoeal diseases, yellow fever, measles and rubella. In 2004, the WHO conducted training on the
The West African Ebola epidemic of 2013–2016 was a wake-up call for donors to support laboratories and for governments to establish national research laboratories. The INRSP already existed in Mali, and the institute’s ex-director and a current lecturer both recounted how donors had supported the INRSP with equipment that enabled it to perform Ebola diagnostic tests on regional samples. These key informants believed that this timely and efficient action contributed to the containment of Ebola in Mali.
Many key informants criticised donor support for its focus on specific diseases. The former head of several Senegalese MoH directorates (2004–2012) complained that donors for AIDS and malaria programmes only support selected laboratories with equipment and training. Two biotechnologists active in the Malian national association of laboratory technicians highlighted the lack of long-term vision and soundness of donor support during the Ebola outbreak when just a few technicians were trained and general biosecurity was only maintained as long as Ebola was a threat. A Burkinabé pharmacist recounted how a donor had given 10 microscopes – even though the (vertical) programme only needed three – but had not allowed the extra seven microscopes to be used for other services. Informants also criticised the fact that some donors imported their machines, not considering what was already available. For example, the head of the Directorate for Sexual and Reproductive Health in Burkina Faso recounted how, as a medical doctor in the region, she experienced that the laboratory equipment given by donors differed from what is normally used in the country. For instance, they received CD4 count machines that used different reagents and could be maintained or repaired by only one person in West Africa when the machines were out of commission for three months.
Until the late 1990s, there were few investments in the expansion of laboratory capacity, partly as a result of economic austerity that affected the overall health sector, but also because laboratories were not considered a priority. From the 1990s onwards, the development of laboratories was mainly influenced by the emergence of potential pandemic diseases that require laboratory confirmation for treatment and control. New technology has led to the expansion of laboratory services. However, operating a laboratory (including machines and equipment) depends on the availability of amenities such as electricity and running water. At the time of this report, unavailable and erratic public amenities challenge proper laboratory functioning. Not only do power cuts hinder testing, power fluctuations also cause equipment breakdown.
The MoHs in these economically constrained countries have had and still do have to operate with limited public finances, relying heavily on external financial aid for the running of public health services. Donors have therefore played the most important role in how laboratories have been developmentally geared towards specific diseases; national policymakers did not take a leading role. Dependence on donors puts the MoHs in a weak position in terms of setting priorities for laboratory development and research. Donor support for specific diseases did and might not strengthen the laboratory system for the diagnosis and follow-up of all health conditions.
An unexpected finding was the big influence of ‘laboratory champions’: persons committed to laboratories, who have a ‘vision’ and ‘fight’ for the development of the national laboratory system. They are individuals who got ‘the laboratory virus’, as the director of the Senegalese Directorate of Laboratories aptly described them. These champions included biologists and pharmacists who lobbied national ministers of health and donors to set up research laboratories, national health ministers and laboratory technicians active in their associations. These champions were often constrained in putting their vision into practice by the larger national context of unsupportive political leadership, general poverty and the lack of basic infrastructure and amenities.
Drawing lessons from the study findings, the following recommendations for laboratory-strengthening programmes are directed at political leaders, MoHs, health facilities and donors:
Have a stand-alone directorate of laboratories with a dedicated national budget, as per the recommendation of the 2008 Maputo Declaration.
Prioritise continuous professional development opportunities for laboratory personnel at all levels, including laboratory assistants trained on-the-job. Professional councils and associations, and the African Society for Laboratory Medicine, should play a role in regulating the profession while the national leadership supports with sufficient funding.
National public health laboratories should be established – this is one of the goals of the Africa CDC, supported by the African Society for Laboratory Medicine – and should have political influence at the MoH to set national research priorities.
Health facility management committees should establish a dedicated budget for the laboratory, reasoning that the laboratory is a source of direct income and needs to function optimally. As the director of a Senegalese regional hospital expressed: ‘That will make the facility function. The laboratory and the radiology are the “lungs” of the health facility’ (Key informant 65, male, interview date 16 March 2015, Kaolack).
The authors acknowledge that personal accounts do not constitute hard, objective data, as is the norm in the medical sector, including laboratory medicine. The authors are also aware that respondents may have constructed this history of, and recommendations for, laboratory development to suit their own or their organisations’ interests. Nevertheless, by triangulating literature and accounts of key informants from three countries and different health professions and levels, the authors opine that this oral history presents a true reflection of the development of medical laboratories in francophone West Africa.
This unique article on the long-term historical developments of the laboratory sector in francophone West Africa demonstrates that by collecting and recording the experiences of people who lived through and have been actors in laboratory developments, a history that would have been otherwise forgotten has been constructed. Many of the historical laboratory sector challenges still exist and will not be surmounted without national leaders prioritising the alleviation of national poverty and the development of basic infrastructure. As exemplified by the champions described in this article, national policymakers must be abreast of their population’s disease burdens and needs and play the important leadership role to donors ensuring donor programmes match the populace’s healthcare or laboratory needs, consequently advancing their population’s healthcare. Ministries of Health should see laboratories as an integral part of the health system, and not simply as part of vertical disease programmes. The retired director of INRSP in Mali aptly reiterated: ‘The laboratory is the brain of the health system’ (Key informant 24, male, interview date 13 August 2015, Bamako).
We thank the francophone West Africa country team members – other than the authors of this article – who participated in the literature studies. In Senegal, they are Mouhamed Ahmed Badji and Papa Ngore Sarr Sadio; in Burkina Faso, Dr Nikiéma Abdoulaye, Dr Paul Somda, Naby Alphonse and Zélé Issa; in Mali, Prof. Bourèma Kouriba, Dr Seydou Diarra and Mamadou Fadiala Sissoko. We also thank the West African and Dutch SociaLab members who contributed to the overall SociaLab study that this study is part of: Dr Aicha Marceline Sarr, Prof. Robert Pool, Prof. Constance Schultz. Special thanks go to Prof. Robert Pool for critically reading the final draft manuscript and Oumou Badji and Sylvain Yaméogo for transcribing the key informant interviews. We are most grateful to the key informants who gave their time and enthusiasm to share their experiences with us; without them this history could not have been written. We apologise for having had to sacrifice their often very rich contributions for the general history.
The authors have declared that no competing interests exist.
W.K. was responsible for the study proposal and design, interviews (Senegal and Burkina Faso), coordination, analysis of key informant interviews and drafting of manuscripts. A.G.N. drafted the literature study and report. M.A. and I.G. conducted interviews (Mali) and drafted the literature study and report. I.S., S.D. and J.S. were involved in the study proposal and design, selecting key informants and the literature study. P.O. worked on the study proposal and design and was the principal investigator at SociaLab. All authors critically commented on the draft manuscripts and gave their approval of the final article.
The study was funded by the Netherlands Organization for Scientific Research, Science for Global Development (NWO/WOTRO) under W07.4.203.00.
Upon request, transcripts of interviews can be provided.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.