National health laboratories are unique in that they cut across all areas of every country’s national health systems delivery. Their core roles and functions are to provide timely, accurate and reliable results to support diagnosis, surveillance and outbreak investigations. In sub-Saharan Africa, there has been a neglect of some national health laboratories that inhibits their ability to immediately manage pandemic diseases of public health importance as soon as they occur (World Health Organization (WHO) 2006a,b; Nkengasong et al. 2010).

The outcome of this neglect has been persistently high levels of laboratory error and lack of functioning quality management systems and accreditation of the majority of these national health laboratories (Amexo et al. 2004; Gershy-Damet et al. 2010). This resulted in lack of confidence in laboratory services by physicians and other care providers (Amexo et al. 2004; Bates et al. 2004; Petti et al. 2006; Polage et al. 2006). However, within the past 10 years, there have been renewed efforts to strengthen laboratory systems and networks by African governments and regional and international partners such as the East Africa Public Health Laboratory Network Project, World Health Organization (WHO), the US President’s Emergency Plan for AIDS Relief (PEPFAR), the Clinton Health Access Initiative (CHAI), the World Bank, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). The focus has been to leverage resources, set up integrated laboratory services and systems, develop comprehensive national laboratory policies and strategic plans for tiered laboratory networks, quality system improvement and accreditation preparedness schemes (World Health Organization (WHO) 2006a,b; Lantos & Hyde 2008; Nordling 2009; Gershy-Damet et al. 2010; Nkengasong et al. 2009; Parsons et al. 2012).

Some examples of recent landmark achievements from the initiative (African governments, PEPFAR, WHO, and international partners) include the launching in 2009 in Kigali, Rwanda, of the WHO-AFRO Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) framework and the Strengthening Laboratory Management Towards Accreditation (SLMTA) programme to provide a more user-friendly and amenable approach to achieving laboratory quality improvement and accreditation (Wenner 2009; Yao et al. 2010). This was followed in 2011 with the establishment of the African Society for Laboratory Medicine (ASLM) in Addis Ababa, Ethiopia, with its primary role being to advocate, support and strengthen medical laboratories in Africa (African Society for Laboratory Medicine (ASLM) Launched 2011). These events together with other landmark meetings (Table 1) that have taken place on the continent could serve as important advocacy tools in bringing the predicament of laboratory services and systems to the attention of policymakers.

There is evidence that some past health gains in sub-Saharan Africa have been reversed due to poor or weak functional health systems and little support from policymakers (World Health Organization (WHO) 2006b; Chopra et al. 2009). Hence, there is a compelling need for governments, ASLM, the African Union, and other regional and international partners to collaborate and ensure effective strengthening and sustainability of current gains. In this article, we present an analysis of past laboratory situation, attempt to describe the journey of national health laboratories advancement in sub-Saharan Africa and provide some suggestions that could be followed to ensure quality system improvement and long-term sustainability of current investments.

We conducted electronic searches in PubMed, supplemented by the authors’ knowledge of other relevant resources, such as the WHO-AFRO and ASLM websites and conference abstracts. The authors also exploited decades of experience working with ministries of health and partners in strengthening laboratory systems in sub-Saharan Africa. The search themes included national laboratories in sub-Saharan Africa, collaboration with partners, outcomes and improvement in laboratory quality systems. Particular emphasis was on gaps in laboratory quality systems, improvements made, sustainability, workforce and public–private partnership. The first step involved screening of articles by reviewing the abstracts and titles. Articles were selected for full appraisal if they have any information relevant to national health laboratories within the past decade. Additionally, cited references from identified articles were also searched for more information relevant to the subject. Overall judgment of all studies ensured that bias and confounding factors could not influence the information presented. The information gathered was grouped into different sections of this review article, showing past laboratory situation and achievements following collaborations with local and international partners. As a result, many accomplishments realised were identified and highlighted with four salient examples, namely policy and advocacy events, WHO-AFRO SLIPTA Framework, SLMTA Training Programme and establishment of the ASLM Secretariat selected for demonstration purposes.

More than 70% of clinical decision-making is predicated upon, confirmed by, or documented by medical laboratory test results (Dighe et al. 2007). Also, the laboratory has been identified as one of six key public health functions that would contribute the most towards health systems strengthening efforts and has the greatest impact on improving the public’s health (Bloland et al. 2012). Despite this recognition, there were still gaps in the strengthening of laboratory services and systems in some African countries, such as poor laboratory infrastructure, lack of laboratory networks, equipment or their maintenance, shortage of well-trained laboratory staff and weak supply chain management systems (Olmsted et al. 2010; Abimiku et al. 2010; Fonjungo et al. 2012). These issues cumulated in a myriad of organisational, functional and professional challenges within the laboratory health system in the continent. Some examples are demonstrated below.

Issues surrounding laboratory health systems strengthening in Africa reached a tipping point that warranted urgent intervention. For example, the emergence of the HIV/AIDS epidemic exposed the fragile nature of some laboratory systems, as they were not equipped to support HIV prevention, treatment and care programmes. There was the need to place more emphasis on national health laboratory systems strengthening to meet the challenges of this disease. As a result of these efforts, some remarkable accomplishments have been noted and have benefitted multiple diseases within national health laboratories in many countries in Africa as demonstrated below.

Developing strategies to raise awareness on the impact and importance of improved laboratory quality systems in Africa has been a huge challenge because the impact of laboratory errors on health services has not been systematically analysed and presented to policymakers. This may partly explain why it took a long time for African leaders and international partners to consider focusing more attention on strengthening public health and clinical laboratories. The improvements in laboratory services and systems in the past decade in sub-Saharan Africa can be linked to some key declarations and also to outcomes and impact of some landmark policy and advocacy meetings (Table 1). More of such advocacy events are recommended to ensure continued support and investment in the national health laboratory sector. Furthermore, accreditation of select laboratories, and showing the benefits of accreditation, could be an important advocacy tool (Zeh et al. 2010).

The recent and steady gains in improvement in laboratory quality systems on the African continent are encouraging and demonstrate that further gains are possible, especially in partnership with stakeholders and with commitment from national and regional governments. It is critical that these gains are maintained for sustainable quality laboratories. Strategies needed to maintain these hard-earned gains include the following.

In the past, African countries have relied much on donor funds to strengthen public health laboratories and other health systems. Sustaining such support is currently threatened by the global recession, relative economic hardship in donor nations and competing demands of health and other national agendas. African countries need to take greater responsibility for public health laboratory challenges and rely less on the global community. In this regard, a partnership between international institutions and African governments in strengthening their laboratory system is critical. Such an arrangement should have a very clear operational budget and a transition plan to local ownership beyond donor funding. There is also the need for better collaboration between African countries and donor and implementing partners to ensure better capacity building of indigenous or African-based institutions.

Sustainability of laboratory systems in Africa is also threatened by an acute shortage of health workers who have left the continent for a variety of reasons (Chankova et al. 2009; Olmsted et al. 2010). It is estimated that while sub-Saharan Africa has 24% of the global disease burden, it has only 3% of the world’s health workers (World Health Organization (WHO) 2006b). Strategies for human capacity development and staff retention, such as adequate compensation, training opportunities, improvements in the work environment through infrastructure renovation, and opportunities to participate in competitive grant writing and operational research, should be encouraged. African-based training institutions with programmes tailored towards African needs are highly recommended as this provides an opportunity for Africans to lead the process and to develop sustainable strategies that encourage staff retention.

An integrated laboratory strengthening approach and the establishment of national laboratory networks should be encouraged to ensure better coordination and effective utilisation of available resources. Where appropriate, broader implementation strategies that fit into and target the needs of the country’s National Public Health Laboratory in line with its laboratory strategic plan should be encouraged. That way, disease- or programme-specific funding can benefit other less funded but country-priority disease areas.

Development of career profiles and representation of laboratory experts at decision-making levels will be very important. There is the need for ASLM and the African Union, together with its governments, to assist in establishing in-country medical laboratory councils as seen with other health professions, and to work with training institutions to develop training curricula that provide a clear path for medical laboratory professionals. Furthermore, the appointment of laboratory professionals and their representation at policy levels are necessary as their input will be important in making decisions that would positively impact the national health systems.

The establishment of public–private partnerships (PPPs) to improve and sustain quality laboratory efforts is also necessary. Public–private partnerships combine the resources of government with those of the private sector to deliver socially beneficial goals such as improving the conditions of laboratories, strengthening laboratory systems and the skills of laboratory personnel. An example of a PPP that has been leveraged to meet some of the challenges and improve laboratories is the Becton Dickinson (BD)-PEPFAR PPP. Through this partnership, BD worked directly with Ministries of Health and other PEPFAR partners to develop country-specific work plans and to provide technical assistance to achieve the goals of the work plan (PEPFAR-BD 2007, 2012). More PPPs like this should be encouraged, especially with indigenous African private sector partners.

The neglect of some public health laboratories in Africa resulted in poor quality of laboratory services and ultimately the lack of trust and utilisation of laboratory results by physicians and other health officials. However, the synergistic efforts of global health partners, national and regional bodies, and governments have resulted in increased awareness and the development of frameworks, tools and processes to support strengthening of laboratory systems and services in sub-Saharan Africa. In particular, the implementation of the SLMTA programme and the WHO-AFRO/SLIPTA process coupled with the successful launch of ASLM as a platform to advocate for evidence-based quality improvement programmes for laboratory within the continent have played catalytic roles. To ensure expansion and sustainability of current gains, government involvement, improved coordination and communication between ASLM and laboratory structures in various counties are essential. Finally, innovative and well-coordinated commitments must be sought from African states and other stakeholders in building sustainable quality systems for public health laboratory services and systems in sub-Saharan Africa.