It’s time to transform laboratory medicine

Global health security can only be achieved by investing in adequate laboratory services in lower income countries, writes Emmanuel Azore, global laboratory services lead at Mott MacDonald.

“No one is safe until we are all safe” became a mantra during the COVID-19 pandemic, stressing the need for coordinated global action to combat the virus. It is a lesson learned from fighting HIV, one of the biggest killers over the past 40 years. Today a similar call to action is critical to drive improvements in diagnostic services and laboratory surveillance systems in low- and middle-income countries (LMICs).

Progress has been slow and fragmented in the two years since The Lancet Commission on Diagnostics set out key recommendations for delivering modern, high quality, affordable laboratory services.

There continues to be a lack of diagnostic testing kits, adequate infrastructure and systems and well-trained laboratory personnel in most LMICs. This undermines the key functions of laboratories in disease detection, surveillance, control and management.

Many diseases and conditions are misdiagnosed or undiagnosed due to a lack of laboratory services. For example, when I got sick on a recent trip to East Africa, doctors were unable to tell from my symptoms that I had dengue fever and not malaria or typhoid. It was not until my blood sample was shipped to Europe and confirmed for dengue fever that my treatment was changed after four days of agony of undiagnosed fever due to lack of laboratory testing services, and the added burden of receiving the wrong medication.

My experience is not uncommon. Only 30% of health facilities in Africa have the necessary equipment and reagents to perform basic diagnostic tests, according to the African Society for Laboratory Medicine.

This has led to a situation where clinicians are overusing antimicrobial drugs, which is making them increasingly ineffective at combating infections. As a result, antimicrobial resistance (AMR) is becoming an increasing threat to global health security.

Removing barriers to progress

One of the critical factors that is holding back progress is the lack of a coordinated approach to the funding and operation of laboratories across health systems, which span public, private and charitable sectors.

National public health systems depend on information from a range of human, animal, environmental and food testing laboratories to understand disease impact within the population, tackle the rise of AMR, set health priorities and allocate scarce resources effectively.

Competing investment priorities in LMICs mean that healthcare is generally underfunded and resources for laboratory services are severely constrained. In this context, everything must be done to ensure that people, data, knowledge and technology are deployed effectively within national laboratory systems to meet international health regulations.

Closer collaboration between international funders, national policy makers and health managers, One Health stakeholders and the private sector has a key role to play in removing barriers to progress.

The value of strong governance

Countries with a central directorate or unit responsible for the governance of laboratories within their ministry of health are in a better position to coordinate and monitor the provision of diagnostics and laboratory services across health systems.

The Ethiopian Public Health Institute (EPHI) is a good example of integrated laboratory governance. It sits within the national structure of health agencies and is accountable to the Ministry of Health. The EPHI has relationships with Ethiopia’s regional, state and city health bureaus, and international partnerships including the WHO, USAID, US Centers for Disease Control and Prevention, and the Food and Agriculture Organization.

In recognition of the value of strong laboratory governance, the World Health Organization Regional Office for Africa (WHO AFRO) has set a target to increase the proportion of its 47 member countries with an effective governance structure for diagnostics and laboratory services from 55% in 2023 to 80% by 2032.

With strong central governance, laboratory networks can be part of a country-led, sector-wide approach to health planning and investment, with costed delivery targets integrated into national budgets.

Sustainable and integrated funding

Investment by international donors is critical in the provision of diagnostic services in LMICs. However, most of this funding is targeted at single diseases at a time, such as malaria, tuberculosis, or HIV, rather than at system-wide improvements in laboratory services. This siloed approach to funding leaves significant gaps in diagnostic services and can lead to unintended consequences.

For example, after a donor funding cycle has ended laboratory services may become unsustainable if not included in national budgets. Also, the funding of different services by different donors leads to a lack of integration, coordination, and standardisation within laboratories and across health systems.

The cross-sector impact of the COVID-19 pandemic has encouraged many national governments to increase their focus on building competencies across national laboratory networks and they have been working in collaboration with donors and other health partners to meet international standards.

Progress to establish robust quality assurance systems, enabling the monitoring and evaluation of laboratory services, could encourage donors to shift from disease-specific funding towards broader investment in laboratory capacity.

Supporting laboratory scientists

Laboratory scientists need advocates at the heart of ministries of health to push for improvements in their training and career development as well as better pay and conditions.

Leveraging private sector technical expertise could be an effective way for governments in LMICs to boost public sector laboratory capabilities. This could include internships, mentorships, work placements, training of public sector professionals in private institutions and research collaborations between public and private institutions.

Central coordination and funding of joint training for human, animal, and environmental laboratory staff would also help to drive collaboration and create new career pathways across One Health sectors. It will be critical in the battle to combat AMR.

Part of our role as management agent for the Fleming Fund, a UK aid programme, is to provide AMR training to human and animal health professionals, including laboratory scientists, microbiologists and epidemiologists in LMICs through a number of grants including the Fleming Fund Fellowship Scheme. Once they have received on-the-job training and mentorship, Fleming Fellows then pass their new skills on to colleagues. This is helping to build a network of multidisciplinary AMR experts, who can drive up standards in AMR surveillance.

Why laboratory systems matter

A strong laboratory system is one of the pillars of a strong health system. Without it, populations face a higher risk of inappropriate treatment and longer recovery periods, lower economic productivity and untreatable conditions due to AMR.

It is worth remembering that the global health security system is only as strong as the weakest link. Until there is coordinated action to invest in adequate laboratory services across the globe, health systems will remain vulnerable to emerging infectious diseases and drug resistance.

What next?

On January 30, 2024, we co-hosted a technical forum in Washington DC to discuss the future of laboratory medicine in health systems.

At the event we launched a report titled Why Laboratory Investment Matters, which sets out recommendations for policy makers, international donors and One Health stakeholders to work together to drive improvements in laboratory services and networks. It is published by Mott MacDonald, Management Sciences for Health (MSH) and ICF.

Read the report