Examining 7 years of implementing quality management systems in medical laboratories in sub-Saharan Africa

Background

Achievement of ISO15189 accreditation demonstrates competency of a laboratory to conduct testing. Three programmes were developed to facilitate achievement of accreditation in low- and middle-income countries: Strengthening Laboratory Management Towards Accreditation (SLMTA), Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) and Laboratory Quality Stepwise Implementation (LQSI).

Objective

To determine the level of accreditation and associated barriers and facilitators among medical laboratories in the WHO-AFRO region by 2020.

Methods

A desk review of SLIPTA and SLMTA databases was conducted to identify ISO15189-accredited medical laboratories between January 2013 and December 2020. Data on access to the LQSI tool were extracted from the WHO database. Facility and country characteristics were collected for analysis as possible enablers of accreditation. The chi-square test was used to analyse differences with level of significance set at <0.05.

Results

A total of 668 laboratories achieved accreditation by 2020 representing a 75% increase from the number in 2013. Accredited laboratories were mainly in South Africa (n = 396; 55%) and Kenya (n = 106; 16%), two countries with national accreditation bodies. About 16.9% (n = 113) of the accredited laboratories were registered for the SLIPTA programme and 26.6% (n = 178) for SLMTA. Approximately 58,217 LQSI users were registered by December 2020. Countries with a higher UHC index for access to HIV care and treatment, higher WHO JEE scores for laboratory networks, a larger number of registered LQSI users, with national laboratory policy/strategic plans and PEPFAR-priority countries were more likely to have an accredited laboratory. Of the 475 laboratories engaged in the SLIPTA programme, 154 attained ≥4 SLIPTA stars (ready to apply for accreditation) and 113 achieved ISO 15189 accreditation, with 96 enrolled into the SLMTA programme. Lower-tier laboratories were less likely to achieve accreditation than higher-tier laboratories (7.7% vs. 30%) (p < 0.001). The probability of achieving ISO 15189 accreditation (19%) was highest during the first 24 months after enrolment into the SLIPTA programme.

Conclusion

To sustainably anchor quality improvement initiatives at facility level, national approaches including access to a national accreditation authority, adoption of national quality standards and regulatory frameworks are required.     

Why don't medical textbooks teach? The lack of logic in the differential diagnosis

Medical textbooks are an important aid in the process of diagnosing and treating patients. Medical students use these books to acquire the skills necessary for this process, while medical teachers and experienced doctors use them for teaching these competences. We posed the question whether medical textbooks are structured in such a way that medical students are taught to structure knowledge and to make a differential diagnosis in a logical way. Five major textbooks were compared with regard to four clinical problems (gastrointestinal bleeding, anaemia, oedema and heart failure). The presentation appeared to be very variable in respect of logic and systematic arrangement. In fact, it was disappointing that even in well-reputed textbooks, a systematic approach is lacking. We feel there is a need for improvement, in order to facilitate the learning of medical students and to enhance their abilities in clinical problem solving.