An oral history of medical laboratory development in francophone West African countries

Background Underdeveloped and underused medical laboratories in sub-Saharan Africa negatively affect the diagnosis and appropriate treatment of ailments. Objective 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. Methods 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. Results 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. Conclusion 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.


Introduction
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. 1,2,3,4 Recent national surveys of laboratory capacity conducted in Senegal, Mali and Burkina Faso -francophone West Africa for short, and the countries this study focuses on -found that many laboratories still have insufficient personnel, a lack of or dysfunctional basic equipment, and operate in inappropriate rooms. 5,6,7,8 Studies in Senegal on barriers to the uptake of the seven recommended routine maternal diagnostic tests found that laboratory problems were part of the reason why only around one-third of pregnant women received the complete set of tests. 9,10 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. 11,12,13,14 The healthcare sector in colonial times was mainly directed controlling infectious disease control and keeping the colonial workforce healthy to ensure economic productivity. 15 The years after independence saw optimism towards national economic growth that focused on improved healthcare for the general population. 15 The global economic recession of the early 1980s and the structural adjustment programmes of the late 1980s-1990s had a significant negative impact on national economies and forced governments to cut spending and lower their development goals of early post-independence. 15,16,17 The ensuing cuts in the health sector thus created institutional, technological and personnel capacity problems. 13,17,18 The late 1990s saw the emergence of global health initiatives in response to worldwide health-related problems, mainly epidemic diseases, that could pose global security threats.
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.

Methodology Ethical considerations
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.

Study design
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.

Literature review
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 informant interviews
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 Table 1, details are provided in the Online Supplementary Document - Table 2. Key informants were trained in clinical or laboratory medicine (or both) and included retired (n = 8) and current (n = 65) staff members of various departments in the Ministry of Health (MoH), international organisations, private and public health facilities, professional associations, training institutions, and universities; many had worked in several functions. One key informant's professional career commenced during the colonial period, nine commenced in the two decades after the three countries' independence in 1960, while the remainder commenced from the 1980s.

Data analysis and presentation
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 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
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.

Results
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.

Colonial times
In colonial times, all three countries housed renowned research laboratories, including Centre Muraz in Burkina Faso, Institut Pasteur in Senegal and Laboratoire Central de Biologie in Mali. These laboratories were involved in the research and the control of endemic and epidemic diseases -including trypanosomiasis, cholera, onchocerciasis, meningitis, malaria and syphilis -to preserve the labour and military force, 15

Post-independence (≈1960-1979)
After independence, the colonial research laboratories remained -although some under another name (the Malian Laboratoire Central de Biologie became Institut National de Biologie Humaine) -as did those attached to the few public national and regional hospitals. 22 21 In the three countries, assistants trained on-the-job represented a large part of the laboratory workforce.
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 23 and aimed to strengthen public hospital laboratories and establish a national coordinating body and policy. The former INRSP director, recounted that in 1974 this health minister created the Division of Laboratories and appointed him head, telling him to assess the status of laboratories in the country. Based on his situation analysis, he recommended that laboratory services be decentralised to the regional level. Disease outbreaks, in particular the 1974-1975 meningitis and cholera outbreaks, added to the health minister's motivation to decentralise laboratory services. The former INRSP director remembered how cumbersome the control of these outbreaks had been, notably the transportation of suspected cases' stool samples from the regional laboratories to the central laboratories for analysis.

Primary healthcare and structural adjustment (≈1980-the late 1990s)
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. 15,17

Decentralisation of laboratories
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. 24 Insufficient local training opportunities persisted for assistant and specialisation levels. Also, no formal training existed for laboratory assistants and nurses trained on-thejob, who still formed a large portion of laboratory personnel. 27 The saying went: 'You are a laboratory worker and you die a laboratory worker'. Due to the lack of laboratory training and career opportunities, many nurses left laboratory work to pursue further nursing training, although some nurses among our key informants stayed because they liked the work. A clinical biology university professor explained that because there was a lack of advanced specialisation training in medical biology or biochemistry in Senegal, medical doctors such as himself had to go for further studies abroad, mainly to France.

(In)visibility of laboratories in national policies and programmes
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. 28 These Demographic and Health Survey reports and national plans made little reference to laboratories. Only in 1999 did the Malian public health sector set up a referral system for laboratory tests: from first-level Centre de Santé de Référence to second-level regional hospitals to third-level university hospitals. 24 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. 28 Biological pharmacists among the key informants explained that it was demotivating and boring to work in laboratories with so little support and rudimentary equipment when from their training they knew that the technology was more advanced in Europe. However, some doctors in charge of health facilities took the initiative to strengthen their laboratories. A director at the Reproductive Health Directorate Senegal recounted how when he became the medical director of a district health centre (1995)(1996)(1997)(1998), the laboratory gained reference in the area because he asked a French friend to help him equip the laboratory with full blood count and glycaemia machines.
Laboratories became more visible in Senegal in 1990 as part of the

Disease and donors
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 Direction des Laboratoires remembered that in cases of suspected HIV, laboratory staff had to travel to the regions to collect the blood samples and bring them to Dakar for analysis.
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.

Increasing but suboptimal laboratory services
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. 30 Referral laboratories were connected to university hospitals and research laboratories were established for specific diseases. Compared to Mali and Burkina Faso, Senegal had fewer private stand-alone laboratories. In 2012, while Senegal had only 6, Burkina Faso had 80. 31,32,33 With the arrival of more equipment and machines, the array of tests that laboratories could process increased. 34

Improved organisation
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.

National laboratory policies and plans
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. 37 Senegal has no approved plan yet. The laboratory became more integrated into the health system through the specific mention of laboratory testing in management guidelines for certain conditions. For example, in Senegal and Mali, the antenatal care guidelines identify laboratory tests that all pregnant women should receive. 38,39,40

Increased training opportunities
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. Réseau d'Afrique de l'Ouest des Laboratoires is one of the few donor-funded programmes focusing on the laboratory system. It supports the training of different levels of laboratory staff, the renovation and equipment of laboratories, and the equipment of training centres. 43 Involved key informants were very positive about the contributions of Réseau d'Afrique de l'Ouest des Laboratoires. Some other programmes and funds also address laboratory systems, including the Global Health Security Agenda (launched 2014), the Regional Disease Surveillance Systems Enhancement II project and the West African Health Organisation which conducts large laboratory system strengthening through the World Bank funding.

Discussion
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.

Recommendations
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. 44 The WHO Regional Office for Africa, the African Society for Laboratory Medicine and the Africa CDC should continue to remind and support national policymakers who signed the declaration. National policymakers should dedicate more national budget to laboratory development and give the national directorate the mandate to coordinate and guide donor involvement in public and private laboratories at all levels. • 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 establishedthis 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).

Limitations
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.

Conclusion
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).