Why medical laboratory systems in Ghana need proper structures

Seeking health care is one journey no single person can avoid in the course of life on earth. The only difference may lie in the purpose for which an individual needs health care.

The inequality in the health care services delivered across the globe is great. It gets worse in our part of the world when poverty rate is high. In the midst of the scarcity, the little that we are able to enjoy should benefit all in a more efficient and in accordance with acceptable standards.

If I visit the hospital when I am sick (for example having high body temperature (fever)), many things ranging from unknown (Pyrexia of Unknown Origin), body part damage due to tear from diseases not caused by infectious organisms (for example diabetes, cancer, etc), having parasites (examples worms, malaria, Trichomonas vaginalis for vaginal itching and odour, etc), bacteria (that can cause boils, Tuberculosis, diarrhea like cholera, etc), fungi (example Candida that cause “White in women”) and viruses (for example HIV, Hepatitis B, Hepatitis C, Ebola, Dengue, etc) could be suspected.

Any of these could lead to potential break down of the body which can finally end up with death. The medical doctor upon receiving the complaints will suspect what could be causing the malaise but importantly will need to confirm his suspicion no matter what. One of such places that about 85% of such confirmations are done is the Clinical/Medical Laboratory in our various health facilities.

The trained medical laboratory expert (in Ghana could be anyone called Medical Laboratory Scientist, Medical Laboratory Technologist, Medical Laboratory Technician or Medical Laboratory Assistant) study the request made by the medical doctor and advise the patient to produce or the expert collect biological samples that would be appropriate to get acceptable results for the medical doctor to either accept his suspicion or think otherwise.

For instance, if a doctor suspects tuberculosis in someone coughing for a period of time, the medical laboratory expert will teach the patient how to produce and collect sputum (NOT SALIVA), use it for a test and look for the organism that causes tuberculosis (Mycobacterium tuberculosis; one of its siblings causes leprosy). Since some coughs could also be caused by other organisms, the expert will also look for those and go further to suggest drugs that can kill the organism and free the person from sickness.

Also, if someone tells the doctor that he/she feels pains and see blood when urinating, the doctor will look at the age of the person and even sex (whether male or female) to get to a suspicion which the medical laboratory expert might be called upon to confirm prostate problem (in older men), bilharzia parasite and many others to confirm or refute the suspicion. If you don’t have enough blood or haemoglobin which can make you weak, dizzy and pale and you complain to the doctor, upon request, the laboratory expert will investigate to confirm if you have problems with the bones responsible for producing blood in the body, kidneys to find out if they are functioning properly for the blood to be produced or whether other organisms are behaving like “Dracula” and sucking your blood (example Hookworms/worms). All these will help to establish the cause of blood loss. One other commonest test performed by the medical laboratory is to confirm if someone who tastes sugar in his/her urine or difficulty for wound to heal has diabetes.

All these tests are done according to methods just as how the architects and planners lay blocks with sand and cement to build houses. An omission of one of the standards will lead to a collapse of the building along the way. In medical practice in Ghana, there is a Standard Treatment Guidelines which tells how much of malaria drugs should be given to patients to treat malaria and how much of a drug is needed to bring down someone’s blood pressure. Even what drugs to give to improve someone’s blood levels are stated in there.

The best way to do a test to check for blood levels (Haemoglobin) is to get an appropriate equipment, install it as the manufacturer says (mostly the space and the surface where the equipment should be placed to have uninterrupted performance is also described and must be obeyed), know the method, get the appropriate quality controls (which will tell you if the equipment is working as expected and its results could be trusted) and take the suitable sample from the patients to perform the test. For some test like testing for sugar levels to diagnose diabetes, the patients might have to come to the hospital; without eating and the test should be done first thing in the morning. Others like calcium to check for bones strength can be affected just by the way the patient sit during blood sample collection.

In the analogy of the building professionals, just having an architect, building technologists and planners without the necessary equipment will not put up a building. Same as if you have the professionals with their equipment which are not used as described by the manufacturers. In the laboratory, there are standards that are set and used in the worldwide. The standards cover the training of the medical laboratory experts, the kind of equipment to use for the tests you want to do to help the doctor diagnose properly, how those equipment are used and maintained to be able to get the accepted and trusted results, and so on.

Unfortunately, in Ghana there are no acceptable standards by which every clinical laboratory should operate. These standards which will help to establish a trusted system for delivery of medical laboratory services have been developed and no commitment has been made to utilize it for the benefit of Ghanaians. The document which was developed with Ghanaian and international experts if used would address issues affecting the medical laboratory not to perform to its utmost best including;

1. Infrastructure: Most laboratory facilities in Ghana have inadequate space or are inappropriate for their testing needs. Equipment are piled up closer to each other and vibrations from one another could affect the performance of others. It makes it difficult for enough space to be created for movement of staff and more importantly to get place for the comfort seating of clients. I have already mentioned the poor results that a laboratory will produce if at the time of taking the blood sample the patient did not sit properly and comfortably. Is the interest getting a result which will not be useful to manage the patient? The attitude of creating laboratories as afterthought when building health facilities will be halted when the document is in used. Some laboratory tests should not be performed where others are carried out. But in our part of the world, laboratory setup forces experts to prepare and work with the same space for different test thereby increasing patients waiting time to get their results in the hospital.
2. Human Resource: In a human resource profiling by the Ministry of Health (MoH), the public facilities have Medical Laboratory Scientists in a total of less than one (1) professional per 140,000 population in the public facilities. The medical laboratory personnel and services need of the health facilities are woefully inadequate. For instance, using malaria diagnosis alone, an expert should not spend less than 15 minutes to look at the blood slides before releasing results to the medical doctor to say you have malaria or not. This for eight (8) working hours in a day translate to a maximum of 32 microscope slides for patients. World Health Organization (WHO) says that because of where we are, we should force and read not more than 40 microscope slides (meaning one personnel cannot see more than 40 patients’ blood if you want to properly diagnose malaria without compromising quality) in a day not forgetting that one needs about 40minutes to prepare each slide to be ready for reading using the microscope. Typically, in a facility I worked in 2007, I could look at the blood of almost 100 pregnant women when they come for antenatal checkup. That means, I was performing the duty of almost two and half (2 ½) persons on antenatal days just for malaria diagnosis. But it will interest you to know that, in one visit, a pregnant woman coming for antenatal could check for malaria, blood group, haemoglobin type (sickling status: AA, AS, SS, SC, etc), Urine and Stool analysis, HIV and others that might be seen appropriate. On human resources and using antenatal care alone, a facility would need not less than 4 medical laboratory personnel to handle their patients to offer optimum quality of care. As a nation, our interest will be fulfilled as prescribed in the National Health Laboratory Policy (NHLP) if the policy is implemented to benefit all. For the safety of the public, one needs a license to be able to practice as medical laboratory professional in Ghana (ACT 857(Part 1), 2013). Next time you go to the hospital, find out if the person working on you is qualified to do what he or she is doing before you are harmed by a quack.
3. Organization and Management: The current laboratory organization and administrative structures are fragmented resulting in weak oversight and poor coordination of services in both the public and private sectors. There are no clearly defined staffing norms resulting in inappropriate deployment of personnel. Who is needed where and the kind of skills based on the level of tests performed are not properly structured to facilitate properly and quality medical laboratory services. Reporting channel in the laboratory systems are not structured under directorates with respective professionals seeing to the build of laboratory services delivery. Recently, in the news, Tamale Teaching Hospital Laboratory was pencilled for takeover by a private company under a Private Public Partnership (PPP) agreement on the excuse that the laboratory was under performing. The personnel of the laboratory protested that because they are not part of management and are not allowed to budget for their needs despite raising a chunk of the hospital’s finances, things they need to work with are not provided. Thankfully, the government intervened and a medical laboratory professional was put in charge of the facility. Indications after such intervention show that, Tamale Teaching Hospital is an example to look at in medical laboratory management and financing. Similar structures are what the NHLP seek to put in place to resonate across the country for better medical laboratory services. In fact, the bone of contention, the very problem why the policy since 2013 is on the shelve of the Ministry of Health ,Ghana gathering dust and not implemented is about who manages the medical laboratory services and structure in the various facilities. A physician or medical laboratory scientist? This is the question that the government has not been able to show direction and almost 1 million dollar investment if not more by the USA government is left unused for the purpose the policy was produced.
4. Laboratory Testing, Laboratory Supplies and Equipment: Although laboratory services are available throughout Ghana, its distribution is not equitable thus limiting access to services. One thing I cannot imagine if for patients to travel long distances to access certain laboratory test services. For instance, if one has a problem with the prostate and the physician wants a confirmation, eve most regional hospitals will not be able to offer such services to patients. Places like Komfo Anokye Teaching Hospital and Korle Bu Teaching Hospital might not offer such services continuously without periodic gaps. Such patients may have to pay high fees to contract such services from private facilities established closed to the hospitals. In a recent radio broadcast by multimedia group AdomFm, Korle Bu Central Laboratory did not have reagents for such a basic test as for Renal Function. A test that is now available at point of care and could be planned and performed by experts even at health centres if proper policies are in place. The problem in most cases is not about availability of qualified people but rather the needed equipment and supplies to enable the experts perform the tests. Ghana has not developed equipment policy to guide the identification, procurement, installation and use of equipment. This has led to a multiplicity of different types of equipment in the country some of which are inappropriate and substandard. Again, due to the imbalance financial systems that exist for the management of medical laboratories in Ghana, the needed reagents and consumables needed to serve Ghanaians are purchased at will by facility managers but not when they are needed. It is surprising that a policy which seeks to create and establish financial systems to adequately fund medical laboratory services to avoid break in services (prevent down times) due to shortages of consumables or need for equipment and also the needed number of personnel to reduce patient waiting time.
5. Lack of Requisite Standards: If prudent measures to provide the needed funds to continuously run medical laboratory services can be sacrificed on the altar of professional superiority and not be implemented, one is not surprised of the lack of care for systems for monitoring and ensuring quality. The poor quality of testing has led to lack of trust in and poor use of laboratory services for patient management and treatment in most public facilities. The common language clients are told is to be directed to private medical laboratories to get some test performed and such could had been done at a reduced cost with trust if common things like getting quality control systems are implemented. The deliberate act to collapse medical laboratory services in our public facilities and turn around to call private companies to come and run using the same experts is unpatriotic and wish the government will “shine” its eyes. The earlier the NHLP is adopted and implemented the better for us than to put our trust in the hands of private individuals.
6. Biosafety and Biosecurity: Laboratories, by the very nature of their work, routinely handle pathogens that pose potential risks to both staff and the general public. In 2015 to 2016, Ghana had an outbreak of cholera. That bacteria on its own is a weapon that need not be left without control after it has been cultured to grow in our hospital laboratories and at disposal. It is not surprising we heard of the allegations of sale of blood by someone as was published on the internet in the central region. The NHLP provides guidelines to securely dispose of medical laboratory waste for the benefit of Ghanaians and thereby making our environment safe. There is the need to protect the citizenry against these highly infectious pathogens through sound guidelines.

The least said about;

1. Laboratory Information System: The laboratory generates information which is normally of confidential nature and should be protected from unauthorized access and use,
2. Disease surveillance and Response: The laboratory is a critical component of any disease prevention and outbreak response system. The laboratory, therefore, needs to be organized and strengthened to provide the necessary support to the system,
3. Operational Research: There is, a paucity of good health related operational research in general and laboratory specific research in particular,
4. Monitoring and Evaluation (M&E): The health sector M&E system is generally weak and this is more pronounced in the health laboratory services where it is erratic at best and often non-existent

the better.

If the government has the interest to ensure good health state of the Ghanaian populace, then I wish the NHLP is embraced, adopted, implemented and be committed to its success to make sure there is adequate, quality, affordable and proper medical laboratory services for all in trust.