The study showed that overall compliance with standard laboratory practice across all types of health facilities was low. None of the 43 medical laboratories assessed met or surpassed the minimum (150) standards for quality, as defined by the WHO SLIPTA checklist.

Although the level of compliance was low across facility types, government and CHAG facilities performed better than private health facilities. The low compliance with standards by laboratories seen in private health facilities could be attributed to inadequate resource flow to the private health sector and weak management and organizational capacity. Previous assessments of the private sector revealed that inadequate resources have resulted in poor infrastructure, obsolete equipment, inadequate human resource capacity and poor quality of care [12,13].

The low compliance observed across health facility types could be attributable to the fragmented regulation of laboratory services and the marginalization of laboratory services. The attitude of laboratory professionals towards quality could also be the reason for the poor performance of laboratories. The attitude of laboratory personnel has been identified as a barrier to providing quality laboratory services[14]. Kalra & Kopargaonkar (2016) further intimated that the quality components of a laboratory process are seen as “additional work” which interferes with their actual jobs by a workforce that is overworked and exhausted [14]. Hence, a change in attitude may be brought about by incorporating quality elements into the workplace culture and providing rewards for quality promotion actions and accomplishments.

It is interesting to note that Agboli et al. (2018), in their assessment of selected medical laboratories in healthcare facilities in the Volta region, Ghana, found that none of the laboratories met or surpassed the minium compliance score, similar to the findings in this current study [10]. A recent survey conducted by Mulleta et al. (2021) in their assessment of laboratories in Ethiopia [15] found that nearly 80% (79.8%)of laboratories could not meet the minimum(<150) requirement for quality laboratory service provision, corroborating what was observed in this study[15]. Similarly, Mesganaw et al. (2023), in their systematic review of studies on medical laboratory quality management and challenges in Ethiopia, found that 91.7% of quality management practices were inadequate and the quality of medical laboratories was poor [16].

Furthermore, this study found that the performance of all laboratories in the twelve-quality system essentials was below standard. A recent assessment of laboratories in the Philippines made similar observations [17]. The quality system essentials are the building blocks of quality management systems and must be included in laboratory quality systems to ensure accurate, reliable and timely laboratory results. It is, therefore, not surprising that laboratories performed poorly in the compliance scores. The WHO indicate that although implementing quality management does not guarantee an error-free laboratory, it helps ensure high-quality laboratory services that detect and prevent errors from recurring [18]. It is, therefore, imperative that medical laboratories implement a quality management system to minimise errors and maintain high-quality laboratory services.

Inadequate quality has been identified as a barrier to providing optimal laboratory services in low and middle-income countries [19]. Medical laboratory services contribute about 70% of the data required for patient treatment and management, and therefore, quality laboratory services are a foundation for better patient management. The current finding suggests that medical laboratories are not fulfilling their mandate as required by standard practice and cannot play their crucial role in the healthcare delivery system due to poor compliance with standard laboratory practice. Medical laboratories operate in a complex environment, and ensuring high-quality services requires rigorous implementation of standards and guidelines [2].

The disproportionate distribution of laboratory professionals’ results from recruitment without recourse to the workload and expertise of laboratory professionals. Schneidman et al. (2014), in their assessment of neglected cadres in the healthcare system on the continent, indicate that, in sub-Saharan Africa, Laboratory professionals are predominantly among the neglected cadres in healthcare systems; often there are inadequate numbers, a skewed distribution, and limited career opportunities [20]. They further argued that insufficient professionals consequently affect the provision of quality laboratory service [20]. It is, therefore, not surprising that the current study made a similar observation eight years on; this is quite a worrying trend and needs to be addressed by health managers. Inadequate laboratory professionals affect service performance, as reflected in the low compliance scores recorded across all facility types in this study. Wilson and colleagues (2018), in their assessment of pathology and laboratory services in low and middle-income countries, identified inadequate human resource capacity as a critical barrier to providing medical laboratory services [19].

The lack of phlebotomists in the medical laboratory set-up, as evidenced in the current study, is a major concern. The study found that only tertiary health facilities had some phlebotomists; however, it was inadequate for the operation of the facility. The term “phlebotomy” refers to the procedure of drawing venous blood, and Phlebotomists are healthcare professionals who have received training to collect blood samples [21]. According to Ghana’s health sector staffing norm, only regional and tertiary hospitals must have a phlebotomist [22]. The lack of a framework for phlebotomy and its resultant lack of phlebotomists across the tiers of laboratory practice in Ghana’s health sector is a grave deficiency. The need for phlebotomists in the diagnostic process is highlighted because 60% of laboratory errors occur due to improper methods for collecting venous blood samples in the laboratory testing process. [23]. According to Waheed et al. (2013), even the most advanced laboratory equipment cannot provide accurate results from a specimen that has been improperly collected [24]. Hence, phlebotomists should be considered an essential component of the healthcare system, as they are important in providing suitable laboratory specimens for testing [21]. Mbah (2014) observed that employee cross-training for numerous duties is required in most healthcare facilities across Africa due to resource constraints, potentially eroding specialized skills and leading to excessive workloads (Mbah, 2014). However, in his assessment of phlebotomy and quality in the African laboratory, he argued that using skilled phlebotomy-specific laboratory personnel could significantly reduce pre-analytical error rates in the laboratory diagnostic value chain [25].

Therefore, there is an urgent need to institute pragmatic measures to address the quality gap and related factors that contribute to providing quality medical laboratory services in Africa, particularly in Ghana.