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Dorothyetal. Human Resources for Health (2023) 21:89
https://doi.org/10.1186/s12960-023-00876-8
RESEARCH
Evaluating theeectiveness ofUganda’s
Supranational TB Reference Laboratory quality
management system training program
Nakiwala Dorothy1* , Benjamini Niringiyimana1, Wekiya Enock1, Ocung Guido1, Kabugo Joel1, Adam Isa1,
Anita Katuramu1, Orena Beatrice1, Christine Nansubuga Korsah1, Lillian Kyomugasho1, Denis Oola1,
Kenneth Musisi1, Eunjung Kim2, Nayeong Yu2, Ruth Kaliisa2, Yeni Lee2, Bounggui Kim2, Ssenyonga Ronald3,
Noah Kiwanuka3, Katamba Achilles3 and Moses L. Joloba1
Abstract
Background Achieving the targeted organizational goals through effective training can increase employee satisfac-
tion. Since 2015, the Supranational Reference Laboratory Uganda (SRL Uganda) has trained National Tuberculosis
Reference Laboratories (NTRLs) from 21 countries in a variety of areas that cover both technical and programmatic
aspects pertinent to TB laboratories. The Laboratory Quality Management System (LQMS) under SRL coordinates
actions intended to ensure sustained quality of the laboratory services offered by the National TB Reference Labora-
tories. In order for laboratory results to be helpful in a clinical or public health setting, they must be accurate, reliable,
and timely. The LQMS course aims to provide learners with knowledge on how to attain and maintain this quality.
Prior to this study, there was hardly any data available on the effectiveness of LQMS trainings provided by SRL Uganda;
using Kirkpatrick model, which is popular among researchers for evaluating the efficacy of the training program, this
paper seeks to establish the effectiveness of the LQMS training offered by the SRL Uganda.
Method We evaluated the effectiveness of LQMS training within the Uganda’s SRL network for courses offered dur-
ing the period 2017 and 2021 for participants from the Southern and East African sub-Saharan region.
Results In 2017 and 2021, respectively, test results from 10/17 and 9/17 showed overall post-test scores above 80%.
Of the 18 labs evaluated, 14 showed improvement; of these, 7 labs were from the Eastern region and the other 7 were
from Southern Africa; one facility in this region also maintained its accreditation. In the post-evaluation assessment,
attendees of the LQMS course gave feedback of strongly agree and agree variety.
Conclusion More SRL Uganda network laboratories in the regions achieved a 5-star SLIPTA level rating
and among these, 5 NTRLs got ISO 15189:2012 accredited by the end of 2021, while one maintained its accreditation
status. This proves that the Laboratory Quality Management System training program was an effective tool in improv-
ing the quality of laboratory services, work practices, and processes.
Keywords LQMS, SLIPTA, WHO AFRO checklist, NTRL accreditation, Training, Sub-Saharan Africa, SRL
Open Access
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
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regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom-
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Human Resources for Health
*Correspondence:
Nakiwala Dorothy
nakiwaladorah@gmail.com
Full list of author information is available at the end of the article
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Dorothyetal. Human Resources for Health (2023) 21:89
Background
Training is a useful investment and is one of the most
important factors in human resource development [1].
rough training, employers can shape employees’ com-
petencies and develop their potential to perform tasks [2]
more efficaciously toward attainment of organizational
goals. Effective training can improve employee satisfac-
tionby motivating them and making them realize their
potential and career goals [1].
e Uganda National Tuberculosis Reference Labora-
tory (NTRL) which doubles as a Supranational Reference
Laboratory (SRL) since 2013 has immensely expanded
the frontiers of its mandate beyond providing external
quality assurance and supporting disease surveillance
studies in the region; to becoming a training HUB in TB
diagnostic programs.
For the last 7 years since 2015, Uganda has provided
trainings to the regional NTRLs from 21 countries based
in sub-Saharan African on both technical and program-
matic areas. e level of trainings is internationally rec-
ognized with the SRL-Uganda’s training program being
accredited by International Accreditation for Continuous
Education and Training (IACET) in 2021. e trainings
include development of National Strategic Plans (NSP),
preparation of Proficiency Testing (PT) panels, imple-
mentation of phenotypic and genotypic Drug Susceptibil-
ity Testing (DST), Bioinformatics (Genomics), Biosafety
& Biosecurity and implementation of Laboratory Qual-
ity Management System (LQMS), Benchmarking visits
among others.
e most crucial aspect of medical laboratory testing
is the implementation of LQMS that wholly coordinates
activities that direct and control laboratories with regard
to quality (ISO 15189:2012). e LQMS course offered by
SRL-Uganda aims to impart participants with knowledge
on how to achieve quality laboratory results with insights
of accuracy, reliability, and timeliness to positively impact
clinical or public health decisions. e LQMS training is
conducted for 10 days (41 contact hours) with method-
ology of knowledge and skills transfer following didactic
sessions. e training materials were developed by SRL-
Uganda with reference to ISO 15189:2012 and global lab-
oratory initiative (GLI).
For any training course to show effectiveness, there is
need to provide trend analysis of implementation among
the trainees enrolled on the program over time to rec-
ognize achievement of its intended outcomes [3]. It has
been documented that training evaluation is a criti-
cal component of analyzing, designing, developing, and
implementing an effective training program, creating
room to also identify training needs [4–10].
Using Kirkpatrick model, we evaluated the reaction,
learning, and results impact of QMS training program
within Uganda SRL network participating laboratories
based in two African regions (Eastern, and Southern
Africa) over two time points (2017 and 2021). Kirkpat-
rick’s model assesses the effectiveness of training pro-
grams at four levels: (1) response of the trainee to the
training experience (including training experience); (2)
the learner’s learning outcomes and increases in knowl-
edge, skill, and attitude toward the attendance experience
(how much attendees learned the content after train-
ing). is level usually measured through using a pre-
test and post-test; (3) the students’ change in behavior
and improvement (whether the learning transferred into
practice in the workplace); and (4) results (the ultimate
impact of training) [4, 7, 8].
Methods
Study design andparticipants
is was a retrospective cross-sectional study that was
conducted at the SRL-Uganda to evaluate the effective-
ness of the LQMS offered for the period 2017 and 2021.
e study involved laboratory personnel under the
SRL-Uganda network that underwent two LQMS train-
ing in 2017 and 2021. e countries included Kenya, Tan-
zania, Somalia, South Sudan, Burundi, Eritrea, Rwanda,
and Somaliland from the Eastern region, and Lesotho,
Zimbabwe, Zambia, Malawi, Botswana, Mauritius, Sey-
chelles, Mozambique, and Namibia from the southern
region.
e LQMS training entailed the 12 Quality System
Essentials (QSE) that included Organization, Person-
nel, Equipment, Purchase and Inventory, Process con-
trol, Information Management, Documents and records,
Occurrence Management, Assessment, Process Improve-
ment, Customer service, and Facilities and Safety.
Measurement variables
We used e Kirkpatrick’s Model that is a framework
with four measurable levels designed to evaluate the
effectiveness of training programs, i.e., Reaction, Learn-
ing, Behavior, and Results [4]. ree out of the four lev-
els of the Kirkpatrick’s model were evaluated under this
study as follows:
For Level 1—Reaction; we assessed the general satis-
faction and perception of participants about the training
courses they had received from SRL Uganda. Data were
collected using self-administered evaluation forms at the
end of the training course and these were anonymized to
ensure confidentiality. e evaluation form consisted of
different parameters on which participants were assessed
and this includes Relevance of the training to partici-
pants’ work, overall rating of the training, overall training
objectives/outcomes met, ability to apply the knowledge
and whether the training met participants’ expectations.
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Page 3 of 6
Dorothyetal. Human Resources for Health (2023) 21:89
For each question, scores were graded using Likert scale
from 1 to 5 (1—strongly disagree, 5—strongly agree).
For Level 2—Learning; participants’ knowledge on the
course content was assessed before and after the LQMS
training course to determine if the learning objectives
had been met. Data on participants’ performance were
collected from pre- and post-tests for this evaluation.
Satisfactory performance was achieved if a participant
scored above 80% in the post-test.
For Level 4—Results; we assessed the outcome and
impact of the training using Data derived from the LQMS
scores using the WHO AFRO SLIPTA assessment check-
list and evidence of record accreditation within the study
period.
Data analysis
We analyzed data using STATA ver 15.0. We performed a
two-sample test for proportion. We described the coun-
tries by region and sex of the participants. Data were pre-
sented in tabular form.
Level 1: Reaction—to determine for each item/ques-
tion: relevance of the training to participants’ work,
overall rating of the training, overall training objec-
tives/outcomes met, ability to apply the knowledge and
whether the training met participants’ expectations,
we summed up the total number of participants who
responded to each category on the Likert scale and we
used a bar graph to present the total number of partici-
pants who responded to each of the five questions along
the categories of the Likert scale.
Level 2: Learning—we compared the proportion of
participants who score ≥ 80% between the pre- and post-
test scores by region in 2017 and 2021, respectively. We
assessed for any significant difference (p ≤0.05) in the
knowledge of participants between the pre- and post-test
scores.
Level 4: Results—we compared the Quality Manage-
ment System status of the laboratories before and after
the LQMS training based on the WHO AFRO SLIPTA
assessment results and certificates of international
accreditation to ISO 15189:2012.
Results
A total of 34 participants from 17 countries in sub-Saha-
ran Africa were evaluated for LQMS trainings organized
in 2017 and 2021 by Uganda SRL. Of these, 20 partici-
pants were from the Southern African region while 14
were from the Eastern African region, we had 20 females
and 14 males (Table1).
An overall post-test score of above 80% was achieved
by 10/17 and 9/17 participants in 2017 and 2021, respec-
tively. ere was a significant (p = 0.001 and < 0.001)
improvement in participants’ knowledge over the two
trainings. Better performance was observed in the South-
ern African region in both 2017 and 2021(Table2).
Of the 17 country laboratories that were assessed, 14
showed improvement, among these, 7 laboratories were
from Eastern African region and 7 from the Southern
African region, 1 facility maintain its accreditation status.
In terms of WHO AFRO SLIPTA star-level rating, there
was a tremendous improvement with more SRL Uganda
supported laboratories progressing from star 0, 1, 2, 3, 5
in 2017 to star 1, 2, 3, and ISO 15189:2012 Accreditation
(Fig.1).
In 2015, from baseline data we had 7 laboratories at 0
stars (Red color), 3 labs at 1 star (Orange color), 2 labs at
2 stars (Yellow color), 3 labs at 3 stars (Blue color) and 2
labs at 5 stars (Green color). After the initial LQMS train-
ing in 2017, we observed a tremendous improvement
where a number of labs moved from star 0 (Red color)
to star 3 (Blue color) and 5 (Green color) and eventually
8 laboratories got accredited for ISO 15189:2012 by 2022
post-LQMS training.
Strongly agree and agree were the only evaluation
responses from all the participants that attended LQMS
training in both 2017 and 2021 as reflected in Fig.2
Discussion
In this cross-section study, we evaluated the effectiveness
of LQMS training program at Supranational Reference
Laboratory Network. e study focused on the three
domains of the Kirkpatrick’s program evaluation model
that includes reaction, learning, and results.
e findings of the study indicated that the LQMS
training program was effective based on the three
domains.
As far as reaction is concerned, participants were sat-
isfied with the LQMS training in terms of relevance to
their work, training objectives/outcomes, participants’
expectations met and will be able to apply the knowl-
edge gained. ese findings are similar to studies con-
ducted by [11], effect of in-service educational courses
on human resources’ efficiency from university experts’
Table 1 Number of participants that attended the LQMS
training in 2017 and 2021 by region and sex
Eastern African region (Kenya, Tanzania, Somalia, South Sudan, Burundi, Eritrea,
Rwanda and Somaliland), Southern African region (Lesotho, Zimbabwe, Zambia,
Malawi, Botswana, Mauritius, Seychelles, Mozambique and Namibia)
African regions Sex Overall
Male Female
Eastern 9 5 14
Southern 11 9 20
Total 20 14 34
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Page 4 of 6
Dorothyetal. Human Resources for Health (2023) 21:89
point of view suggested that half of the staff believed that
the workshop was perfect.
Our study findings showed that participants from two
regions had a significant improvement in knowledge over
the two LQMS trainings with an overall countries’ labo-
ratories post-test score of 10/17 and 9/17 respectively in
2017 and 2021. e finding further showed a better per-
formance in the Southern Africa region in the 2 years
compared to the Eastern region. e results suggest that
the training program was one of the effective way in
increasing participant knowledge. In line with our study,
[12] found that training was effective in increasing the
participants’ learning and knowledge in study where they
examined the effect of in-service training on cardiopul-
monary resuscitation using Kirkpatrick’s model [12].
In this study, we show that 14 (78%) country labora-
tories significantly improved as per the WHO AFRO
SLIPTA assessment and international accreditation
(includes maintenance and attainment). Half of the coun-
tries’ laboratories were from the Eastern Africa region.
ese results showed that participants used the knowl-
edge attained to improve practices and processes in their
laboratories. It is possible that some of the improvement
we observed was due to post-training activities such as
technical assistance and regular follow-up supervisory
visits, ongoing mentorship, and affordable, cost-effective
bench marking visits to countries with similar operating
environments, backgrounds, and cultures [13, 14] as well
as other special fundings. e extensive Proficiency Test-
ing Program offered by SRL Uganda to regional NTRLs
at no cost was crucial in removing a stumbling block
toward accreditation.
Further analysis of the results revealed that two
labs did not significantly improve while three labs
kept their star rating of three stars. High staff turno-
ver, poor knowledge transfer, a limited leadership
Table 2 Performance scores from the LQMS training in 2017 and 2021 (using the learning level in the Kirkpatrick’s Evaluation Model
with an 80% cut off)
African regions 2017 Two
proportions
p-value
Pre-test Post-test
Eastern 0/7 2/7
Southern 1/10 8/10
Overall-1 1/17 10/17 0.001
2021
Pre-test Post-test
Eastern 0/6 2/6
Southern 0/11 7/11
Overall-2 0/17 9/17 < 0.001
Fig. 1 Choropleth map of ECSA/SRL-Uganda supported countries comparison by WHO AFRO SLIPTA level rating at baseline (2015), mid project
(2018) and current level (2022), (before and after project intervention) (2015–2022)
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Page 5 of 6
Dorothyetal. Human Resources for Health (2023) 21:89
commitment to quality improvement, and the belief
that TB is not a big problem making it a non-prior-
ity area worth funding all could have played a role in
this, despite being heavily resourced [15] Due to the
full-time commitment and participation of LQMS
mentored staff, we were able to witness that labora-
tories in conflict zones with equally limited resources
made a significant shift from star 0 to star 1 despite
the upheavals. In addition, SRL Uganda is currently
providing them continuous technical support as they
move closer to ISO 15189:2012 accreditation. The
strength of this study is that it included representative
participants from East and Southern Africa region and
tasked them with the sole responsibility of enhancing
the quality of TB diagnostic services. This study used
the standardized structured tools to collect data used
in evaluating the training program.
The study did not evaluate the third level of the
Kirkpatrick model and was limited by availability of
published data on all the four Kirkpatrick model lev-
els to compare our findings with findings elsewhere.
The training program evaluation was further limited
by the ability of participants to reply to the surveys in
English with varied clarity, which led to some confus-
ing or shortened responses, which further limited the
responses for program evaluation. The choice of the
study design limited comparability of our results with
laboratories that did not receive LQMS training.
Conclusion
e Laboratory Quality Management System training
program was effective in improving the quality of labo-
ratory work practices and processes. Further research
ought to be carried out in assessing the 3rd level (behav-
ior) of Kirkpatrick’s model in assessing the impact of
LQMS training on improving the quality of laboratory
services and to understand the causal relationship and
isolate the impact of the training program from other
concurrent or subsequent support.
Acknowledgements
We would like to express our gratitude to the distinguished participants from
the various countries that participated in the LQMS mentorship programme
run by SRL Uganda and significantly applied the knowledge and skills they
acquired to raising the quality of TB laboratory services.
Author contributions
ND, BN, WE, OG, KJ, IA, AK, LK, DO and MLJ contributed to the conception of
the study; ND, BN, WE, OG, KJ, IA, AK, LK, DO, SR, NK, KA and MLJ contributed
to the design of the work; ND, BN, WE, OG, KJ, IA, AK, LK, DO, SR, NK, KA and
MLJ contributed to the acquisition and analysis of data; ND, BN, WE, OG, KJ, IA,
AK, OB, CNK, LK, DO, KM, EK, NY, RK, YL, BK, SR, NK, KA and MLJ contributed to
the interpretation of data; ND, BN, WE, OG, KJ, IA, AK, OB, CNK, LK, DO, KM, EK,
NY, RK, YL, BK, SR, NK , KA and MLJ drafted the work and substantively revised
it; ND, BN, WE, OG, KJ, IA, AK, OB, CNK, LK, DO, KM, EK, NY, RK, YL, BK, SR, NK, KA
and MLJ approved the submitted version; ND, BN,WE, OG, KJ, IA, AK, OB, CNK,
LK, DO, KM, EK, NY, RK, YL, BK, SR, NK, KA and MLJ agreed both to be personally
accountable for the author’s own contributions and to ensure that ques-
tions related to the accuracy or integrity of any part of the work, even ones
in which the author was not personally involved, appropriately investigated,
resolved, and the resolution documented in the literature. All authors read and
approved the final manuscript.
0
2
4
6
8
10
12
14
16
18
20
AgreeStrongly agreeAgree Strongly agree
2017 2021
Participant response
Participant evaluation feedback
Training met my expectation Able to apply the knowledg e Overall training objective outcome Overall rating of the training Training relevant to my work
Fig. 2 Training evaluation feedback for participants that attended the Laboratory Quality Management System (LQMS) training in 2017 and 2021
as organized by SRL Uganda
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Dorothyetal. Human Resources for Health (2023) 21:89
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Funding
The author(s) received no special funding for this work. The financial support
to run all the above activities was part of the funding such as Participants
enrolled into this training program were facilitated by ECSA-Global fund
project and World Vision (For Somaliland) under Funding Number QPA T
ECSA 890(2015-2019) and QPA T ECSA 1832(2019-2022). The review process,
standardization of the developed training material and accreditation of the
training programme was supported by the Korea Foundation for International
Healthcare (KOFIH) under Funding Number 2019130766.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical permission and approval to conduct the study was sought from
the National Health Laboratory Diagnostic Services REC and a waiver was
obtained from the National Tuberculosis Reference Laboratory Management
to utilize the training data respectively.
Competing interests
The authors declare that they have no competing interests.
Author details
1 National Tuberculosis Reference Laboratory/WHO Supranational Reference
Laboratory, Kampala, Uganda. 2 Korea Foundation for International Health-
care (KOFIH), Seoul, Korea. 3 College of Health Science, Makerere University,
Kampala, Uganda.
Received: 28 November 2022 Accepted: 16 November 2023
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