International Journal of Medical Laboratory Research (IJMLR)

LIMITED FUNGAL DIAGNOSTIC CAPACITY OUTSIDE REGIONAL REFERRAL HOSPITALS IN UGANDA: A STRUCTURED LITERATURE REVIEW OF DIAGNOSTIC GAPS, BARRIERS, AND OPPORTUNITIES

 

M Habert, N Jackson, MS Arthur, M Posiano, L Robert, S Geoffrey, M Glorias, W Ivan, K Enock, K Ronald, OB Wathum

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ABSTRACT: Background: Fungal diseases are important but under-recognized causes of morbidity and mortality, with diagnostic challenges being greatest in low- and middle-income countries. Uganda has a substantial population at risk because of HIV, tuberculosis, chronic respiratory disease, malignancy, critical illness, and other immunocompromising conditions. Recent estimates suggest a high national burden of serious fungal disease, yet access to advanced identification, antigen detection, molecular diagnosis, and antifungal susceptibility testing remains limited. Evidence describing routine fungal diagnostic capacity in general hospitals, health center IVs, health centre IIIs, and private-sector facilities is particularly sparse. Objective: To synthesize available evidence on fungal diagnostic capacity in Uganda, with emphasis on services outside regional referral hospitals, identify major laboratory and health-system barriers, and describe practical opportunities for strengthening decentralized fungal diagnosis. Methods: A structured literature review was undertaken using PubMed/MEDLINE, relevant institutional publications, and reference lists of eligible studies. Literature published mainly from January 2020 to August 2026 was prioritized. Search concepts covered fungal infections, diagnostic capacity, laboratory services, Uganda, sub-Saharan Africa, cryptococcosis, candidiasis, aspergillosis, histoplasmosis, fungal culture, antigen testing, molecular diagnostics, and antifungal susceptibility testing. Uganda-specific evidence was prioritized, with African studies used to contextualize gaps where local evidence was insufficient. Because the original search was not conducted as a prospectively registered systematic review with preserved database exports, retrospective PRISMA screening counts were not fabricated; the review is therefore reported as a structured literature review rather than a systematic review. Results: Available evidence demonstrates substantial fungal disease burden alongside important diagnostic gaps. Uganda's National Microbiology Reference Laboratory reported limited capacity for identification of several clinically important fungi and absence of antifungal susceptibility testing. Regional referral laboratories rely mainly on microscopy, culture, and cryptococcal antigen lateral-flow testing, whereas published evidence on lower-tier facilities is limited. African studies report similar deficiencies in infrastructure, trained personnel, fungal antigen assays, molecular diagnostics, species-level identification, quality assurance, and antifungal susceptibility testing. Uganda's experience with decentralized cryptococcal antigen testing shows that selected point-of-care fungal diagnostics can be implemented in lower-level facilities when supported by reliable supplies, staff training, clinical algorithms, and referral systems. Conclusion: Fungal diagnostic capacity remains an important laboratory-system gap in Uganda, especially below higher-level referral facilities. A national facility-level assessment should include public, private-not-for-profit, and private-for-profit facilities. A tiered approach combining decentralized microscopy and selected rapid tests with robust specimen-referral networks, regional mycology hubs, strengthened national reference services, sustainable procurement, workforce development, and quality assurance offers a feasible pathway for improving access.

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Keywords: fungal infections; fungal diagnostics; diagnostic capacity; medical mycology; Uganda; laboratory services; antifungal resistance; regional referral hospitals; point-of-care diagnostics

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