Background

Despite the rapid scale-up of HIV prevention, care, and treatment interventions in Uganda, laboratory services in the public sector

were severely limited at the start of the USAID Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project in 2010. Public Regional Referral Hospitals (RRHs) and General Hospitals (GHs), which provide services to a large population of HIV-positive clients, had poor laboratory infrastructure, inadequately maintained or lacking equipment, and insufficiently trained laboratory staff. Routine monitoring tests, including CD4 counts, hematology, and chemistry for HIV positive clients, required referral to other laboratories supported by other projects. This negatively impacted the evidence-based clinical care service delivery.

SUSTAIN Approach to Laboratory Strengthening

To ensure provision of sustainable HIV services, SUSTAIN works with the Ministry of Health (MOH) to improve access to quality laboratory

services in Uganda. The project supports 12 RRHs, 7 GHs and 2 health centre (HC) IVs.

In December 2010, SUSTAIN conducted a joint needs assessment with the MOH, Central Public Health Laboratories (CPHL), and the USAID Targeted HIV/AIDS Laboratory Support (THALAS) project, which resulted in formulation of a Laboratory Services Strengthening and Improvement Plan. The plan was approved by the MOH and aimed to address three key areas of need: infrastructure, equipment, and human resources. Based on level of need and workload requirements, SUSTAIN is using a phased approach to strengthen the 21 supported laboratories.

IMPROVING THE QUALITY OF LABORATORY SERVICES AT UGANDA’S PUBLIC HEALTHCARE FACILITIES

HEALTH CARE IMPROVEMENTPROJECT

Phionah Kisakye, a lab technologist at Jinja RRH, uses a sysmex machine procured by the USAID SUSTAIN project, May 2013

KAMPALA

Tokora HC IV

Soroti RRH

Nebbi GH

Mubende RRH

Moyo GH

Mbale RRH

Masaka RRH

Lira RRH

Kotido HC IV

Kawolo GH

Kabale RRH

Kaabong GH

Jinja RRH

Hoima RRH

Gulu RRH

Gombe GH

Fort Portal RRH

Entebbe GH

Arua RRH

Abim GH

Moroto RRH

General Hospital

Health Center Level IV

GH

Regional Referral Hospital

Type of Healthcare Facility

RRH

HC IV

KAMPALA

Tokora HC IV

Soroti RRH

Nebbi GH

Mubende RRH

Moyo GH

Mbale RRH

Masaka RRH

Lira RRH

Kotido HC IV

Kawolo GH

Kabale RRH

Kaabong GH

Jinja RRH

Hoima RRH

Gulu RRH

Gombe GH

Fort Portal RRH

Entebbe GH

Arua RRH

Abim GH

Moroto RRH

General Hospital

Health Center Level IV

GH

Regional Referral Hospital

Type of Healthcare Facility

RRH

HC IV

USAID SUSTAIN Supported Hospital Laboratories

September 2013

SUSTAIN is funded by the United States Agency for International Development (USAID) and is made possible by the generous support of the American people. SUSTAIN is managed by University Research Co., LLC (URC) in partnership with The AIDS Support Organisation (TASO), Integrated Community Based Initiatives (ICOBI), Initiatives Inc., and Health Research Inc.

For more information, please contact Francis Ocen (focen@urc-chs.com)

Improving the Qual i ty of Laboratory Services at Uganda’s Publ ic Healthcare Faci l i t ies2

Key Interventions

Infrastructure Improvement:Together with MOH engineers, CPHL, and hospital teams, SUSTAIN participated in the development of specifications for remodeling and expanding the existing laboratory structures, selection of contractors, and supervision of the renovation work. Following the lab specifications, the project supports improvement of laboratories.

Provision of Equipment:This involves procurement and installation of new equipment, including automated CD4, chemistry, and hematology machines, as well as general use equipment (centrifuges, refrigerators, roller mixers, automated pipettes, and microscopes). In addition, SUSTAIN supports repair and routine servicing of existing equipment and supply of power back-up systems.

Quality Improvement:SUSTAIN, in collaboration with the MOH and HealthQual International, promotes the use of quality improvement (QI) approaches for laboratory services through trainings, on-site mentorships, and shared learning sessions.

Laboratory Accreditation:SUSTAIN supports laboratories to participate in the World Health Organization Region Office for Africa’s (WHO/AFRO) Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) program. The support involves training, supervision, and mentorship of laboratory staff in good laboratory practices with the target of achieving Star 3 (on scale of Star 1-5) by 2014, and eventually applying for accreditation.

Human Resource Strengthening:SUSTAIN supports health facilities to recruit critically-needed laboratory staff, while also training the existing MOH staff in good clinical laboratory practices, inventory management, laboratory organization and management, leadership skills, specific technical skills (including equipment use), laboratory accreditation, logistics management, and QI.

Progress and Achievements To-Date• Improved laboratory space and physical infrastructure. Renovation and

laboratory space improvement activities have been completed at eight supported RRHs and three GHs (Jinja, Moroto, Gulu, Mbale, Fort Portal, Mubende, Kabale, Hoima, Entebbe, Kawolo, and Nebbi). Renovations included roof replacement, new terrazzo floors, work tops, air conditioning, water supply, and space extension.

Select Laboratory Renovations

Before

Laboratory at Fort Portal RRH

Laboratory at Kabale RRH

Laboratory at Lira RRH

After

Improving the Qual i ty of Laboratory Services at Uganda’s Publ ic Healthcare Faci l i t ies 3

“

’’

Chemistry analyzer at Jinja RRH

Hands-on user training for HumaStar

• Equipment installation and repair. Repair and servicing have been done for old equipment (CD4 partec analyzers at seven laboratories and Hematology at five laboratories). SUSTAIN also procured and installed new automated and analyzers supportive equipment at renovated laboratories.

Key Interventions continued

External Quality Assurance:SUSTAIN has supported laboratories to participate in the national and international External Quality Assessment (EQA) schemes to ensure results produced are accurate, reliable, and comparable with national and international standards.

MOH Regional Medical Equipment Maintenance Workshops (RWs):Recently, the project started initiatives to upgrade the capacity of seven regional medical equipment workshops to maintain and repair bio medical equipment. This is expected to reduce equipment downtime and improve efficiency. The RWs are located in the cities of Lira, Arua, Hoima, Gulu, Mbale, Fort Portal, and Kabale.

Laboratory Sample Transportation Hubs:In mid-2013, SUSTAIN started supporting MOH interventions to implement reliable referral systems to enable lower-level health care facilities to effectively refer specimens to RRH and GH laboratories and receive timely results. The support is aimed at promoting timely initiation of clients on treatment, monitoring of treatment outcomes, diagnosis, and management of opportunistic infections.

Hub handover event at Fort Portal RRH

Before the Mbale RRH laboratory improvements,

the maximum number of tests we could do per day

was 10. With the new automated equipment, we

are now able to run up to 50 tests per day and the

turn-around time for receiving results is down from

2 days to only 10-30 minutes.

Dr. Benon Wanume, Mbale RRH Director

Improving the Qual i ty of Laboratory Services at Uganda’s Publ ic Healthcare Faci l i t ies4

Score on the TB Smear EQA Scheme (January–March 2013)

Perc

enta

ge S

core

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20

40

60

80

100

EntebbeFort PortalG

ombe

Hoim

a

Jinja

Kabale

Kaabong

Kaw

oloLira

Masaka

Mbale

Moyo

Nebbi

Mubende

SorotiPass MarkFacility Score

0

20

40

60

80

100

EntebbeFort PortalG

ombe

Hoim

a

Jinja

Kabale

Kaabong

Kaw

oloLira

Masaka

Mbale

Moyo

Nebbi

Mubende

SorotiPass MarkFacility Score

• External Quality Assurance (EQA). With support from the USAID SUSTAIN project, 17 laboratories are now enrolled in the United Kingdom EQA Scheme (UKNEQAS) for CD4, and 12 are participating in the Hematology scheme. Additionally, all 21 supported laboratories are participating in TB smear proficiency panel testing.

Laboratory In-charges from

18 hospitals completed a leadership

development course together with other

members of the hospital management

team. Up to 59 laboratory technologists

and technicians have been seconded

to all supported hospitals.

The number of laboratory tests at

SUSTAIN supported laboratories

increased by 225% for CD4, 47% for

complete blood count, and 78%

for renal function tests between

April-June 2012 and April-June 2013.

• Laboratory Logistics Management. SUSTAIN supported the national laboratory reagent/commodities’ quantification exercise, including reagents for both old and new equipment. Through continuous mentorships, support supervision, and training, the hospital-level capacity for logistics has improved.

• Strengthened systems for sustainable laboratory

services. For the first time, a national standardized list and guidelines are available for recommended laboratory tests at each level of the health care system, including testing methods and the type of equipment. The list, which was developed with SUSTAIN’s support, is expected to ease the burden on the national procurement system, which will no longer be strained to maintain a large number of different types of equipment or to provide a very wide range of reagents for laboratories performing the same tests.

• Laboratory human resources strengthening.

Twenty-two laboratory staff identified by SUSTAIN were trained as support to trainers in Laboratory Logistics Management by THALAS and CPHL. SUSTAIN also participated in the development of the training curriculum, job aids, and standard operating procedures.

• Support for national laboratory sample transportation

system hubs. SUSTAIN has taken over the support of 12 old laboratory sample transportation hubs from the MOH. An additional nine new hubs have been launched and are ready to start operating in October 2013. These 21 hubs will offer support to 608 peripheral health units, with critically needed laboratory tests for disease diagnosis, surveillance, and patient monitoring. This support will not be limited to HIV/AIDS-related tests, but will gradually include other diseases like tuberculosis, malaria and other outbreak diseases.

• Improved lab services at supported health facilities.

Public sector capacity to conduct laboratory tests has improved. SUSTAIN procured and distributed equipment, including for CD4, chemistry, hematology at 12 supported facilities, and also repaired and installed available equipment from the MOH, which improved quality of laboratory services. As a result the referral of laboratory specimens from public project-supported hospitals to other labs for processing of CD4, clinical chemistry, and hematology was no longer neccessary after June 15, 2012. Only viral load and DNA-PCR dry blood spot test specimens continue to be referred.