Background

Despite the rapid scale-up of HIV preven-tion, care and treatment interventions in Uganda, laboratory services in the public sec-

tor 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 in-sufficiently trained laboratory staff. Routine monitoring tests— including CD4 counts, haematology, and chem-istry for HIV-positive clients—also required referral to other laboratories supported by other projects. This negatively impacted the evidence-based clinical care service delivery.

USAID/SUSTAIN Approach to Laboratory Strengthening

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

laboratory services in Uganda. The project supports 12 regional referral hospitals, 3 general hospitals and 2 health centre (HC) IVs.

Following a joint needs assessment with the MOH, Central Public Health Laboratories (CPHL) and the USAID THALAS Project in December 2010, the project set out to provide technical and operational support for delivery of laboratory services aimed at addressing three key areas of need: infrastructure, equipment and human resources. Based on level of need and workload requirements, USAID/SUSTAIN has used a phased approach to strengthen the 17 sup-ported laboratories shown on the map.

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

HEALTH CARE IMPROVEMENTPROJECT

A laboratory technologist conducts syphilis tests at Fort Portal RRH,

November 2013.

October 2014

USAID/SUSTAIN is funded by the United States Agency for International Development (USAID) and is made possible by the generous support of the American people. USAID/SUSTAIN is managed by University Research Co., LLC (URC) in partnership with The AIDS Support organisation (TASO), Integrated Community Based Initiatives (ICOBI), Health Research Inc. For more information, please contact Francis Ocen (focen@urc-chs.com)

S T R E N G T H E N I N G U G A N D A’ S S Y S T E M S F O R T R E AT I N G A I D S N AT I O N A L LY

KAMPALA

Tokora HC IV

Soroti RRH

Mubende RRH

Mbale RRH

Masaka RRH

Lira RRH

Kotido HC IV

Kawolo GH

Kabale RRH

Kaabong GH

Jinja RRH

Hoima RRH

Gulu RRH

Fort Portal RRH

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

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, USAID/SUSTAIN participated in the development of specifications for re-modelling and expanding the existing labora-tory structures, selection of contractors and supervision of the renovation work.

Provision of Equipment:In addition to procurement and installation of new equipment, such as automated CD4 machines, chemistry and haematology analysers, USAID/SUSTAIN supports repair and routine servicing of existing equipment and supply of power back-up systems.

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

Laboratory Accreditation:USAID/SUSTAIN supports laboratories to participate in the World Health Organization’s Africa Region (WHO/AFRO) Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) programme. The sup-port involves training, supervision and men-torship of laboratory staff in good laboratory practices with the target of achieving 3 stars (on scale of 1-5) by 2014 and eventually apply-ing for accreditation.

Human Resource Strengthening:USAID/SUSTAIN supports healthcare facili-ties 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 techni-cal skills (including equipment use), laboratory accreditation, logistics management and QI.

External Quality Assurance:The project supports laboratories to participate in national and international EQA schemes to ensure results produced are accurate, reliable and comparable with national and international standards.

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

lab space improvement activities have been completed at sixteen health-care facilities (Arua, Entebbe, Fort Portal, Gombe, Gulu, Hoima, Jinja, Kabale, Kawolo, Lira, Masaka, Mbale, Moroto, Mubende, Nebbi, and Soroti). Renova-tions included roof replacement, new terrazzo floors, work tops, air condition-ing, water supply and space extension. Renovations for 4 laboratories in the Karamoja sub-region (Abim, Kaabong, Kotido and Tokora) are ongoing. Three renovated laboratories (Entebbe, Gombe, and Nebbi) were transitioned to other implementing partners between October–December 2013.

• Equipment installation and maintenance. Automated machines for CD4, chemistry and haematology testing and ancillary laboratory equipment were procured and installed for 14 supported laboratories.

Selected Laboratory Renovations and Equipment Installations

Laboratory at Moroto RRH

Laboratory at Kabale RRH

Laboratory at Lira RRH

Laboratory at Arua RRH

Automated machines for laboratories in Karamoja have been procured in collaboration with the USAID/SCMS Project to be installed following completion of renovations. Power backups (inverters, UPSs and automatic voltage stabilisers) have also been installed for all equipped laboratories to

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

Key Interventions continued

MOH Regional Medical Equipment Maintenance Workshops (RMEMWs):In 2013, the project started initiatives to up-grade the capacity of 7 regional workshops to maintain and repair biomedical equipment and reduce equipment downtime. The RMEMWs are located in Arua, Fort Portal, Gulu, Hoima, Kabale, Lira and Mbale.

Laboratory Sample Transportation Hubs:In mid-2013, USAID/SUSTAIN started sup-porting the MOH to implement reliable refer-ral systems to enable lower level healthcare 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, moni-toring of treatment outcomes and diagnosis and management of opportunistic infections.

Laboratory technicians perform microscopy tests at Mubende RRH.

protect against power surges/outages. Supportive equipment (centrifuges, fridges, thermometers, roller mixers, pipettes, vortex mixers) were provided to support testing services.

• Support for laboratory accreditation activities. Phased on-site Strengthening Laboratory Management Towards Accreditation (SLMTA) mentorships and trainings were conducted at 14 supported laboratories to enable them attain accreditation rating. Assessments conducted by both the MOH and USAID/SUSTAIN determined the progress of these laboratories on a scale of 1-5 stars: 1 laboratory (Arua) scored Star 4, 6 laboratories (Fort Portal, Kaabong, Lira, Mbale, Moroto and Soroti) scored 2 stars, 4 laboratories (Hoima, Kabale, Kawolo, Tokora) scored 1 star and 3 laboratories (Gulu, Jinja, Masaka) remained at star 0.

A Hub rider delivers samples collected

from lower healthcare facilities for

processing at Kabale RRH.

• Participation in External Quality Assurance (EQA) schemes. All of the 17 project-supported RRH laboratories are enrolled in the UKNEQAS haematology scheme and the Biorad EQA scheme, including the TB smear proficiency panel testing, and 13 of the laboratories are also enrolled in the UKNEQAS CD4 scheme. USAID/SUSTAIN has procured computers, scanners and internet modems for all supported laboratories to enable them to submit their results and receive feedback on their performance.

Performance on TB EQA Scheme (April - June 2014)

Perc

enta

ge S

core

Moroto

Mubende

Tokora

Pass MarkFacility Score

0

20

40

60

80

100

Mbale

Gulu

Abim

Arua

Jinja

Kaabong

Kaw

olo

Lira

Mbale

Gulu

Abim

Arua

Jinja

Kaabong

Kaw

olo

Lira

Moroto

Mubende

Tokora

Pass MarkFacility Score

0

20

40

60

80

100

Automated machines

for CD4, chemistry and

haematology testing

and ancillary laboratory

equipment were procured

and installed for 14

supported laboratories.

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

• Laboratory logistics management. USAID/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.

• Laboratory human resources strengthening. Sixty-five laboratory staff (including 17 hub support staff) identified by USAID/SUSTAIN were trained to support laboratory lo-gistics management by THALAS and CPHL. The project also participated in the development of the training curriculum, job aids and standard operating procedures.

Hands-on user training for HumaStar

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 supported hospitals.

The number of HIV-related laboratory

tests at USAID/SUSTAIN-supported

laboratories increased from 249,950 in

2010–2011 to 928,308 in 2013–2014 -

a 271% increase in the total test volume.

Test volumes were significantly boosted by

the increase in the number of automated

tests directly supported by the project:

980% increase in renal function tests,

665% increase in liver function tests,

451% increase in CBC tests, 327%

increase in HIV antibody tests, and

282% increase in CD4 tests.

project-supported public hospitals to other laboratories for processing was no longer necessary after June 15, 2012. Only viral load and DNA PCR dry blood spot test specimens continue to be referred.

• Strengthened systems for sustainable laboratory ser-

vices. USAID/SUSTAIN supported the development of a national standardised list, and guidelines are available for recommended laboratory tests at each level of the healthcare system, including testing methods and the type of equipment. The list, if adhered to, will ease the burden on the national procurement system by rationalizing the approved equipment and necessary reagents for laboratories performing the same tests.

• Support to RMEMWs. USAID/SUSTAIN procured 7 vehicles for workshops at Arua, Fort Portal, Gulu, Kabale, Masaka, Mbale and Soroti Hospitals. Also, 7 biomedical engineering technicians were seconded to the RMEMWs. To strengthen the technical capacity of the workshops, engineering technicians are constantly trained on repair and maintenance of specialised labora-tory equipment for CD4, CBC, and chemistry testing. Equipment repair and servicing tools have been pro-cured by USAID/SUSTAIN and will be distributed to the 7 RMEMWs. The maintenance workshops support maintenance of laboratory and other medical equipment in the respective regions.

• Support for national laboratory sample transporta-tion system hubs. USAID/SUSTAIN supports routine technical, operational and coordination support to 17 hubs that serve a total of 463 lower healthcare facili-ties in the respective catchment areas. The scope of

• Improved laboratory services. Public sector capacity to con-duct laboratory tests at supported facilities has improved due to equipment procured and installed by USAID/SUSTAIN. The project also had additional equipment available from the MOH repaired and installed, which further improved quality of laboratory services. As a result, the referral of labora-tory CD4, clinical chemistry, and haematology samples from

Improving the Qual i ty of Laboratory Services at Uganda’s Publ ic Healthcare Faci l i t ies 5

Total HIV related tests conducted between September 2010–September 2014

Spotlight on improving turnaround time (TAT) for TB smears: Experience from Kabale RRH laboratory team

• Problem: 40% of TB results were dispatched within 3 hours at the beginning of the April-June 2014 quarter. The Kabale RRH laboratory QI team was supported to conduct a problem analysis during an on-site QI mentorship by the USAID/SUSTAIN team.

• Causes: The team found that big batches of samples (more than 10 samples) were being processed at the same time, increasing sample waiting time and prolonging the TAT for results. Also, TAT for some of the sputum microscopy samples received was not recorded in the laboratory TB register, yet those samples contributed to the denominator for the indicator values, leading to inaccurate calculations of the laboratory’s overall TAT rates.

• Changes introduced: The following changes were implemented by the QI team and monitored on a bi-weekly basis from April 2014:

• Smaller batch processing for sputum smears (maximum 10 samples)

• Task allocation and role clarity for laboratory staff using the duty roster

• Sensitisation of laboratory staff to monitor and record TAT in the laboratory TB register

• Results: By the end of June 2014, 100% of Kabale RRH’s TB sputum microscopy results were being dispatched within 3 hours.

laboratory tests supported includes DNA PCR for early infant diagnosis (EID), diagnosis of multi-drug resistant TB, histopathology examination and disease outbreak investigations; samples are referred to the consolidated MOH/CPHL EID, TB and histopathology laboratories respectively. Samples for CD4, clinical chemistry and CBC tests are processed from the hubs.

• Support for laboratories to implement QI activities. The project supports laboratories to monitor various QI indica-tors and implement process improvement changes. These indicators include turnaround time (TAT) for TB and CD4 tests, sample acceptability for automated tests and equip-ment up-time. See the following spotlight for an example of QI activities and results.

200,000

400,000

600,000

800,000

1,000,000

Yr 1 Yr 2 Yr 3 Yr 4

249,950287,892

591,332

928,308

Tota

l HIV

-rel

ated

tes

ts

USAID STRENGTHENING UGANDA’S SYSTEMS FOR TREATING AIDS NATIONALLY (SUSTAIN)

Plot 7, Ntinda View CrescentNaguru, Kampala, Uganda

+256 (0) 312-202-046 / +256 (0) 414-287-499Fax: +256 (0) 414-287-614 www.sustainuganda.org

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