Background

Strengthening laboratory services is an essential part of the USAID/Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project scope. When the proj-

ect started in 2010, supported public regional referral hospitals (RRHs), general hospitals (GHs) and selected health centre (HC) IVs—which provide HIV services to a large portion of the popula-tion—had poor laboratory infrastructure, inadequately maintained or no equipment and insufficiently trained laboratory staff. After seven years of project implementation working in collaboration with Ministry of Health (MOH), supported hospitals now have im-proved laboratory structures and work spaces following renova-tion and remodelling activities, modern and automated laboratory equipment and trained laboratory staff in order to provide quality laboratory services to clients. Routine monitoring tests— includ-ing CD4 counts, hematology and chemistry for HIV-positive clients—which previously required referral to other laboratories are now conducted on-site providing much needed services to clients at no cost.

IMPROVING THE QUALITY OF LABORATORY SERVICESAT UGANDA’S PUBLIC HEALTHCARE FACILITIES

OCTOBER 2017

Authors: Stanley Bulime, Patrick Kakeeto, Francis Ocen, Julian Natukunda, Gladys T. Tugume and Augustin Muhwezi

The USAID Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project supports the Uganda Ministry of Health to strengthen sustainable and innovative approaches for HIV and TB service delivery at selected healthcare facilities. This project is made possible by the support of the American people through the United States Agency for International Development (USAID). The content of this publication does not necessarily reflect the views of USAID or the United States Government. For more information, please visit www.sustainuganda.org.

S T R E N G T H E N I N G U G A N D A’ S SY 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

USAID/SUSTAIN Strategic Approach

To ensure the 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, three general hospitals, two health centre IVs and one private not-for-profit hospital.

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 the delivery of laboratory services aimed at addressing three key areas of need:

u Infrastructure improvement;

u Equipment; and

u Human resources.

Based on the level of need and workload requirements, USAID/SUSTAIN has used a phased approach to strengthen the 18 supported laboratories shown on the map.

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

Matany HMoroto RRH

SUSTAIN–supported Healthcare Facilities A technician uses one of the new desk top computers in the renovated laboratory facility. ©URC 2015

THE REPUBLIC OF UGANDAMINISTRY OF HEALTH

SUSTAIN-supported Healthcare Facilities by 2017

Improving the Quality of Laboratory Services at Uganda’s Public Healthcare Facilities2

Key Activities and Interventions

Conducting infrustructure im-provement activities: In collabo-ration with the MOH Infrastructure

Division, the project participated in the development of specifications for remod-eling and expanding laboratory struc-tures, the selection of contractors and the supervision of the renovation work. In 2011, the project initiated renovations and remodeling at supported laboratories to improve work spaces, including: space expansion; roof and floor repairs; the in-stallation of work tops and shelving; paint-ing; and the provision of water reservoirs and laboratory sinks.

Providing laboratory equipment: The project procured and installed new equipment, such as automated CD4 ma-chines, chemistry hematology analyzers and other supportive equipment includ-ing fridges, centrifuges, vortex mixers, roller mixers,pipettes and thermometers. Additionally, the project supports equip-ment user trainings for laboratory staff, the repair and routine servicing of existing equipment and the supply of power back-up inverter systems.

Conducting quality improvement activi-ties: The project, in collaboration with the MOH, promotes the use of quality improve-ment (QI) approaches for laboratory servic-es through trainings, on-site mentorships and shared learning sessions. Some of the lab QI indicators being monitored include turn around time (TAT) for TB and CD4 tests, sample acceptability for automated tests and equipment up time.

Strengthening laboratory management towards accreditation: The project sup-ports laboratories to participate in the World Health Organization’s Africa Region

(WHO/AFRO) Strengthening Laboratory Management Towards Accreditation (SLMTA) program. The support involves training, supervision and mentorship of laboratory staff in Laboratory Quality Management System (LQMS) essentials with the target of achieving a minimum of three stars (on a scale of 1-5). Phased SMLTA mentorships and trainings were conducted for 18 laboratories to enable them to attain a star rating after SLIPTA assessments on the journey towards ac-creditation to ISO 15189:2012 standard.

Strengthening human resources for health: The project supports healthcare facilities to recruit critically-needed labora-tory staff while training the existing MOH staff in good clinical laboratory practices, logistics and inventory management, laboratory organization and management, leadership skills, specific technical skills (including equipment use), laboratory accreditation, QI, receptor mentorship skills, Biosafety and Biosecurity, LQMS, Laboratory Internal audits and Equipment & methods verification.

Participating in external quality assur-ance (EQA): All the 18 laboratories are supported to participate in national and international EQA schemes to ensure test results produced are accurate, reliable and comparable with national and inter-national standards. All the 18 laboratories are enrolled on UKNEQAS scheme for CD4, and national EQA for TB smear mi-croscopy, GeneXpert and HIV rapid tests. Eleven laboratories at RRHs are also enrolled on UKNEQAS scheme for CBC. The supported laboratories are enrolled on different schemes, including CD4 and national proficiency testing schemes for TB and HIV tests.

Participating in MOH regional medical equipment maintenance workshops (RMEMWs): The project procured seven vehicles for workshops at Arua, Fort Portal, Gulu, Kabale, Lira, Mbale and Soroti Hospitals in addition to supporting recruitment of biomedical engineering technicians for the respective RMEMWs. To strengthen the technical capacity of the workshops, equipment repair and servicing tools were procured by USAID/SUSTAIN and distributed to the seven RMEMWs. Engineering technicians are routinely trained on the repair and main-tenance of specialized laboratory equip-ment for CD4, CBC chemistry testing, and other refrigeration equipment - Fridges and Air-conditioners.. In 2015, the project supported the seven workshops to con-duct equipment inventory and to create a data repository in order to enhance the planning and implementation of equip-

A mentoring and coaching session at Kabale Regional Referral Hospital. ©URC 2016

A lab technologist operates a humastar machine at Kabale RRH. ©URC 2016

Patrick Kakeeto (right), SUSTAIN’s Laboratory Advisor, conducts a one-on-one mentorship with a laboratory technician at Kaabong General Hospital. ©URC 2015

Improving the Quality of Laboratory Services at Uganda’s Public Healthcare Facilities 3

ment maintenance activities for both labo-ratory and other medical equipment in the respective regions.

Supporting laboratory sample and results transport net work (Hub system): In mid-2013, the project started supporting the MOH to implement reliable referral systems to enable lower level healthcare facilities to effectively refer specimens to national reference and hub laboratories in order to receive timely results. The support aims to improve timely initiation of clients on treatment, monitoring of treatment outcomes and diagnosis and management of opportunistic infections. In 2015, the project supported the MOH initiative to rollout viral load testing as a preferred approach for diagnosis of treatment failure in patients on antiretroviral therapy. The project also procured two computers for LIMs, Internet modems, printers and other stationary for each hub to support the electronic results download and printing.

Strengthening laboratory logistics management: In 2014 and 2016, 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.

Key Achievements and Progress To-date

Provided essential HIV-related tests, general healthcare and specialized laboratory tests:

The number of HIV-related laboratory tests at SUSTAIN-supported laboratories increased from 254,232 in 2010–2011 to 1,135,814 in 2014-2015—a 347% increase in the total test volume (Figure 1). The big boost in test volumes was attributed to increases in the number of well-equipped laboratories which were able to conduct tests on-site and the engagement of clinicians to increase uptake of the laboratory tests.

Improved laboratory Star space and physical infrastructure: Renovation of laboratories was completed at 18 laboratories, including five hub laboratories in the Karamoja region (Moroto, Kaabong, Abim, Tokora and Kotido). The renovations included roof replacement, expansion of laboratory working space, repair of proper work tops

and sinks, terrazzo floors, air conditioning and provision of solar systems and rain water harvest tanks. Other laboratories renovated were Arua, Entebbe, Fort Portal, Gombe, Gulu, Hoima, Jinja, Kabale, Kawolo, Lira, Mbale, Nebbi and Soroti.

Installed modern laboratory equipment: Automated machines for CD4, chemistry and hematology testing and ancillary laboratory equipment were procured and installed for 21 supported laboratories, four of which were later handed over to other implementing partners (Entebbe, Gombe, Moyo and Nebbi). Power backups (inverters, uninterrupted power supply systems and automatic voltage stabilizers)

have also been installed at supported laboratories to protect against power surges/outages. Supportive equipment (centrifuges, fridges, thermometers, roller mixers, pipettes and vortex mixers) were also provided to support testing services.

Improved laboratory star ratings for ac-creditation: At baseline, all laboratories were at star zero. However, the March 2016 assessment conducted by MOH-CPHL rated supported laboratories as follows: Mbale at 5 stars; Kabale at 4 stars; five laboratories at 3 stars (Fort Portal, Masaka, Kawolo, Kaabong and Gulu); an-other five laboratories at 2 stars (Lira, Arua, Soroti, Moroto and Tokora); three labora-tories at 1 star (Hoima, Jinja and Matany); and Kotido and Abim laboratories were still at zero stars (Figure 2). Six laboratories (Kabale, Fort Portal, Masaka, Arua, Lira and Mbale were amongst the 16 laborato-ries nationally selected to be fast tracked towards accreditation. 12 SLMTA cohort 3 laboratories were assessed in March 2017 as shown in Fig xxx. Two laboratories at-tained 3 stars, seven laboratories Hoima, Jinja, Kaabong, Matany, Mubende, Kotido and Tokora 2 stars and Gulu 1 star.

Achieved better performance for laboratories enrolled in EQA schemes: Between April and June 2016, fifteen out of the eighteen laboratories participating in the UKNEQAS CD4 scheme scored 100% acceptability of test results. Two laboratories, Mbale and Mubende, did not participate in this survey due to lack of reagents and delayed panel (sample) receipt at the facility.

Strengthened the laboratory workforce: A total of 65 laboratory staff were support-

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Star status at Continuous/Endline/Midterm assessmentStar Status at Baseline assessment

Target starHighest Achievable Star

Cohort 1 Cohort 2

Figure 2. Performance of the supported laboratories on the SLMTA program

Figure 1. Total HIV laboratory tests performed by SUSTAIN, 2010-2015

2013 2014 20152011 20122010

ed to attend different relevant in-service trainings, including: laboratory logistics management, SLMTA, internal labora-tory audit, biosafety and biosecurity and Equipment and methods verification. The project also supported laboratory staff to develop standard operating procedures (SOPs) and job aides for laboratory testing and management procedures.

Improved laboratory services: Public sector capacity to conduct laboratory tests at supported facilities has improved due to equipment procured and installed by USAID/SUSTAIN. Repair and instal-lation activities were conducted for ad-

ditional equipment from the MOH. All 18 supported laboratories are now able to perform the core laboratory tests for HIV care. However, specialized tests, such as viral load, DNA polymerase chain reaction (PCR), multi-drug-resistant tuberculosis (MDR-TB), and histopathology tests, are referred to the national reference laborato-ries through the hub system.

Strengthened systems for sustainable laboratory services: USAID/SUSTAIN provided technical support to MOH in the development of a national standardized laboratory equipment list, and guidelines-now available for recommended labora-

Biomedical Engineering Technicians attend a training on basic maintenance of the BD FACs Count CD4 machine. ©URC 2015

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Figure 3. Quality improvement indicators, 2014-2017

tory tests at each level of the healthcare system, including testing methods and the type of equipment. The standardized guidelines for equipment and the rational-ization of the laboratory supply chain has helped to streamline the national procure-ment system for essential laboratory sup-plies. The project logistics staff participated in the laboratory supplies quantification tools training, and this is expected to aid proper forecasting and quantification of laboratory supplies at both the facility and national level.

Supported regional medical equipment maintenance workshops: Coordination and joint efforts from regional workshop staff contributed to the reduction of automated equipment downtime for laboratory equipment, from 22% in 2015 to 14% in 2016. The target is to reduce downtime for all equipment even further to 5% or less through effective routine and preventive maintenance.

Supported national laboratory and results transportation system hubs: USAID/SUSTAIN supports routine techni-cal, operational and coordination support to 18 hubs that serve 470 lower healthcare facilities in the respective catchment areas. The scope of laboratory tests supported in-cludes DNA-PCR for early infant diagnosis (EID), diagnosis of MDR-TB, histopathology examination and disease outbreak investi-gations, among others. These samples are referred to the consolidated MOH/CPHL EID, TB and histopathology laboratories respectively. Samples from lower level fa-cilities for CD4, clinical chemistry and CBC tests are processed from the hubs.

Supported laboratories to implement QI activities: Progressive improvement to target values was achieved for all quality indicators being monitored across differ-ent quarters in Year 5 and 6 of the project (Figure 3).

FY15Q1 FY15Q2 FY15Q3 FY15Q4 FY16Q1 FY16Q2 FY16Q3 FY16Q4 FY17Q1 FY17Q2 FY17Q30%

20%

40%

80%

60%

100%

120%

% Acceptable testing % of TB TAT % of CD4 TAT