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Maintaining a molecular lab in Uganda comes with many challenges, but the one at the top of the list for Charles Kiyaga was sample transport. In an effort to reduce turnaround times and improve cost efficiencies, Kiyaga implemented a sample transportation network that is a model for efficiency in emerging markets.
Kiyaga works within the Central Public Health Laboratories (CPHL) in the Ministry of Health as the national coordinator for the Early Infant Diagnosis (EID) program in Uganda. His innovative sample transport network is based on creating local networks at the sub-district level, which are then coordinated at health facilities that act as “hubs” where samples are brought in from lower health facilities within a radius of about 25 miles (40km). One hub serves an average of 30 health facilities.
From each hub, the samples are sent by courier for testing to a central laboratory in the city of Kampala. In Uganda, a sample may have to travel distances of up to 621 miles (1,000 km) to reach the central testing laboratory. The sample courier rides a motorbike from lower health facilities to a hub on scheduled regular visits. By the end of the week, the courier visits all sites for each hub. In the beginning, 19 such hubs were set up to reach more than 625 health facilities.
The new system reduced sample and result transit time from what used to be one to two months, to the current five to 10 days that it is today. The same sample transport system has reduced the cost of transporting a DBS parcel by 62 percent.
Although it started as a network for moving EID DBS samples, the impressive performance inspired the addition of other sample types. The network now moves all sample types that include CD4, CBC, Chemistry, TB, Pathology specimens, Surveillance, outbreak-suspected samples and so on. To handle the fresh specimens, cold boxes were gives to each of the hubs. Upon reaching the hub, samples like CD4, CBC and Chemistry that can be run at the hub are sorted out and the rest are referred to other referral testing laboratories through the courier via CPHL.
“Uganda is not a very big country. All upcountry distances can be covered in one day,” said Kiyaga. “The scheduled visits of once a week per site works well for non-perishable samples, and those whose collection can be synchronized with the scheduled visits, however for emergency samples like for surveillance and suspected outbreak samples posed a challenge. To solve this challenge we devised a backup rider system, where each hub had a backup rider to attend to emergency samples.”
As a result of increasing access to quality lab services across the board, development partners have increased funding to this innovation. They are now in the process of adding 57 additional new hubs, to make a total of 76 hubs across the country. The 57 new hubs will on average reach an additional 1,700 health facilities through the bike riders, bringing the total of health facilities reached at least once a week through the sample transport network to 2,300 health facilities.
More health system strengthening efforts are now geared toward the hub system. PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief) has structured its Country Operation Plan (COP) beginning with their financial year 2012 on hubs. From now on, all their partners will implement activities through the hub system. PEPFAR is adopting the same system for programs in other countries.
When thinking about setting up a molecular lab, Kiyaga recommends planning ahead and consider what type of sample one is going to use, and how it is going to be handled and transported, as well as related sample quality issues. Also consider how results are going to be transported. It’s important to consider what systems and processes need to be in place for an efficient and effective molecular laboratory.
“We are adding another functionality to hubs by installing GSM printers, which use mobile internet communication to enable transmission of results from the central EID lab to hubs in real time, further cutting down on the time lost through result transport,” said Kiyaga.
Moving forward, Kiyaga is working to strengthen the lab services at hubs to elevate their capacity to international standards. Kiyaga plans to use the experience acquired through EID lab consolidation to set up a similar system for viral load, building on the already existing system for sample transport. He is also planning to add neonatal sickle cell screening and build on the already existing system for sample transport. He looks forward to many other innovations and developments that will come along to improve molecular lab services in the country.