Demonstrating How to Improve Operational Efficiency in Uganda’s Overall Pathology Service - Part 3

Ibrahimm Mugerwa1, Tony Boova2, Van Der Westhuizen2, Christopher Okiira1, Agnes Nakakawa3, Micheal Kasusse3, Suzan Nabadda1, Gaspard Guma1, Suleiman Ikoba1, Charles Kiyaga4
 
1Uganda National Health Laboratory Services, 2Beckman Coulter Life Sciences, 3Makerere University, 4ASLM

 

Greater efficiency for lab inventory management 

The initial assessment found that supplies would be delayed, with frequent stock outs, due to poor communication because there was no clear chain of command for coordinating this activity. This was especially problematic for viral load and early infant diagnosis supplies (EID). 
 
Ordering of supplies was found to be erratic, with no account being taken of the distribution cycles of the National Medical Stores (Uganda’s procurement agency). Further, there were no standardized tools and mechanisms for managing stock levels for Vital, Essential and Necessary (VEN) laboratory commodities. 
 
To resolve this, CPHL worked with the new regional hubs coordinator to set up a centrally coordinated mechanism for distribution of viral load and EID supplies via the hub system. This led to a marked increase in the number of samples referred from the hubs to CPHL. Further, an exchange service was implemented between labs for buffer stock and other commodities.
 
Time management skills’ training was initiated for regionally-based staff so that they understood how to coordinate ordering with the centralized system run by the National Medical Stores. Towards the end of the pilot study, improvements were also noted in the transportation of supplies from central supply depots to hubs (via a CPHL centrally managed courier service) and their subsequent distribution to lower level facilities.
 

Improved workflow and reduced turnaround times

The Ugandan regional hub system defines turnaround time (TAT) in two ways:
TAT1 –samples from lower health facilities to the hub: from the time the sample is dispatched to the result being generated by the hub.
TAT2 –samples sent by the hub to CPHL the subsequent return of the result.
 
In the three months before the study started, TAT1 was averaging 2.7 weeks while TAT2 was around 4.3 weeks (see full TAT data for the eight hubs in Appendix 4). In addition, some results were misplaced due to the lack of adequate documentation and tracking system. Improvements were almost immediate, and by the end of the pilot, TAT1 and TAT2 were down to one week or less (Figure 3).
 

Figure 3:  Significant reductions in both TAT1 and TAT 2 during the 12 month pilot study 

Kiyaga C, Lee HH, Allain JP (2015) Adherence to Early Infant Diagnosis Testing Algorithm, a Challenge to Early Infant Diagnosis Program in Resource Limited Settings of Uganda. J HIV Clin Scientific Res 2(2): 030-039

FLOWC-HIV White paper 1 fig 2 - Section 3 

A specific objective was to increase patient access to essential diagnostics for HIV/AIDS and opportunistic infections in the West Nile Health Region. The low volume of tests being carried out was a major factor in the lack of patient access. 
 
Overall, sample volumes went up more than 350% in the 12 month pilot study (Figure 4). Complete blood counts went up 5% between the first and second quarter of the intervention. 
Between the second and third quarter of the pilot study, the number of CBCs increased by 585.  The slight dip (Figure 5) in quarter three is accounted for by normal migration patterns during festival time.  Between the first and fourth quarters, increases in the volume of hematology specimens processed at the hub went up by almost 60% (Figure 5). For improvements in CD4 and GenXpert volumes see Figure 5a.
 

Figure 4:  Overall Sample Volume Increases

FLOWC-HIV White paper 1 fig 2 - Section 3

Figure 5:  Overall increases for CBC sample volumes


FLOWC-HIV White paper 1 fig 2 - Section 3

Figure 5a:  Overall increases for sample volumes including CD4 and GenXpert


FLOWC-HIV White paper 1 fig 5a - Section 3



Before intervention, the hubs in the area  averagely sent 38,534 viral load samples per quarter. This increased by 130,346 VL samples, an almost 350% rise. Before the intervention, lower sites were sending the hubs 1,517 VL samples each quarter.  This increased well over 800% to 13,958 samples.  Figure 6, charts 1 and 2.
 
 

Fig.6:  Quarterly viral load sample processing improvements over the 12 months

This isn't clear in the original but I have retained.  The use of the word hub here needs clarifying.  

FLOWC-HIV White paper 1 fig 6a - Section 3
Showing quarterly VL tests at the Hub

FLOWC-HIV White paper 1 fig 6b - Section 3
2 Showing quarterly VL tests at the lower facilities    


FLOWC-HIV White paper 1 fig 6c - Section 3
3 Showing quarterly VL tests sent to CPHL

   

Download and Read the Full Case Study

FLOWC-HIV White paper trio V2 - Section 3

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CD4 Testing in Remote Areas

Demonstrating Operational Efficiencies in Uganda: Part 1​

Stimulating efficiency while empowering and mentoring local laboratory professionals in workflow management underpins the remarkable improvement in the routine laboratory service of Uganda’s West Nile Health Region.

Demonstrating Operational Efficiencies in Uganda: Part 2​

Uganda’s Central Public Health Laboratories (CPHL) recognized that its regional laboratory service was suffering from a number of operational and governance challenges that were affecting service delivery and patient outcomes.

Demonstrating Operational Efficiencies in Uganda: Part 3​

The initial assessment found that supplies would be delayed, with frequent stock outs, due to poor communication because there was no clear chain of command for coordinating this activity.

Demonstrating Operational Efficiencies in Uganda: Part 4​

One of the challenges for accurate cost and performance evaluation was understanding, and quantifying, the differences between the pilot study region – and the control