[This article was published in 2009 and updated in May 2012. Read the update here.]
In certain African countries such as Tanzania, lack of health care infrastructure impedes progress not only in controlling the HIV/AIDS epidemic but in the overall provision of health services. Even when sufficient stocks of medication are available,shortcomings with certain ancillary services, such as laboratory testing, contribute to the challenges of diagnosing and treating HIV/AIDS and other diseases.
Abbott, the global health care company, was compelled to action in the late 1990s as the HIV epidemic in Africa was worsening. In 2000, Abbott CEO Miles White saw firsthand the issues of crumbling infrastructure during his visit to Muhimbili National Hospital, Tanzania’s most advanced medical institution and university medical center. Reflecting on the experience, Miles said “I learned more in 10 minutes at Muhimbili than I had in reading all the newspapers and reports.”
It was evident that, in order to address HIV in Tanzania, health system deficiencies needed to be modernized. After the visit, a comprehensive plan was put in place to fight AIDS in Tanzania by first addressing the weak health system that resided at the top of the Tanzanian health infrastructure, Muhimbili National Hospital. Abbott with the support of the government of Tanzania, began a program to systematically improve laboratory infrastructure and services. While the initiative is a work in progress, Abbott has obtained measurable improvements in both turnaround time and the quality of patient results.
“In 2007, the regional laboratories in Tanzania were devoid of automation, similar to where we were in the U.S. in the mid-80s,” says Larry Wood Jr., program manager for Abbott Fund Tanzania. Wood, who is in charge of implementation and training in the project, explains, “Although they are relying on manual methodologies in many cases, local laboratory staff can generate acceptable results.”
AIDS and Other Conditions
While HIV affects the population at a rate of about 5.7 percent throughout the country, in some places the rate goes much higher, up to 12 percent in the Lake Victoria region, for instance. But non-HIV patients often bear the brunt of the laboratory inequities in Tanzania.
“When antiretroviral therapy became available for people with HIV, laboratory services in the region were very poor, because the outdated facilities were not equipped to deal with the influx of patients needing ongoing disease and drug monitoring. It was hard for any of these labs to provide adequate patient care, without proper equipment, reagents, training and technical expertise. A physician without laboratory results is treating the disease blindly, unable to definitively define the best course of treatment for the patient’s changing condition,” says Gloria Kulaya, M.D., M.P.H., technical manager for monitoring and evaluation for the Abbott Fund Tanzania.
Global AIDS agencies like PEPFAR and the Global Fund tried to improve the situation by funding the update of laboratories and tests performed specifically for HIV patients. “This improved services for those with HIV, which is its charter; however non-HIV patients didn’t receive the full benefit from the rehabilitations. For example, if you were HIV-positive, you’d get your results back quickly; if not, you could wait at least a week for your results,” Kulaya says.
Abbott’s first major intervention was to rehabilitate Muhimbili’s 52,000-square-foot Central Pathology Laboratory, in which the laboratory staff struggled to keep up with the hospital’s workload using broken and outdated equipment. The Abbott Fund installed new chemistry, hematology and immunology instruments and stocked the lab with reagents. In addition, the laboratory, and eventually the entire hospital, was fully computerized. To address the challenge of maintaining and servicing instruments, two Abbott field service engineers were dedicated to the new laboratory. Abbott field service personnel have access to the requisite parts and training to ensure that instruments are available 24 hours a day, seven days a week. In addition, the company also provides a full-time technical adviser to work alongside the technicians and train them on the use of quality control, instrument maintenance, reagent procurement and general laboratory operations and management.
Abbott also funds non-Abbott instruments and reagents. Most recently, Abbott Fund purchased a highly technical molecular instrument to diagnose HIV in infants early enough (before 18 months) to effectively treat them before they are overcome by the disease. As a result of this significant investment in equipment, training and personnel, Muhimbili is one of the highest quality and
most sophisticated laboratories in East Africa.
Creating Efficiencies Through Standardization
In 2007, with the experience of Muhimbili as a reference point, the government of Tanzania asked Abbott Fund to consider renovating each of its region’s laboratories; Tanzania has 20 regions and three larger regional-level laboratories for a total of 23 laboratories that needed immediate attention. Abbott agreed and began working with the government to determine the implementation strategy.
Abbott Fund, a foundation funded solely by Abbott, visited each lab together with its lab designers, architects and designated government officials. The team makes a determination as to whether the laboratory can be renovated or requires demolition and completely new construction. Key to the strategy is the intent to deliver a standardized final laboratory.
Standardization is an important aspect of the project. “From the very beginning, we wanted to provide a standardized solution,” says Christy Wistar, M.B.A., vice president of Abbott Fund Tanzania. “We wanted all 23 buildings to look and feel alike.” That goal has been partially hindered by the fact that some of the projects are complete teardowns, while others are rehabilitations. Right now the ratio is running about 50/50, she says.
While each of the labs differs in small ways, the overall plan to provide a standardized design helps to maintain control of the process and costs. As part of the program, Abbott installs safety equipment to provide protection from infection and contamination of laboratory staff. “The bio-safety cabinets and fume hoods are an important component of our overall program. It’s not only about better quality results but also better and safer working conditions
for laboratory personnel,” says Wood.
Prompt Quantification of Benefits
Of the 23 laboratories slated for renovation, eight are now complete, five are under construction, and 10 more labs are planned for 2010, according to Wistar. Each lab costs between $400,000 and $500,000 dollars, she adds, a little more than originally planned but not out of line considering inflation and an expected three-year project investment of $10 million.
While many of the rehabilitated labs are just now coming on line, Abbott measured improvements at one lab, the trial project in Mt. Meru Hospital, Arusha, Tanzania. There, the number of tests performed rose from an average of 15,000 to 134,000 per year, while turnaround time decreased from an average of three to 14 days to less than 24 hours. The number of clients using laboratory facilities also rose, from an average of 5,000 to 38,000 per year.
For some of the more recently completed labs, it is too early to measure results. Kulaya says they came up with a list of five indicators — among them the number of patients served, the number of test requests completed, instrument status, reagent inventory status, and turnaround time of results. The laboratories report back to Abbott Fund on Monday of every week. Currently, data collection is taking place manually because the monitoring system is not yet computerized.
Overcoming Logistical Difficulties
Even in the newly modernized laboratories, shortages of training, power or reagents sometimes mean that patient tests are not completed.
With the exception of Muhimbili, where Abbott supplied instruments for clinical chemistry, hematology and immunoassay, the Tanzania Ministry of Health is supplying laboratory equipment for the regional laboratories.
“One of the major challenges with the equipment purchased by the government is that until recently, no plans were made for service. Relatively new equipment can be inoperable for weeks or months because the local distributor is not a reliable source of service or parts. The problems are worse when equipment is donated without provision for local procurement of consumables or service.
“Through our day-to-day contact with the laboratories we’ve found that, often due to a lack of reagents or hardware issues, relatively new analyzers are inoperable,” says Wood. “For example, we found an instrument where the hard drive had failed on the system after installation, and without a service plan in place, the staff put a blanket over the system and the associated tests were not performed for weeks. “I can’t tell you how critical qualified service and support are to the management of a modern laboratory,” says Wood.
As part of their training and implementation program, Abbott provides mentors to work with lab personnel side-by-side for two months during the start-up process to ensure the lab has good processes and procedures in place and is able to work through many on-site operational issues. Supervision of sites is also done weekly by e-mail, fax or telephone to ensure the sites are running, instruments are in good condition, and reagents and quality control are available.
However, by far the most difficult logistical problem facing labs in Tanzania is that of keeping reagents in supply. A reagent is a consumable resource used with the analyzer to produce the test result, like paper is to a printer. A busy laboratory requires hundreds of different reagents with different expiration dates, making laboratory inventory and procurement a huge logistical
challenge in a country like Tanzania.
At Muhimbili, Abbott provides reagents and other consumables at no charge or they are purchased from local suppliers. Abbott support personnel are responsible for managing inventories and ordering supplies. In the regional labs, because it isn’t Abbott instrumentation, two local distributors as well as the government’s own procurement agency, are responsible for supplying the country’s laboratory supplies.
The reagent ordering process has been a source of frustration for the laboratory staff in Tanzania. “The main thing is that it just takes too long, forms are filled out manually, requiring signatures and sent by mail to the Medical Stores Department, where there is a huge backlog of forms,” says Kulaya. In fact, often, reagents are shipped out to the laboratories without regard to need or inventory on site. It’s called a “push” system whereby reagents are pushed from the Medical Stores Department to the laboratories without an order. This inevitably ends with oversupply and storage issues for some supplies and running out of others.
Abbott is trying out a new method of ordering reagents at the labs, Wood says. “We’re trying to convert from a “push” system to the more traditional “pull” system where reagents are ordered as needed. Right now, we have a pilot program, and we should have feedback from that within the next six months,” he adds.
Ensuring the Future Through Education in the Lake Victoria Region
One of the regions hardest hit by the AIDS crisis, the Lake Victoria region in the north, with its population of 13 million, may also serve as another kind of laboratory for solving some of the country’s global health problems. In addition to building or renovating labs across Tanzania, Abbott is partnering with U.S.-based Touch Foundation Inc., to increase medical education. The Touch Foundation was working on the health care worker shortage in Tanzania and enlisted Abbott support, when Abbott was beginning the lab modernizations in the Lake Victoria region.
Every year, Abbott funds more than 100 scholarships for medical technologists, for a full three-year program, at (Weill) Bugando University College of Health Sciences in the Lakes region.
“Well-trained lab managers and medical technologists are the key to ensuring the future of these laboratories,” says Wistar. “We need to ensure that Tanzania has a next generation of qualified medical technologists. Beyond training laboratory staff to use the equipment or conduct tests and read results, Abbott’s mentoring program is instilling a new discipline. Through daily observation and a weekly phone questionnaire, we’re communicating that the role of the laboratory is vital to the health care system and it’s not acceptable to let patients and physicians down. We’ve established, most importantly, a new sense of accountability.”
By John Otrompke, J.D.
Christy Wistar contributed to this article.