# Presentation: 792945

## Organizing a National Laboratory System

- The Tanzania Experience

- Workshop on Building Laboratory Quality Systems:  A Route to Reliable Laboratory Data
- Gaborone, July 27-August 1,2003
- Dr Y.A. Ipuge, Ministry of Health.

## Tanzania-Profile

- Union of Tanzania Mainland and Zanzibar
- Size, 945,020 sq km on east coast of Africa
- (N) Uganda, Kenya,
- (E) Indian Ocean
- (S) Mozambique, Malawi, Zambia and
- (W) Congo -DR, Burundi and Rwanda
- 26 Administrative regions
- Population 34.6 million annual growth rate 2.9%
- 51% women and 46% under age of 15 years

## Functions of Health Laboratory Services

- To assist clinicians in diagnosis of disease conditions and monitoring treatment of patients.
- Epidemiological surveillance of diseases and health conditions.
- Surveillance of potentially epidemic diseases and response to epidemics.

## Functions of Health Laboratory Services

- Analysis of environmental samples (water, food).
- Training of health personnel “in good diagnostic practices.
- Supporting research and clinical trials.

## Structure of Health Care delivery system in Tanzania

| Level | Services | Responsible |
| --- | --- | --- |
| District | Community based services
Dispensary/Health Centres
District (Level 1) Hospital
CHMT (DHMT) | Local Government Councils |
| Regional | Regional (Level2) Hospital 
RHMT | Regional Secretariat |
| National | Policy, Legislation, Quality,Standards
Tertiary (Level 3) Hospitals | Ministry of Health |

## Organization of Tanzania Laboratory System

- Dispensary, health centers, district
- Regional
- Zonal referral
- Central Pathology Laboratory
- Program specific Laboratories (NTLP, NACP)

**Notes:**
Share our experience in Tanzania, regarding recent efforts to strengthen laboratory services throughout the country by addressing the system at a national level.
Our current organization, hierarchy of our structure (as above)
Useful to share with you some of our history, especially as it affected our central national laboratory

## Linkages and Coordination in the Tanzania Laboratory System

- Local Governments are responsible for Dispensary, Health Center and District hospital level
- Regional Administrations are responsible for district level
- Ministry of Health is responsible for Zonal Referral and Central Pathology Laboratory

**Notes:**
Share our experience in Tanzania, regarding recent efforts to strengthen laboratory services throughout the country by addressing the system at a national level.
Our current organization, hierarchy of our structure (as above)
Useful to share with you some of our history, especially as it affected our central national laboratory

## Current Situation of Laboratory Services in Tanzania

- Quality and efficiency of Laboratory Services has declined dramatically in the past two decades.
- This has been associated with a:
- Change from a centralized to a decentralized model.
- Reduction in resources specifically allocated for the laboratory services.

## Decline in Quality and Efficiency of Laboratory Services

- Quantity and quality of equipment, reagents and supplies are inadequate
- Quality assurance program are fragmentary or absent
- Clinicians have limited confidence in the capacity of Laboratory services to assist in the patient management

## History – Tanzania National Laboratory System

- Robert Koch established the first government health laboratory in Tanzania in 1897 at Ocean Road.
- By independence in 1961, the Ocean Road Laboratory had grown into the Central Pathology Laboratory functioning as:
- Reference diagnostic laboratory
- Public health laboratory

**Notes:**
Share our experience in Tanzania, regarding recent efforts to strengthen laboratory services throughout the country by addressing the system at a national level.
Our current organization, hierarchy of our structure (as above)
Useful to share with you some of our history, especially as it affected our central national laboratory

## Central Pathology Laboratory1961-1976

- After independence (1961) the Central Pathology Laboratory added the following functions:
- Central laboratory stores for ordering and distribution of laboratory equipment and supplies
- School of Medical Laboratory Technology
- Equipment maintenance workshop

**Notes:**
Share our experience in Tanzania, regarding recent efforts to strengthen laboratory services throughout the country by addressing the system at a national level.
Our current organization, hierarchy of our structure (as above)
Useful to share with you some of our history, especially as it affected our central national laboratory

## Central Pathology Laboratory 1961-1976

- Training of Health Laboratory Technicians
- SOPs, quality assurance policies
- Provision of supplies, equipment to all laboratories
- Diagnostic Reference activities
- Public health functions
- Technical support

**Notes:**
Need for a systems approach to laboratory quality has been emphasized in the workshop.  I would like to describe how evolving problems in our central reference laboratory demonstrated how important it is to have a strong central laboratory at the national level.

## Relocation of CPL to Muhimbili Hospital

- In 1971, the Federal Swiss Government and the Federal Republic of Germany provided funds for a new building and equipment for CPL.
- CPL moved to the grounds of teaching hospital (Muhimbili) to make it more accessible to hospital, students and staff.
- Hospital Laboratory was closed and its staff were moved to new premises.

## Decentralization

- In 1972, management of Health Services was decentralization in line with new government administration structures
- Dispensary and health center labs managed by local government
- District  and Regional hospital labs managed by Regional Development Directorates
- Referral hospitals managed by MOH

## Muhimbili Medical Centre 1976

- In 1976, Muhimbili Hospital was merged with the Faculty of Medicine to form the Muhimbili Medical Centre.
- Central Pathology Laboratory taken over by the Muhimbili Medical Centre.
- Chief Pathologist was not absorbed into the Centre and was forced to move to MOH Headquarters (later to Botswana).
- Position not filled until 1998, in a new MOH structure

## CPL Dismembered

- Under the Muhimbili Medical Centre separate academic departments were set up in the Laboratory services Division.
- Most were very small departments with one or two members of academic staff
- Later, the Laboratory Services Division was replaced by  five separate Departments reporting to Director General

## Effect of Decentralization on CPL Functions

- There was no longer a separate budget for the CPL as it became part of the hospital.
- The CPL gradually became a laboratory for the Centre, without an oversight or supervisory role to the peripheral hospital laboratories.
- Referral diagnostic services for the regional and district hospitals suffered (esp. histopathology).

## Effect of Decentralization on CPL Functions

- Public health services started to compete for resources with clinical services (the need to provide patient services).
- The School of Medical Laboratory Technology was separated from the laboratory departments, thereby losing its main source of practical teaching staff and facilities.
- The CPL stores were merged into the MMC stores, eliminating support to the periphery.

## Effect of Decentralization on CPL Functions

- The equipment workshop for the CPL and peripheral laboratories was merged with the engineering department of the Centre.
- Spare parts stopped being stocked and the zonal workshops were left without support and eventually died.
- Equipment deteriorated without routine maintenance or repair.

## Earlier steps.........

- In 1989, AMREF commissioned to conduct a situation analysis of Tanzania’s Laboratory services (Jane Carter & Orgenes Lema).
- Recommendations still valid in terms of direct improvements needed for specific laboratories.
- Team of experts drafting a new Policy Guideline in 1991 proposed a centralized National Health Laboratory Service

## A turning point ..........

- In 1997, two acts enacted for regulation of private health laboratories and registration of health technologists.
- Diagnostic Services Section formed in 1998, and a microbiologist appointed to head it.
- Responsibility for implementing policy guidelines
- Laboratory
- Radiology
- Equipment maintenance

## A turning point ..........

- National Standard Guidelines for Health Laboratory Services published 1998.
- Strong advocacy for a national laboratory service was initiated including:
- participation in national and international meetings
- Participation in health sector reform process
- Active involvement in the ministerial budget preparation process.

## How We Approached the Problem

- Appointed a “Ministerial Task Force for Reform of National Health Laboratory Services in Tanzania”.
- External Technical Support for the Task force provided by:
- South African Consultant (June and October 2001).
- CDC-GAP Laboratory Support Team (May 2001 to date).

## Terms of Reference, broadly .....

- To conduct an assessment of the ‘state of the laboratory services capacity and organisation’
- To examine linkages to other ministries, NGOs, private sector, other agencies and international linkages
- To provide a vision of how the laboratory services could be re-organised.

## Methods used by Task Force

- Review of literature, previous studies (AMREF), Health Sector Reforms, Public Service Reforms.
- Visiting a selection of laboratories at different levels.
- Interviewing laboratory workers, health managers and political leaders.
- Workshops with key stakeholders, briefing meetings for senior MOH management.

## Problems associated with absence of a strong central national lab

- Difficulty with accessing supplies, reagents, equipment and spares.
- When available, of what quality??
- Decreased quality of laboratory training
- No source of proficiency testing,  QC,
- Collapse of diagnostic referral services
- Loss of public health laboratory functions.
- ...........and other many more difficulties

## Proposed Solutions for Tanzania

- Recommendations from all teams
- AMREF (Carter& Lema), 1989
- Nicholas Crisp, 2001
- CDC-GAP Laboratory Support team (Tom Hearn, Carlyn Collins & Toby Merlin), 2001, 2002
- Ministerial Task Force, 2002
-   ..........propose actions with  the same aim ....
**    ****to improve the quality, efficiency, equity, and financial viability of laboratory services** (The goal of laboratory reform).

## Proposed Solutions for Tanzania

- Changes in health laboratory services are needed to assure that:
- Specimens are properly and safely **collected**.
- Specimens are properly and safely **transported to the laboratory**.
- Specimens are properly and safely **delivered to the correct technician**.
- Specimens are properly and safely **processed**

## Proposed Solutions for Tanzania

- Changes in health laboratory services are needed to assure that:
- Clinicians receive **accurate, timely reports** of laboratory results.
- Data are **reliably stored** for the management of queries and epidemiological reporting.
**Revenue** is collected for services rendered.

## FOR EXAMPLE (phase 1B)

- <date/time>

**Integrated  National Lab Service**

- Present poor system

**National Blood Transfusion Service**

**FOR EXAMPLE (phase 1B)**

- PRESENT

- PHASE ONE

- PHASE TWO

- Better system

**TANZANIA**

## What should be done .......

- A centralized model for the laboratory services delivery is recommended by creating an autonomous NHLS that will be responsible for running the national, zonal and regional laboratories that are administratively independent from the hospitals.

## What should be done .......

- The proposed NHLS should be established as an autonomous agency or independent institution with an organization structure comprising of a Board of Directors and  an Executive Management Team.

## What should be done .......

- Economic analysis of the recommended option needs to be carried out to clearly illustrate the long-term financial implications and socioeconomic benefits of the proposed reform prior to implementation.

## What Should Be Done .......

- The Government should organise a stakeholders’ meeting to secure support and funding of the selected option.

## Importance of organization and management 

- Tanzania experience emphasizes how organization can affect Quality.
- A centralized NHLS may appear to be an expensive option, but services of poor or undefined quality are ultimately more expensive.
- The vision may be clear, but there are many obstacles for implementing the obvious option

## ENDNOTE 
“There is nothing more difficult to undertake, more dangerous to conduct or more uncertain in its success, than to initiate a new order of things”
Machiavelli, in “The Prince”

**“****There is nothing more difficult to undertake, more dangerous to conduct or more uncertain in its success, than to initiate a new order of things”**
**Machiavelli, in “The Prince”**

## ASANTE SANA!

- Thank you!

**Restructuring of the National Laboratory      System**