A comprehensive approach to improving laboratories lays the groundwork for better population health
Few laboratories in the Liberian health system meet basic international quality standards. The Liberian-German Health Programme aims to change this by investing in the people, systems, equipment and infrastructure that are needed for labs to perform their core functions.
Getting to work
In Sinoe County, a remote area of Southeast Liberia, Peter Kaung goes to work every day excited that he is able to do his job. Two years ago, when Peter completed his training as a biomedical engineer technician, or BMET, and took up his post with the County Health Team, he knew how to fix much of the broken equipment he found at the hospital, but he didn’t have any tools to work with or a space to work in. He was responsible for repairing and maintaining equipment at more than 30 other clinics and health centers spread across the county, but he had no way to reach them.
Thanks to the leadership of the Liberian Ministry of Health, and to a German-supported project in Southeast Liberia, Peter can now put his training to use. He has a set of tools, a newly-renovated workspace at the county hospital, a laptop, and a motorcycle which he uses to travel between facilities. If he runs into difficulty with a repair he can turn to a senior biomedical technician based in nearby Maryland County for help, or to a newly-established network of BMETs working in the other counties of the Southeast.
The fact that Peter can do his job means that laboratory staff, doctors and nurses in Sinoe County are better able to do theirs, too. Over the past two years he has successfully repaired centrifuges, microscopes, water baths, autoclaves, oxygen compressors, refrigerators, operating theater lamps and incubators. As a result, his colleagues are able to run critical diagnostic tests, to maintain laboratory specimens at the correct temperature, to sterilise medical instruments, and to keep vaccine supplies cold and premature babies warm.
‘What I love about my job is that I can help to save lives through technology,’ Peter says. ‘I’m happy when I’m able to fix something that the staff really need to give services to patients.’
The Ministry of Health is pleased, too. ‘The support the BMETs are getting in the Southeast has greatly reduced the turnaround time for repairs and is making a difference in terms of the quality of services being provided,’ says Wymah Youyoubon, the director of the Health Technology Management Unit in Monrovia. ‘Without a doubt, this approach is working.’
Strengthening the health system, post-Ebola
Biomedical engineering technicians are the newest cadre within the Liberian health system and a prime example of the commitment the Government of Liberia has made, since the Ebola outbreak of 2014-2016, to providing universal access to basic health services and to making the health system more resilient in the face of public health emergencies. Germany, through its Federal Ministry for Economic Cooperation and Development (BMZ), is one of the Ministry of Health’s major partners in this effort. Through the Post-Ebola Health System Strengthening (PEGSS) project, which is part of the Liberian-German Health Programme, GIZ works with the Ministry of Health and health teams in five counties to strengthen the health system to deliver quality services to all Liberians and protect them against disease outbreaks.
One of the project’s major aims is to strengthen the quality of public health and clinical laboratories. According to the Services Availability and Readiness Assessment conducted in 2016, most laboratories in the Southeast lack the human, technical and financial resources to perform even routine tasks. Deficits in equipment, consumables, staff training, infrastructure and systems for maintaining medical technology are widespread. This is not only detrimental to the quality of care being provided to patients, it also makes it difficult to conduct public health surveillance activities and to tackle the rising challenge of anti-microbial resistances which threaten the effective prevention and treatment of a range of infections.
A comprehensive strategy to improve laboratories
The PEGSS project is attempting something unique in southeast Liberia: a comprehensive, multi-level approach to strengthening laboratories. The overarching idea is that better-skilled and empowered staff, improved lab systems and procedures, and targeted infrastructure improvements can foster lasting systemic changes despite significant resource constraints. In this effort GIZ is working closely with Partners in Health, an international NGO with an established base of operations in Maryland County and a long-term commitment to strengthening health systems there. In addition to investments in infrastructure and equipment, Partners in Health (PIH) mentors and carries out on-the-job training for County Diagnostic Officers and BMETs in the five counties, and brings them together in technical networks to foster mutual learning and support.
Building on synergies with other German-supported initiatives in Liberia, the project is also supporting the extension of solar technology to laboratories to overcome erratic electricity supplies and is building the capacity of laboratory staff by supporting them to attend scientific conferences.
‘Quality management is essential to building laboratory capacity, but there are so many things that have to come into play: equipment that works, better trained people, sound systems and processes, and improvements in infrastructure,’ explains Damien Bishop, the project director for GIZ. ‘Our approach is to bring these different strands together, building where we can on the work of other partners, to help the government realise its vision.’
A new laboratory as a hub for the region
A central element of the strategy to improve laboratory performance in the Southeast is the expansion of the main laboratory of JJ Dossen Hospital in Maryland County. Handed over to the Ministry of Health in October 2019 by the German Ambassador to Liberia, Mr Hubert Jaeger, the newly expanded laboratory will provide a safe and efficient working space for laboratory staff, accommodate new equipment procured by GIZ, and support the introduction of more sophisticated diagnostic procedures. Building on previous investments in staff and equipment by PIH and the World Bank, the medical laboratory will become a diagnostic hub for the entire region and serve as a regional reference laboratory for public health surveillance.
To maximise the impact of the new laboratory for the region, the County Health Teams, the German consulting firm Health Focus, and PIH are working together to create a pilot surveillance system for anti-microbial resistance and are identifying ways to improve antibiotic prescribing by clinicians in county hospitals. As part of the PEGSS project, they are establishing standard operating procedures for the lab, upgrading the skills of laboratory staff to support new microbiological testing services, and establishing transportation and referral systems to link the lab to others across the Southeast. The reference lab will play a critical role in the system, testing samples collected at sentinel sites across the Southeast to identify targeted pathogens and to establish their drug sensitivity pattern. This will inform clinical decision making and prescribing practices at the local level and feed into the development of national guidelines.
‘The construction of the regional laboratory with full microbiological capacity at JJ Dossen is one of the biggest achievements of the project thus far,’ says Alfred Nyumah, the Quality Manager at the Ministry of Health’s National Diagnostic Division.
A step-by-step approach to improving quality management
Complementing the activities at the improved laboratory, a senior laboratory manager working for PIH has been mentoring County Diagnostic Officers in the five counties through regular visits and group training sessions held on site and in Harper. The focus has been on gradually improving the quality of the six hospital laboratories in line with the Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) approach, an initiative of the World Health Organization Regional Office for Africa (WHO AFRO). German support for the SLIPTA approach in Liberia builds on previous investments by the United States Agency for International Development and aims at supporting laboratories to reach one-star status (five stars is the highest) – a significant achievement for laboratories working in resource-constrained settings.
At the start of the project none of the laboratories in the Southeast met the standard for a single SLIPTA star. But by March 2019, an interim assessment conducted by an independent auditor showed that all six hospitals had improved their scores markedly – and that three were well on track to achieve one-star status.
One of these is Rally Time Hospital, in Grand Kru County, which had one of the lowest scores on the baseline assessment. According to Gebah Mannah, the County Diagnostic Officer in Grand Kru, the project has helped him to do his job better: ‘Thanks to this process we now know how to attack things step by step. SLIPTA gives me benchmarks to aim for, and the mentoring helps me to be able to work up to those standards. We have a lot more confidence now about how to grow our work.’ Mannah also values the laboratory coordination meetings which are now being held regularly with lab supervisors and staff from across the county.
‘One of the main lessons learned from the approach taken by GIZ and PIH is how important it is to be present in the region. The benefits of the direct monitoring and onsite coaching are clear,’ says Alfred Nyumah of the Ministry of Health.
Finding creative solutions to shared challenges
Given the Southeast’s geographical isolation from the rest of the country, strategies which foster learning and mutual support within the region are particularly needed. The project has facilitated the establishment of technical networks by bringing together County Diagnostic Officers, lab managers and the BMETs from the five counties into face-to-face meetings and virtual support groups. The groups have been quick to use these new networks as opportunities to learn from one another and to find creative solutions to shared problems.
The County Diagnostic Officers have set up a regional platform, using WhatsApp, to exchange supplies and materials as a way to overcome frequent supply chain challenges. During a recent meningitis outbreak in Grand Kru, for example, the hospital ran out of the reagent needed to run tests on cerebrospinal fluid. Gebah Mannah posted an urgent query to the group, learned that supplies were available in Maryland County, and travelled there by motorbike to collect the reagent. ‘This requisition system we’ve developed is great – it helps us to deal with stock outs and also to reduce the volume of expiries,’ says Mannah.
The BMETs also use WhatsApp to support one another at a distance. They post questions about tricky repairs, along with photos, and receive quick replies from one another or from the senior biomedical technician in Maryland County. They also regularly come together for meetings and coaching sessions at a newly renovated BMET workshop in Harper, which serves as a hub and training space for the region and beyond.
A model for achieving sustainable results
The project’s holistic approach is starting to pay off. The investments made in people, systems, infrastructure and equipment in the Southeast over the past two years mean that several labs are on track to receive their first SLIPTA stars; microbiological testing is now being done for the first time in a rural area in Liberia; and preventive and curative maintenance is happening in real time, helping to protect investments in the health system. Through on-the-job training, laboratory staff across the Southeast now have avenues to improve their skills. The combination of targeted investments, personal empowerment and skills development is laying the groundwork for these improvements to be sustained over time, despite the resource constraints which the health system will continue to face.
‘Comprehensive approaches are uncommon because they’re seen as expensive, but in fact it’s what achieves results,’ says Ashley Damewood, the Director of Policy and Partnerships at PIH Liberia. ‘We need to invest simultaneously in the supply and demand sides of the system to help the Ministry achieve its goal of building a more responsive, resilient system. Germany has done this in the area of lab and biomedical systems. It’s an approach that should be championed.’
The Ministry of Health, and particularly the National Diagnostic Unit and the Health Technology Management Unit, has taken note and is exploring ways to replicate this model in other parts of the country. Discussions with other development partners are ongoing; the Global Fund, for its part, has already committed to financing elements of the BMET support activities in the other 10 counties in Liberia.