Tackling Communicable Diseases in East Africa: Power of Laboratory Networking

Challenge

At project inception, all countries faced similar challenges --a high burden of tuberculosis (TB), emergence of multidrug-resistant TB (MDR-TB), and elevated threat of disease outbreaks (e.g. Ebola, Marburg, yellow fever).  Policymakers recognized that health systems in the region were ill prepared to deal with these challenges given the historical underinvestment in laboratories.  Less than 1 percent of public sector laboratories on the continent were accredited, reflecting the poor state of facilities, including lack of trained personnel, and weak quality management systems.  Most countries had limited capacity to diagnose MDR-TB which required more efficacious diagnostic techniques. The region had only one TB supranational laboratory which could not respond to the demand from countries for technical support.  Public health officials in East Africa recognized that lack of access to quality laboratory services contributed to misdiagnosis, compromised patient care, inability to detect public health threats quickly, resulting in disease transmission and higher healthcare costs.

Approach

In 2009, the World Bank convened East African officials who developed a vision for communicable disease control, emphasizing: (i) country-led innovations; (ii) south-south collaboration; and (iii) an evidence-based approach.  They agreed to establish a network of public health laboratories to strengthen clinical care, and ensure timely disease outbreak responses.  The laboratory network aims to promote specialization in service delivery, introduce regional quality standards, and serve as a platform for learning, training and research.  Authorities recognized that, working together, they could accomplish more than if each acted alone.  Each country serves as a center of excellence in a specialized area, piloting innovations, sharing good practices, and fostering efficiencies in disease outbreak preparedness and response.  The East, Central and Southern Africa Health Community (ECSA-HC), together with the East African Community, facilitates knowledge sharing and feeds recommendations to policymakers.

Results

• Specialization: In 2013, the Uganda TB Reference Laboratory reached international accreditation, and qualified to serve as a WHO Supranational Reference Laboratory (SRL), becoming the second of its kind in Africa, and subsequently signing agreement with 20 countries to provide specialized services, limiting need to use facilities on other continents. 
• Accreditation: The proportion of facilities reaching at least two stars (project target) on the regionally recognized quality improvement scheme towards accreditation rose from 23 to 90 percent during 2011-2016.  Introduction of a unique peer review mechanism by which countries assess each other’s performance annually is promoting peer-to-peer learning, building regional capacity, and demonstrating the power of networking.
• New Technologies: Roll out of molecular technologies has improved access to TB diagnostic services, strengthened turnaround time, and picked up missing cases.  With the Gene Xpert machines, facilities were able to conduct nearly 82,000 tests, accurately diagnosing MDR-TB within several hours, rather than waiting months for culture results, implying that drugs are prescribed with greater accuracy, saving time and money.
• Enhanced Disease Control: Capacity to detect outbreaks and mount rapid effective responses has been boosted through: establishment of eight cross border committees across the five countries; ten joint investigations and tabletop simulations (e.g. Ebola, Marburg, Cholera); steep rise in laboratory-confirmation of pathogens (from roughly 8 to 88 percent); and roll out of a mobile phone disease outbreak reporting system.
• Training and Research: Training and mentorship have resulted in an expanded pool of qualified assessors, lab managers and disease surveillance officers (roughly 10,300 trained) and operational research has generated new evidence and knowledge to inform public policy.  Research has confirmed the effectiveness of the GeneXpert as a diagnostic tool, and has found significant resistance to commonly used antibiotics. Rwanda’s experience with performance based financing for laboratories has served as a model for rolling out similar schemes in the other countries.

Bank Group Contribution

IDA financing: US$78.66 million (Kenya, Rwanda, Tanzania, Uganda), May 2010; US$15 million (Burundi), May 2012; US$50 mission Additional Financing to bolster disease outbreak and response capacity (Burundi, Kenya, Tanzania, Uganda), July 2015.  Bank-supported analytic work:

• Laboratories: A Weak Link to Improving Health Outcomes in Low-Income Countries (2009)
• Laboratory Professionals in Africa: The Backbone of Quality Diagnostics (2014)
• Opportunities Abound: Public Private Partnerships for Laboratory Services in East Africa (2015)
• Evaluating the Economic and Health Impacts of Investing in Laboratories in East Africa (2015)
• Evaluation of Performance-Based Financing for Public Health Laboratories in Rwanda (2016)

Partners

The project has supported multiple partnerships to leverage additional support.

• Centers for Disease Control and Prevention: conducted scoping missions to inform project design; provided support at country level; partnered with Bank to design the Uganda SRL with construction funded by the Bank.
• WHO: prepared simulations to document TB diagnostic gaps; participated in Mid-Term Review; provided External Quality Assessment panels to national laboratories through National Institute for Communicable Diseases.
• African Society for Laboratory Medicine: trained and certified laboratory assessors; and participated in annual peer assessments.
• Global Fund: provided US$6 million grant to operationalize the Uganda SRL.

Moving Forward

With the recently approved US$50 million Additional Financing the East Africa sub-region will redouble disease prevention and control efforts, drawing lessons from the Ebola outbreak which demonstrated the importance of investing smartly and strategically in disease surveillance and diagnostic systems.  The Global Fund support for the Uganda SRL bodes well for sustainability, as regional capacity established under the Bank project will be consolidated and institutionalized.  The country-led approach has fostered ownership and capacity building has improved the probability of institutional sustainability.  Additional work is needed to ensure financial sustainability of ongoing investments which require substantial recurrent cost financing.

Beneficiaries

“The launching of Gene-Xpert is a major milestone in diagnosis of TB. This is particularly important for us in Wajir where patients travel hundreds of miles to get services.” Medical Officer, Kenya.

“Two months before I visited the Mbale Hospital I had been receiving treatment for fever and flu at a clinic near my home without any sign of recovery. I thought it was HIV”, says Aliyi Mwanika, a 30-year old motorcycle-rider.  With the aid of the Gene Xpert machine his illness was correctly diagnosed as Multi-drug resistant TB and he was placed on treatment at the Bank-supported facility. “After six months I was able to go back to work”, notes Mwanika.

“I visited several private clinics in town where laboratory results had shown that I had no TB. I was taking antibiotics without any sign of improvement. I was getting weaker with each passing day”, explains Masaba Enoch, a 37-year old businessman with a persistent cough. With the early introduction of the Gene Xpert machine at the Mbale Regional Referral Hospital he was quickly diagnosed with TB. “After receiving treatment for two weeks, I was informed that I was suffering from the multi-drug resistant TB” he says.  “I feel better. I am happier now” Masaba notes after initiating treatment.

 “The accreditation of the Uganda TB laboratory by the reputable South African National Accreditation System is encouraging.  It shows how together we can build strong regional institutions capable of serving others laboratories in the network”, Alex Opio, Project Coordinator.

“Financial incentives played a major role in improvements since staff worked harder as they see the fruits of their work through the rise in accreditation status, better managed, safe and equipped labs”, Gilbert Biraro, Rwanda technical expert.