Implementation and performance evaluation of an integrated specimen referral system in Burkina Faso using the national courier services (2020-2022).

Introduction: In 2017, the Ministry of Health and Public Hygiene (MoH) of Burkina Faso designed and piloted a specimen transport system using the national courier services (La Poste BF) in 4 districts. Based on satisfactory performance indicators, the MoH set a vision aimed at scaling up this system to strengthen disease detection and surveillance of epidemic prone diseases across the country. This work describes the implementation process, performances, and lessons learned. Methodology: This work describes the implementation process, performances, and lessons learned. Under the leadership of the Directorate of Population Health Protection within the MoH, a stepwise approach was used to bring together multiple partners across sectors to develop the first needed documents including a guide, an implementation plan, Standard Operating Procedures, and data collection tools. Then, the execution phase included equipment purchase, trainings, and consensus on a financing mechanism. Key indicators were defined to allow performance monitoring. Result: The integrated biological specimen referral system (SITEB) was officially launched in January 2020 to transport human biological specimens of priority diseases including COVID-19 from district level to reference laboratories nationwide. As of December 31, 2022, La Poste BF transported 168,856 packages containing 206,314 specimens from all 13 regions. 99.66% of packages were delivered in <24 h as required, and 99.68% of specimens were in good condition at reception. COVID-19 specimens represented respectively 18% and 63% of samples transported in 2020 and 2021. Discussion: The political will combined with the experience gained during the pilot phase and the commitment and support from all stakeholders laid to the foundation of the effective implementation of this system. Collaboration between two government entities (MoH and Minister of Transport, Urban Mobility, and Road Safety) to benefit public health has led to reasonable pricing for sustainability. Although all documents integrate the "One Health" approach, the system ensures the transport of only human samples for now. Despite security constraints, Burkina Faso has successfully set up a system using the national postal service to ensure the routine transport of specimens for all diseases under laboratory surveillance including laboratory tests for HIV and TB from the district level to reference laboratories nationwide. This system has also proved to be useful and efficient in managing public health emergency.

Providing specimen transport through an online marketplace in the Northern region of Ghana.

Background: Integrated diagnostic networks, which are themselves dependent on robust specimen transport solutions, are fundamental to effective healthcare systems. Objective: This study aimed to pilot an online marketplace for the transport of specimens throughout a laboratory network in Ghana. Methods: Independent drivers were matched with health facilities that required specimen transport using a suite of mobile applications and web portals developed for this study. This marketplace was piloted with seven drivers, two laboratories, and five health facilities in Ghana's Northern region from March 2019 to October 2019. Results: During the pilot, 182 deliveries were completed for 691 patients, including 4118 laboratory tests for antenatal care, disease surveillance, and clinical testing. Testing included 34 tests for communicable and non-communicable diseases. All but two specimens (laboratory cancellations) were successfully delivered and tested. The median time from request to encrypted emailing of results was 19.7 h, while that for a drop-off request was 0.9 h. In the midwife registry, the median time from patient visit to result recording was 1 day, compared to 4 days in the same months in 2018, and the number of mothers without documented testing decreased from 41 to 3. Similarly, the proportion of tuberculosis specimen deliveries from Buipe Polyclinic to Tamale Zonal Laboratory taking over 1 day fell from 62% at baseline to 3% during the pilot. Conclusion: An online marketplace successfully orchestrated the delivery of laboratory specimens under a variety of clinical circumstances, reducing overall turn-around time without diminution of the overall specimen delivery process. What this study adds: This study established the efficacy of an online marketplace to orchestrate timely and high-quality delivery of specimens within a laboratory network.

Evaluation of the postal service for referral of specimen of drug resistance tuberculosis in Amhara region, Ethiopia; mixed method.

BACKGROUND: In Ethiopia, specimens of presumptive drug resistant tuberculosis cases are transported by courier system from district sample collection centers to reference laboratories. It is essential to track the effectiveness of the referral system and identify challenges in order to take timely and appropriate actions. We assessed turnaround time and quality of specimens, and explored challenges of the specimen referral system in Amhara region, Ethiopia, 2017. METHODS: With mixed methods, we retrospectively examined 385 randomly selected presumptive drug resistance TB specimens, and interviewed 53 purposively selected key informants from laboratories and post offices. We calculated median TAT and proportion of acceptable quality. We analyzed qualitative data thematically. RESULTS: Of the 385 specimens, 94.5% (364/385) had acceptable quality at arrival in the reference laboratories. All the 364 specimens had result. Three - fourth (76.1%) of results were dispatched to the referring health facilities within the recommended turnaround time. Ineffective communication and lack of feedback among institutions were mentioned as challenges. CONCLUSION: The postal service was effective in keeping quality and majority of test results were timely delivered. Yet, there were operational challenges. Therefore, effective communication, using dedicated vehicle for specimen shipment and awareness creation on specimen collection and handling are recommended.

Creating a National Specimen Referral System in Guinea: Lessons From Initial Development and Implementation.

In the wake of the 2014-2016, West Africa Ebola virus disease (EVD) outbreak, the Government of Guinea recognized an opportunity to strengthen its national laboratory system, incorporating capacity and investments developed during the response. The Ministry of Health (MOH) identified creation of a holistic, safe, secure, and timely national specimen referral system as a priority for improved detection and confirmation of priority diseases, in line with national Integrated Disease Surveillance and Response guidelines. The project consisted of two parts, each led by different implementing partners working collaboratively together and with the Ministry of Health: the development and approval of a national specimen referral policy, and pilot implementation of a specimen referral system, modeled on the policy, in three prefectures. This paper describes the successful execution of the project, highlighting the opportunities and challenges of building sustainable health systems capacity during and after public health emergencies, and provides lessons learned for strengthening national capabilities for surveillance and disease diagnosis.

Combatting Global Infectious Diseases: A Network Effect of Specimen Referral Systems.

The recent Ebola virus outbreak in West Africa clearly demonstrated the critical role of laboratory systems and networks in responding to epidemics. Because of the huge challenges in establishing functional laboratories at all tiers of health systems in developing countries, strengthening specimen referral networks is critical. In this review article, we propose a platform strategy for developing specimen referral networks based on 2 models: centralized and decentralized laboratory specimen referral networks. These models have been shown to be effective in patient management in programs in resource-limited settings. Both models lead to reduced turnaround time and retain flexibility for integrating different specimen types. In Haiti, decentralized specimen referral systems resulted in a 182% increase in patients enrolling in human immunodeficiency virus treatment programs within 6 months. In Uganda, cost savings of up to 62% were observed with a centralized model. A platform strategy will create a network effect that will benefit multiple disease programs.

Strengthening the Tuberculosis Specimen Referral Network in Uganda: The Role of Public-Private Partnerships.

BACKGROUND: Diagnosis of multidrug-resistant tuberculosis and prompt initiation of effective treatment rely on access to rapid and reliable drug-susceptibility testing. Efficient specimen transport systems and appropriate training on specimen referral contribute to optimal and timely access to tuberculosis diagnostic services. METHODS: With support and technical assistance from a public-private partnership (PPP) between Becton Dickinson and the US President's Emergency Plan for AIDS Relief, the Uganda National TB Reference Laboratory (NTRL) and National TB and Leprosy Program redesigned the tuberculosis specimen transport network and trained healthcare workers with the goal of improving multidrug-resistant tuberculosis detection. RESULTS: Between 2008 and 2011, the PPP mapped 93% of health facilities and trained 724 healthcare and postal staff members covering 72% of districts. Strengthening the tuberculosis specimen referral system increased referrals from presumptive multidrug-resistant tuberculosis cases by >10-fold, with 94% of specimens reaching the NTRL within the established target transport time. CONCLUSIONS: This study demonstrates the potential of PPP collaborations with ministries of health to positively influence patient care by strengthening laboratory systems through increased access to drug-susceptibility testing in Uganda. Ongoing efforts to integrate specimen transport networks will maximize resources and improve patient management.

Improved Specimen-Referral System and Increased Access to Quality Laboratory Services in Ethiopia: The Role of the Public-Private Partnership.

BACKGROUND: Nonstandardized specimen-transport logistics, lack of laboratory personnel to transport specimens, lack of standard specimen containers, and long turnaround time (TAT) hindered access to quality laboratory services. The objective of the Becton, Dickinson, and Company (BD)-US President's Emergency Plan for AIDS Relief (PEPFAR) Public-Private Partnership (PPP) was to support country-specific programs to develop integrated laboratory systems, services, and quality improvement strategies, with an emphasis on strengthening the specimen-referral system (SRS). METHODS: In 2007, through the Centers for Disease Control and Prevention (CDC), the Ethiopian Public Health Institute (EPHI) joined with the BD-PEPFAR PPP to strengthen laboratory systems. A joint planning and assessment committee identified gaps in the SRS for prioritization and intervention and piloted the system in Addis Ababa and Amhara Region. RESULTS: The PPP established standardized, streamlined specimen logistics, using the Ethiopian Postal Service Enterprise to support a laboratory network in which 554 facilities referred specimens to 160 laboratories. The PPP supported procuring 400 standard specimen containers and the training of 586 laboratory personnel and 81 postal workers. The average TAT was reduced from 7 days (range, 2-14 days) to 2 days (range, 1-3 days) in Addis Ababa and from 10 days (range, 6-21 days) to 5 days (range, 2-6 days) in Amhara Region. CONCLUSIONS: This study highlights the feasibility and untapped potential of PPPs to strengthen laboratory systems. This planned and structured approach to improving specimen referral enhanced access to quality laboratory services.

Specimen Referral Network to Rapidly Scale-Up CD4 Testing: The Hub and Spoke Model for Haiti.

OBJECTIVES: Regular and quality CD4 testing is essential to monitor disease progression in people living with HIV. In Haiti, most laboratories have limited infrastructure and financial resources and have relied on manual laboratory techniques. We report the successful implementation of a national specimen referral network to rapidly increase patient coverage with quality CD4 testing while at the same time building infrastructure for referral of additional sample types over time. METHOD: Following a thorough baseline analysis of facilities, expected workload, patient volumes, cost of technology and infrastructure constraints at health institutions providing care to HIV patients, the Haitian National Public Health Laboratory designed and implemented a national specimen referral network. The specimen referral network was scaled up in a step-wise manner from July 2011 to July 2014. RESULTS: Fourteen hubs serving a total of 67 healthcare facilities have been launched; in addition, 10 healthcare facilities operate FACSCount machines, 21 laboratories operate PIMA machines, and 11 healthcare facilities are still using manual CD4 tests. The number of health institutions able to access automated CD4 testing has increased from 27 to 113 (315%). Testing volume increased 76% on average. The number of patients enrolled on ART at the first healthcare facilities to join the network increased 182% within 6 months following linkage to the network. Performance on external quality assessment was acceptable at all 14 hubs. CONCLUSION: A specimen referral network has enabled rapid uptake of quality CD4 testing, and served as a backbone to allow for other future tests to be scaled-up in a similar way.