SATURNO: LA JOYA DEL FIRMAMENTO

Table 28. Baseline and targets for Diagnostic Services11

EXPECTED OUTPUTS / OUTCOMES BASELINE 2011 TARGETS 2015 TARGETS 2018

% Laboratories with at least two trained staff in good laboratory practices within the lab network.

76 100 100

Number of A0 and A1 Lab

Technicians in place in DH and HC

151 291 516

The overall objective for health technologies is to ensure availability of effective, quality, and timely diagnostic support to the management of illnesses and health conditions at all levels in line with internationally accepted norms and standards.

HSSP III will achieve these objectives through the following:

1. Establishment of health technology based on international norms and standards; 2. Ensuring an uninterrupted and timely supply chain of equipment and consumables; 3. Availing qualified and adequate technology personnel;

4. Strengthening diagnostic and research capacity;

5. Establishment and implementation of a national Quality Assurance Program for health technology.

5.4.1 Ensure technology infrastructure according to norms and standards (including ICT)

Over the period of HSSP II, significant progress was made in the area of health technologies. Policy and technical standards were defined for all levels (health post; health centers; district, provincial, and central hospitals) and laboratory routine activities were decentralized to the peripheral level. Each district has two professionals trained and supervised to improve laboratory performance. The National Reference Laboratory, with support from DPs, has established a sound performing laboratory network throughout the country, conducts specialized biomedical testing at the central (referral) level, and provides quality control for all other laboratories. The NRL is in the process of obtaining accreditation, together with the laboratories of the Kigali Teaching Hospital, the Rwanda Military Hospital, and the King Faisal Hospital. The NRL also has a "rapid response team" that supports epidemiologic surveillance.

Despite the successes above, the demand for health technology has overwhelmed the existing health infrastructure. With competing priorities for domestic funding, health technology infrastructure has been largely donor and partner dependent, leaving important mandates and areas unfunded. There is no prescribed and consistent menu of services within the laboratory network. Incomplete information communication technology infrastructure for the NRL compromises the ability to attain accurate laboratory data such as workload, type, and number and cost per laboratory tests. Furthermore, communication of laboratory results encounters unnecessary delays. Absence of relevant logistics and transport interferes with the supervision and mentoring by higher levels and also prevents effective laboratory outreach services.

Work in this area under HSSP III will focus on construction and equipping of a new NRL building, improving space in laboratory networks according to norms and standards, updating the laboratory information system at NRL and district levels, and full accreditation of the NRL to meet international standards. Health technology advances under HSSP III needs to widen in scope to cover latest diagnostic, therapy, and laboratory technology. Dentistry and surgical equipment needs must be addressed to ensure adequate provision of care.

11

Diagnostic services include equipment and consumables of the Medical Laboratory and Radiology (X-Ray, CT- scan, MRI, etc.).

5.4.2 Ensure an uninterrupted and timely supply chain of equipment and consumables

Inadequate and irregular availability of equipment, supplies, and reagents has posed a big challenge to the sustainability of test packages, with interruption in diagnostic services, and often resulting in less cost- effective interventions. Lack of robust inventory systems and weak procurement and supply chain management (PSCM) further aggravates the situation. Investments will be made during HSSP III to assess the medical equipment and diagnostic needs, based on the disease pattern and burden, and to use this to better inform procurement and supply chain management. The needs at each level of health service delivery will be quantified and the capacity to plan and manage equipment, reagents, and supplies, using relevant software, will be strengthened through training in PSCM.

5.4.3 Availability of technology staff (lab and radiology)

A number of challenges remain regarding staff: there are inadequate numbers of qualified personnel and no capacity-building plan for health technology staff at all levels. Consequently, maintenance, supervisory, and mentorship capacity remains weak. Lack of inputs to implement the skills gained after training, lack of motivation, and absence of a career path has led to ―brain drain‖ and exacerbated the situation of inadequate HR. A further challenge is inadequate knowledge and skills on quality system management. The change in technology (manual vs. automated, analogue vs. digital) has increased the need to retrain existing staff.

HSSP III will address capacity-building through training of trainers, training of the relevant cadres, and supervision and mentoring support to laboratory personnel in the laboratory network to improve performance. Qualified staff will be recruited to narrow the HR capacity gaps.

5.4.4 Strengthening diagnostic and research capacity

HSSP II has seen improvements in availability of guiding documents and has enjoyed the support of both the GOR and donors. However, challenges have been encountered in timely and proper diagnosis. Apart from stock-outs of reagents and consumables, the performance of specialized laboratory tests at the central level has been suboptimal, often with lack of appropriate diagnostic equipment, especially for outbreak investigations and testing for drug resistant pathogens. Delays and loss of results due to insufficient information management systems continue to compromise timely and correct treatment and management of illnesses.

Diagnostic capacity

HSSP III will expand specialized testing by procurement and installation of appropriate diagnostic equipment, based on the most recent technology in laboratory and imaging sciences. Staff will be trained to improve lab surveillance and confirmation of priority epidemic diseases, including monitoring of drug resistance pathogens (HIV, TB, and other bacterial infections). Collaboration with external advanced laboratories and with the Food and Water Laboratory at Huye to provide the specific services will be enhanced through entering into a memorandum of understanding with these institutions. A procurement plan for diagnostic equipment, reagents, and supplies will be developed and implemented. Servicing and maintenance of diagnostic equipment and instruments will be contracted to competent private entities. Research capacity

During HSSP II, there was insufficient training on research, and it was not set as a top priority in previous planning. During HSSP III, collaboration between the NRL, research institutions, and training institutions will be enhanced to support training in research methodologies using up-to-date tools. Research results will be published and disseminated to inform policy and improve diagnostics.

5.4.5 National Quality Assurance Program for health technology

Quality is of paramount importance in provision of effective diagnostic services. The challenges that have been faced in ensuring quality have included lack of sufficient facilities for preparation and administration of proficiency panels, inaccurate calibration of equipment, and inadequate instrument servicing and maintenance. Given the importance of maintenance of a quality management system for health technologies, HSSP III will emphasize proper documentation, use of SOPs, and quality control samples,

as well as periodic external quality assessments. Capacity-building of NRL will enable development and implementation of a national Quality Assurance Program for laboratory diagnostics. A system of accreditation of lower laboratories and other diagnostic centers will be established and assessed at regular intervals. Training will be undertaken in quality assurance and biosafety, and a continuous education program will be a requirement for annual assessment of the various technologists and technicians.