WHO AMDS Partners and Stakeholders Meeting, GenevaApril 2-3, 2009
Strategies for Strengthening Laboratory Supply Chains
Carmit Keddem, Technical AdvisorUSAID | DELIVER PROJECT
Overview
• Importance of laboratory logistics systems• Assessment of laboratory systems • Design and implementation of laboratory
logistics systems• Standardization of laboratory equipment and
supplies
Importance of Laboratory Logistics Systems• Public health programs depend on laboratory
testing for:• Screening• Diagnosis• Patient management • Disease surveillance
• Without supplies, labs cannot perform tests, compromising provision of vital services
• Many tests require simultaneous availability of multiple commodities
Logistics Cycle
Activities to Strengthen Laboratory Supply Chains
Assessment
QuantificationReview
and update
System Implementation
Use DataFor
Decision-Making
Standardization
Quantification
System Design
Purpose of Laboratory System Assessments
• To understand the current state of laboratory services, capacity, and logistics
• To identify and prioritize supply chain interventions within the context of lab management practices
• To provide baseline for evaluation and ongoing monitoring & evaluation
The Assessment Tool for Laboratory Services (ATLAS):• Comprehensive tool to review
all aspects of lab services:– management practices– testing capabilities– logistics system & commodity availability
• Both diagnostic and M&E tool• Customized for each country• Can be used in combination
with other tools
Country Case Study: Malawi Laboratory Assessment• Quantitative and Qualitative Components
– Central-level policy workshop – 40 total sites visited, representing labs at all levels (2
Central Hospitals, 13 District Hospitals, 25 Health Centers)
• (Illustrative) Findings– No standard equipment list in place – Stock levels of lab products are not monitored
systematically – Service disruptions due to stock out of lab supplies – No logistics data used for quantification and
procurement planning
Purpose of Designing and Implementing a Laboratory Logistics System
To obtain and movelaboratory commodities in a timely fashion to the places where they are needed at a reasonable cost.
Building Blocks in Designing a Laboratory Logistics System• A logistics management
information system• An inventory control system• Distribution systems• Storage mechanisms• Monitoring and supervision
systems• A pipeline diagram of the
supply chain Example: Pipeline Diagram from Zambia
Designing a Laboratory Logistics System for HIV, TB & Malaria Commodities in Ghana
• Participants:– PHRL and lab staff from all levels; program
managers; CMS/RMS; partner and donor organizations
• 1-week participatory design workshop format:– Capacity building (logistics concepts and terms)– Review of assessment results– Participants designed system elements in small
working groups (LMIS, ICS, Storage/Distribution)– Large group discussion to harmonize final system
Design Considerations and RecommendationsProduct Considerations Design Recommendation
Shelf life for laboratory commodities ranges from 3- 24 months
Design length of the pipeline to accommodate shelf-life of most products; Products with less than 3 months shelf-life go through separate supply chain.
Laboratory commodities are bulky If storage is limited, choose ICS requiring lower stock levels; Accommodate additional trucks in distribution schedule.
Exact consumption for liquid/powder reagents difficult to measure and track
Use issues from the store room as a proxy for consumption.
Logistics and LMIS forms relatively new concept to lab personnel
Involve stakeholders from all levels and programs from design; Pilot the design prototype first to build confidence in the system
The Design and Implementation Process and Timeline
…In one country the design and
implementation process is projected
to take 24 months; the process can range from12-24 months, depending on the country context.
PEPFARImplementing Partner
Laboratory Standardization
• Prerequisite for optimizing laboratory supply chains
• Precedes laboratory system design and implementation and quantification
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Opportunities for Standardization
• Greater global attention and funding of laboratory supplies and supply chains strengthening
• Maputo meeting (January 2008) made recommendations on laboratory testing and standardization
• Global consensus and focus on the importance of standardization
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What is Standardization?
• Standardization is the process of setting:- Test menus, - Test techniques, - Laboratory equipment, and - Operating procedures.
…for each type of test at each level of the system
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Practical Example of Standardization
Step 1: Develop a list of test menu by level•HC: HIV Rapid Test, RDT, Pregnancy Test, Hemoglobin, CD4•District : HIV Rapid Test, RDT, Pregnancy Test, Hemoglobin, CD4, Viral Load, AST/ALT
Step 2: Define techniques and equipment for each test; select according to certain criteria
Western District
East District
Northern district
Southern district
Central district
CyflowSL3
Guava
District Hospital
FACS Calibur
Sysmex kx21 Cyflowcounter
FACS Count
Health Center
refer samples to district-level laboratory
Coulter-manual
FACS Count POOCH
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Desired Outcome of Standardization
• To streamline list of tests, techniques and equipment by level
…. and therefore the total number of products required. For example:
• Kenya: 3,000 300• Botswana: 800+ 500
PEPFARImplementing Partner
Country Experiences
• Kenya, Uganda (2004, 2005)• Initial request for logistics system design and
quantification of laboratory supplies• Standardization identified as a
pre-requisite for both activities
• Ghana, Ethiopia (2007)• Standardized equipment in place at
time of logistics system design
• Zambia , Botswana (2007, 2009)• As in Kenya, Uganda, standardization identified
as pre-requisite for logistics system design and quantification
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Steps in Standardization
1. Assess existing test menus, techniques, standard operating procedures and equipment at facilities from all levels
2. Hold consensus building workshop with stakeholders from all levels
3. Update laboratory policy documents with new standards
4. Determine timeframe for reviewing and updating standards
5. Disseminate and implement standards at all facilities and levels
PEPFARImplementing Partner
Benefits of Standardization
• Rational decision making in product selection, forecasting, quantification and procurement
• Manageable supply chain by streamlining the number of laboratory products
• Affordability through economies of scale• Agile supply chain allowing redistribution of
supplies to reduce stock imbalances• Efficiency in training and management of staff• Quality assurance of testing by increasing
reliability and consistency of results
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Challenges in Standardization
• Rapidly changing technology• Involving and reaching consensus among
all stakeholders• Allocating time and resources to implement
transition plan• Changing provider behavior to comply with
new standards• Compliance with existing long term
contracts with suppliers
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Standardization Process in Botswana
Process to Date:Assessment (2007) and Quantification (2008)
Identify need for standardizationStandardization Workshop (2009) precedes
logistics system design process
Next Steps:Committee working to revise current policy on
procurement of standardized equipmentFinalize and get agreement on the list of test
menus, techniques, equipment, and productsFinalize and get approval for implementation
plan and use it to rollout new standards
PEPFARImplementing Partner
Benefits of Standardization in Zambia
• Negotiated maintenance contracts with purchase of reagents
• Decreased procurement costs through economies of scale
• Transferred stock to save $30K in potential losses from expiry
• Developed a priority list of product (185) to manage in the national laboratory logistics system
• Increased availability of standard products from 30% to 98%
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Challenges of Standardization in Kenya
• Significant debate on standardizing hematology machines
• 6 different systems existed at 16 sites, initially no consensus reached
• Unable to quantify and procure reagents and consumables for hematology
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Challenge Approach/ResultNon-standard equipment existing in system
Reagents not provided through the MOH supply chain
Service providers not following standard testing guidelines
National review of laboratory technical SOPs (dissemination pending)
Acceptance of partner donations of non-standard equipment
Parallel supply chains for reagents and consumables for non-standard equipment
Approaches to Address Challenges to Standardization in Zambia
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Key Lessons Learned in Standardization
• Standardization is a process• Requires time and resources
• The standardization process must be collaborative
• Participation of stakeholders from all levels• Standardization is a key first step in
optimizing and strengthening laboratory supply chains
PEPFARImplementing Partner
Thank you!