REPUBLIC OF SIERRA LEONE
REPUBLIC OF SIERRA LEONE
MINISTRY OF HEALTH AND SANITATION
NATIONAL HEALTH LABORATORY STRATEGIC PLAN
2016 - 2020
DELIVERING QUALITY LABORATORY SERVICES
TABLE OF CONTENT
FOREWORD4
PREFACE5
ACKNOWLEDGEMENTS6
Executive Summary7
ACRONYMS9
SECTION 1: CONTEXT13
CHAPTER 1- Introduction13
CHAPTER 2: SWOT Analysis21
CHAPTER 3: POLICY ENVIRONMENT25
CHAPTER 4: STRATEGIC DIRECTIONS27
SECTION 2: STRATEGIC OBJECTIVES, INTERVENTIONS AND TARGETS30
CHAPTER 1: GOVERNANCE31
CHAPTER 2: HUMAN RESOURCES DEVELOPMENT AND MANAGEMENT35
CHAPTER 3: LABORATORY INFRASTRUCTURE AND EQUIPMENT38
CHAPTER 4: LABORATORY SERVICES & SUPPORT SYSTEMS41
CHAPTER 5: BIORISK MANAGEMENTBIOSAFETY, BIOSECURITY,
BIOBANKING)45
CHAPTER 6: INFORMATION MANAGEMENT SYSTEMS47
CHAPTER 7: EMERGENCY PREPAREDNESS AND RESPONSE49
CHAPTER 8: RESEARCH, DEVELOPMENT AND ETHICS51
CHAPTER 9: PARTNERSHIPS AND LINKAGES53
CHAPTER 10: TOTAL QUALITY MANAGEMENT SYSTEMS (QUALITY
ASSURANCE)56
SECTION 3: IMPLEMENTATION MECHANISMS58
MONITORING AND EVALUATION71
FRAMEWORK FOR THE MONITORING AND EVALUATION PLAN75
FINANCING THE PLAN76
ANNEXES79
ANNEX 1: IMPLEMENTATION FRAME80
Annex 2: Sample Budget Outline for PHU99
ANNEX 3: Minimum standards107
ANNEX 4: Emergency Response Budget Justifications.109
ANNEX 5: TEAM MEMBERS111
List of Tables and Figures
Table 1: Distribution of health facilities by district July
201518
Table 2: Recommended laboratory staffing..19
Table 3: Strategic Framework .58
Table 4: Strategic time frame .61
Table 5 Indicators and Monitoring Tools ..73
Table 6: Estimated major costs (millions of Leones) to be worked
out for 5 years period75
Table 7 Estimated cost for laboratory emergency response per
district (US Dollars)..76
Figure 1: Lab tiers.19.
Figure 2: Strategic plan process flow...27
Figure 3: Strategic inputs...31
Figure 4: Critical path of development.49
Figure 5: Actions to address all levels of laboratory
network.52
Figure 6:Network of national public health reference laboratory
system55
FOREWORD
The Ministry of Health and Sanitation (MOHS) is moving forward
with its vision to improve services and instituting systems to
deliver and increase access to high quality health care to reduce
national mortality. The ministrys current focus is to put these
systems and supporting structures to meet the demand and supply in
working towards reduced mortality.
The laboratory network system in Sierra Leone now has an
approved policy and this document forms the platform for the
development of the national laboratory strategic plan. The plan
contains the strategic activities that ensure quality and equitable
laboratory services to support disease diagnosis, treatment
monitoring, disease prevention and control, and laboratory support
of national surveillance and rapid response to disease outbreaks.
Activities have been phased over a five year period taking
cognizance of the National Health Sector priority program such as
the Free Health Care Initiative and prevention of Communicable and
Non-communicable infections.
The document was prepared by an expanded National Laboratory
Technical Working Group, constituting of selected laboratory
specialists and related health sector personnel including senior
staff members from Blood Transfusion program, Disease Prevention
Unit, health information, finance, statistics and surveillance
units.
The final draft was validated by stakeholders, which included
all related health units at central and local government health
leads and key partners. The validated draft was reviewed and edited
by the Laboratory and Surveillance and Epidemiology Technical
working group as well as development partners prior to submission,
review, and approval by the Ministry of Health and Sanitation.
On behalf of my ministry, I wish to extend appreciation for the
support of the Association of Public Health Laboratories (APHL),
Sierra Leone for providing technical and financial support from
Centers for Disease Control (CDC), Atlanta. I also commend the
commitment of the National Technical Working group and the
leadership of the Laboratory directorate.
My ministry looks forward to strengthening quality health care
delivery and accessible health care systems that will contribute to
improving the health and well-being of the people of Sierra
Leone.
Dr. Abubakarr Fofanah
Honorable Minister
Ministry of Health and Sanitation, Sierra Leone
PREFACE
The National Health Laboratory Services plays a pivotal role in
the response to an effective health care delivery.
The laboratory services serves as a key component to achieving
both quality clinical care and meaningful public health
interventions.
The Ministry of Health and Sanitation (MOHS) has generated its
2015-2020 directional maps through the national health sector
strategic plan (NHSSP) translated in the Basic Package of Essential
Health Services (BPEHS) to drive improved access to affordable
quality laboratory services and ultimately better health total care
delivery.
Recognising the impact of outbreaks (Cholera-2012 and Ebola
2014-2015) on the implementation of the 2010-2015, this plan
expanded the national priority themes from 7 to 10 each aligned by
an integrated health sector team, to the national indices towards
equitable and sustainable health sector performance
The Laboratory services have gained its recognition as critical
to the advancement of national and global health security. In view
of this, the interventions outlined in this plan puts premium on
the minimum standards package of operations such as adequate water
supply and energy , appropriate infrastructure, skilled human
resource and infections control and outbreak preparedness to ensure
functionality of laboratory services.
The MOHS hope that this plan will serve as the directory for
laboratory support and implementation by stakeholders and partners
coordinated by the Directorate of Hospital and Laboratory Services
towards quality and sustainable laboratory services.
I commend the leadership of the directorate of hospital and
laboratory services and appreciate the collective efforts of all
directorates in the development of this road map.
Dr. Brima Kargbo
Chief Medical Officer
Ministry of Health and Sanitation
ACKNOWLEDGEMENTS
On behalf of the Ministry of Health and Sanitation, I wish to
acknowledge the immense contributions of the national core team and
National Laboratory Technical working Group (LTWG) for a dedicated
work done in generating this document amidst multiple tasks. Their
efforts in reviewing and analysing the many documents amidst a
myriad of activities that led them to work out of call of duty is
highly appreciated.
Key to note are the institution and key partners support to
formulate the supporting tools used such as the comprehensive
laboratory service assessment by DFID through Options Consultancy;
Public Health Laboratory Assessment by US-CDC, China-CDC, WHO, and
APHL; IDSR assessments by the Disease Prevention Directorate
Surveillance officers; and the untiring efforts by the Laboratory
Services and Surveillance managers and team on site verifications
throughout the processes.
Our invaluable thanks to the technical support lead provided by
CDC through APHL Senior Laboratory Specialists, who played an
important background role to define processes and direct collations
as per MOHS focus for a coordinated output.
I appreciate the efforts of the national, regional and districts
health teams and the Public Health Rapid Response Team who
participated in the validation of the document. A special thanks
goes to key partners WHO, US CDC, Options Consultancy, e-Health
Africa, Public health England and China-CDC, who contributed to the
validation of the implementation frame. I do hope partners and
stake holders will use this document to guide objectives as we
drive towards sustainable and quality services.
Dr Victor Matt-Lebby
Director Hospital and Laboratory Services
Ministry of Health and Sanitation
Executive Summary
Laboratory support has a pivotal role in diagnosis and patient
management, disease surveillance and outbreak investigation. At
present, the laboratories of Sierra Leone are not able to provide
adequate support to the clinical care services to meet the
government defined basic health package.
The Ministry of Health and Sanitation subscribe to International
Charters such as the GHSA, IHR and ECOWAS regulations and seek To
develop, strengthen and maintain capacities of laboratories to
detect, assess, notify, and report events. This is in line with the
requirement of the ASLM declaration done in Freetown recently
regarding the need to strengthen laboratory services and to:
Develop national laboratory policies within the National Health
Development Plan that will guide the implementation of a national
integrated laboratory strategic plan
Develop and implement a 5-year national laboratory strategic
plan that addresses quality diagnosis, monitoring and surveillance
of diseases of public health importance at all levels of the tiered
laboratory system.
The above items require Sierra Leone to establish reliable, high
quality laboratory services that can provide trusted information to
guide decision making for quality health care.
In order to meet these requirements, action is needed in 10 key
fields:
1. Governance (Coordination, legal framework and ethics).
2. Human Resource planning, development and management.
3. Infrastructure and Equipment.
4. Laboratory Services & Support Systems (Logistics &
Management Systems).
5. Bio risk management (Health and Safety, Bio-safety,
Bio-security and Bio-banking.
6. Information Management Systems.
7. Emergency Preparedness and Response.
8. Research, Development and Ethics.
9. Partnership & Linkages
10. Total Quality Management Systems.
This document sets out the policies and actions required to meet
these needs in three sections covering the context, the strategic
objectives, interventions and targets and the implementation
mechanisms.
FOCUS: is to meet the National Basic Package of Essential health
services toward increased access to quality service and ultimately
improved health systems within the next 5 years.
1. Capacitating all 14 district laboratories to perform all test
menus of the BPEHS.
2. Strengthening all 5 centres of excellence facility
laboratories as reference labs supporting district and PHU.
3. Coordinating partners supporting laboratories services as per
national priority with geographic equity to produce tangible
outcomes.
4. Instituting Public Health Laboratory network supporting
IDSR.
5. Establishment of integrated outbreak response.
6. Establish professional regulatory body to structure and
monitor laboratory staff.
7. Strengthening commodity security.
8. Support researches of national interest with defined
outcomes.
An estimated costing plan was generated based on the national
2010-2015 investment plan updated within current financial context.
Given that this is a living document, it is hoped that flexibility
is employed to implement to meet the priorities with sustainable
input.
An effective M and E plan to monitor laboratory service delivery
using quality indicator to monitor the 10 quality elements.
ACRONYMS
AFBAcid Fast Bacilli
AFR/RC WHO/AFRO Regional Committee
AIDSAcquired Immuno-Deficiency Syndrome
APHLAssociation of Public Health Laboratories
ASLMAfrica Society for Laboratory Medicine
BPEHSBasic Package of Essential Health Services
CD4Cluster of Differentiation
CDCCentre for Disease Control and Prevention
CHCCommunity Health Centre
COMAHSCollege of Medicine and Allied Health Sciences
CPHRLCentral Public Health Reference Laboratory
DHLSDirectorate of Hospitals and Laboratory Services
DHSS Demographic Health Systems Survey
DOTDirectly observed treatment
DSTDrug Susceptibility Testing
DPIDirectorate of Planning and Information
DPCDisease Prevention Control
EIDEarly Infant Diagnosis
ELISAEnzyme Linked Immunosorbent Assay
EPKEastern Polytechnic, Kenema
EQAExternal Quality Assurance
EQASExternal Quality Assessment Scheme
FBCFourah Bay College
FBOFaith Based Organisation
FHCIFree Health Care Initiative
GFATMGlobal Fund for AIDS, Tuberculosis and Malaria
GHSAGlobal Health Security Agenda
GLRAGerman Leprosy and TB Relief Association
HAPSAT HIV/AIDS Program Sustainability Analysis Tool
HCT HIV Counseling and Testing
HPAHealth Protection Agency (UK)
HIVHuman Immuno-deficiency Virus
HPAHealth Protection Agency of the United Kingdom
HRHuman Resources
IATAInternational Air Transport Association
IDSRIntegrated Disease Surveillance and Response
IHRInternational Health Regulations
IQCInternal Quality Control
LFTLiver Function Tests
LISLaboratory information system
LIMSLaboratory Information Management Systems
LTWGLaboratory Technical Working Group
LSETWGLaboratory, Surveillance and Epidemiology Technical
Working group
M&EMonitoring and Evaluation
MDCSLMedical and Dental Council of Sierra Leone
MDGMillennium Development Goals
MMCET Milton Margai College of Education and Technology
MOHSMinistry of Health and Sanitation
MScMaster of Science
NEQASNational External Quality Assessment Scheme
NGONon-Governmental Organisation
NHSSPNational Health Sector Strategic Plan
NLRCNational Laboratory Regulatory Council
NLSNational Laboratory Services
NPHLSNational Public Health Laboratories Systems
NPHRLNetwork Public Health Reference Laboratories
NQAPNational Quality Assurance Programme
NTBRLNational TB Reference Laboratory
NTDNeglected Tropical Diseases
PCMH Princess Christian Maternity Hospital (Freetown)
PEPFAR Presidents Emergency Plan for AIDS Relief
PHUPeripheral Health -Unit
PMTCTPrevention of Mother to Child Transmission
PPEPersonal Protective Equipment
PRSPPoverty Reduction Strategy Paper
PHLRTPublic Health Laboratory Response Team
QAQuality Assurance
QCQuality Control
RRTRapid Response Team
TQMSTotal Quality Management System
RCHReproductive and Child Health
RHReproductive Health
RT-PCR Reverse Transcriptase Polymerase Chain Reaction
SOPStandard Operating Procedure
TBTuberculosis
TORTerms of Reference
U/EUrea/Electrolytes
USAIDUnited States Agency for International Development
WBCWhite Blood Cell Count
WHOWorld Health Organisation
SECTION 1: CONTEXTCHAPTER 1- Introduction
The first National Laboratory Strategic Plan (2011-2015) was
generated to establish a framework for laboratory operations in
Sierra Leone and to provide the much-needed direction in the areas
of governance, human resource, infrastructure and equipment, stocks
management, health and safety and quality systems. This was to
support the governments drive to provide a basic essential package
of health services, mainly focused on primary and secondary
care.
The significance of a functional laboratory system and its
impact on the treatment outcomes of patients and quality of public
health services cannot be over-emphasised. Laboratory support in
diagnosis and patient management, disease surveillance, outbreak
investigation and response is pivotal, with an increasing demand
for providing scientific evidence as part of the total quality
management cycle. Evidence based decision making in the diagnosis
and management of illnesses is a key component of quality health
care however, laboratories have not grown in tandem with health
care delivery services to enable them adequately meet this
demand.
The 2010-2015 plan was to address all core areas of the
laboratory system, with specific emphasis on six
priorities at the time that needed urgent attention, which
were:
1. Weak coordination and regulation of laboratory practice at
all levels of the laboratory system (Governance).
2. Infrastructural inadequacies (Infrastructure and
equipment).
3. Supply bottle-necks leading to interruption of services
(Reagents and supplies).
4. Bio-risk management (Bio-safety and Bio-security and
emergency response).
5. Inadequate numbers of skilled workers (Human Resource).
6. Inequities in laboratory service delivery.
7. Poor quality systems limiting access to quality assured
laboratory services (Quality systems).
There have been achievements in some of these areas, such as,
higher level of training of laboratory staff (both locally and
internationally), establishment of a public health hub, the Central
Public Health Reference Laboratory, which serves for some epidemic
prone diseases such as Measles, Enteric bacteria diseases and Rota
Viruses; Establishment of molecular unit. There are still areas in
the plans which were not addressed due to the challenges
experienced in the implementation, one of which was the unexpected
and unprecedented Cholera Outbreak in 2012 and Ebola outbreak in
2014-2015, which also exposed the lack of outbreak and emergency
preparedness within the health system.
In spite of the above achievements, Sierra Leone still continues
to experience problems with the management and delivery of quality
assured laboratory services to support national treatment and
prevention programmes, primarily due to weak leadership at all
levels of the tiered laboratory system. Other reasons for this are
the lack of participation of laboratory professionals at policy and
decision-making levels, inadequate number of qualified personnel,
scant and unstructured investment in laboratories and weak quality
control systems.
Background
The 2010 -2015 strategic plan interventions was interrupted with
two major outbreaks thus the total implementation timeframe was 3
years instead of 5 years. The plan used as part of its building
block the revised International Health Regulations (IHR 2005) which
requires countries To develop, strengthen and maintain capacities
of laboratories to detect, assess, notify, and report events. In
addition to the IHR requirement, WHO/AFRO has urged member
countries to commit to strengthening laboratory services, in line
with the following declarations and resolutions:
The Maputo Declaration on strengthening of laboratory systems:
Maputo January 2008.
Resolution AFR/RC58/R2: Strengthening public health laboratories
in the WHO African region: Yaound, Cameroon September 2008.
5th Meeting of the Regional HIV/AIDS Public Health Laboratory
Network, Dakar, Senegal, September 2008.
Resolution AFR/RC59/WP/3: Policy orientations on the
establishment of centres of excellence for Disease Surveillance,
Public Health laboratories, Food and Medicines regulation. Kigali,
Rwanda September 2009.
Resolution AFR/RC59/R2 Drug Resistance related to AIDS,
Tuberculosis and Malaria: Issues, Challenges and the Way Forward.
Kigali, Rwanda September 2009.
This 2016-2020 plan is developed with global health security in
view and thus add to the above; new concepts and strategies that
recognises the pivotal role of laboratory actions in disease
detection, treatment monitoring, and prevention control for a
sustainable health through:
Global Health Security Agenda (GHSA) 2015 : Promote an
integrated IHR accelerated plan towards world safety against
infectious disease threat through innovative, multi-sectorial,
local and international partnership response.
African Society for Laboratory Medicine (ASLM) Freetown
Declaration 2015 ASLM: Recognising the critical role of public
health laboratory systems in supporting GHSA by requesting
countries to establishfunctional public health laboratory networks
for early detection and responses to emerging disease threats.
There is now an increased emphasis in strengthening laboratory
systems including leadership and management structures. Over the
years, the Sierra Leone Ministry of Health and Sanitation (MOHS)
has gradually restructured, with the aim of improving its capacity
to respond in an adequate and timely manner to the health care
needs of the country within a resource constrained environment.
This is in accordance with the Millennium Development Goals (MDG),
World Health Organisation (WHO) and Global Health Initiative (GHI)
support for governments to show leadership and to commit to
strengthening health systems, including laboratory services.
As part of the efforts of the government, several documents and
strategic guidelines were developed, including the Health Sector
COMPACT Guide which provided the coordination platform of partners
in the implementation of National Health Sector Strategic Plan
(NHSSP 2010-2015) and more recently, the Health Sector Recovery
plan 2015-2020, to address the challenging issues especially during
the post-Ebola period.
It was therefore necessary to review the first National Health
Laboratory Strategic Plan, to align it with these documents,
revised and new, such as the revised Basic Essential Package of
Health Services 2015, the Sierra Leone Health Sector Recovery Plan
2015-2020, of the Ministry of Health and Sanitation and the
Emergency Response Manual 2015.
National Laboratory Services Directorate of Hospital and
Laboratory Services
The National Laboratory Services (NLS) program operates under
the Directorate of Hospitals and Laboratory Services (DHLS) of the
Ministry of Health and Sanitation (MOHS) that provides overarching
policy leadership. This includes setting national norms and
standards, building capacity, and monitoring of service
quality.
The NLS systems comprises of clinical-community and hospital
diagnostics laboratories; Regional Reference laboratories, and
Public Health Laboratories. Given the crosscutting support of
laboratory services, the DHLS work closely with Directorate of
Disease Prevention and Control surveillance program and Health
Systems Strengthening (HSS) unit.
The DHLS at central level is inter-connected with the
semi-autonomous District Health Management Team (DHMT) that
provides the localised leadership and implementations through the
District Medical Officer under the District Council.
The DHLS is led by a Director, National Manager, a Deputy
Manager that doubles as the In-Charge of the Central Public Health
Reference Laboratories (CPHRL) and Laboratory Technical Working
Group comprising of a team of Laboratory Technical and Systems
experts.
Basic Packages of Essential Health Services (BPEHS) and National
Health Laboratory Systems
The MOHS has as its priority five themes that will build a
resilient health system. The themes listed below take into
consideration recovery efforts from the recent outbreak and
services that are realistic, achievable and thus sustainable
through the leadership of the government:
1. Patient and health workers biosafety and biosecurity.
2. Human Resource strengthening.
3. Essential Health Services.
4. Community ownership.
5. Information and surveillance.
The BPEHS (2015-2020) serves as the platform for delivering
vision of MOHS outlined in the National Health Sector Strategic
Plan (NHSSP) - 2015-2020 for quality health care. The function of
the package is to direct interventions and monitor progress for the
effective delivery of the themes.
The BPEHS defines the level of services at each strata of care
inclusive of the minimum systems standards such as infrastructures,
HR, Biosafety and support services.
Recognizing the critical role of laboratory services to support
comprehensive health care delivery; the BPEHs 2015-2020 is extended
to include public health laboratory services in line with GHSA to
strengthen prompt diagnosis, outbreak detection and action to
prevent and contain biological threats.
Levels of Laboratory services Tier Systems
There are 4 tiers in the network of laboratories with defined
functions and test menu as per BPEHs criteria based on population
needs, geopolitical zones and systems practicality as follows:
Primary Level:
Laboratory service at chiefdom level is mainly provided at the
Community Health Centre (CHC), which is one of the three primary
levels of the Peripheral Health Units (PHUs). The test menu is
limited to microscopic detection of parasites, basic clinical
chemistry and serology using point of care and rapid testing
device.
Secondary Level:
Laboratory services at district hospitals of over 100-bed
capacity provided extensive range of tests including blood service
screening for safe blood transfusion. The service is more
comprehensive to support secondary medical care with a higher staff
caliber and also support primary level diagnosis.
Tertiary Level
Laboratory services at Regional hospitals at district
headquarter towns (Kenema for the East, Bo for the South, and
Makeni for the North). This level is an expansion of district
hospital services with additional systems capacity such as graduate
level staff, infrastructures and utilities to support complex
equipment and can handle complex infectious diseases and emergency
services.
Public Health Laboratory Services
The public health laboratories serve at national and regional
level to provide overarching support and instituting quality
systems. Key functions include establishing of norms and standards,
emergency and outbreak response, high-end technology testing that
are not cost effective at other levels, targeted training to
improve and strengthen human resource; surveillance and operational
research. Following the recent Ebola outbreak, the MOHS has
established three Regional Hubs as centers for excellence at
regional hospitals. These systems will form part of the Network of
Public health Laboratories (NPHL) linked to the central hub at the
Central Public Health Reference Laboratory, the Jui P3 Lab and TB
Reference Laboratories.
Laboratory Mapping:
Table 1: Distribution of Health Facilities by District, July
2015
In accordance with the BPEH, functional laboratory services are
available in 257 out of 1208 health facilities. These are 233 PHUs
and 24 Government hospitals. The Government laboratories include
district (15) and Regional (5); Forces (2) and Public health
laboratories (3) in various combinations with some sites active in
2 capacities. The community level diagnosis made up of MCHP and CHP
accounts for 632 and 319 facilities respectively with the capacity
of performing community Rapid Diagnostic Tests for pregnancy,
malaria and STI screening for antenatal care.
Following various analyses of field assessments, there are
currently 179 functional laboratories with staff complements of the
MOHS based on the minimum service requirement of the BPEHS. Most of
the primary laboratories are operating as an offshoot of DOT
centers with the capacity of testing the three Global fund
supported diseases: Malaria, TB and HIV.
Figure 1: Laboratory tiers
Human Resource
Laboratory staffing is one of the most acute Human Resource
shortages in the country. The staffing profile per facility as
defined by the BEHP (not inclusive of 24 hour service at district
level) is as follows:
Table 2: Recommended laboratory staffing
STAFF LEVEL
PHU
DISTRICT
REGIONAL
PUBLIC HEALTH LABORATORY INCLUDING SURVEILLANCE RESPONSE,
SENIOR LAB SPECIALIST
5
LABORATORY SPECIALIST
5
5
LABORATORY SCIENTIFIC OFFICER
1
5
5
LABORATORY TECHNICIAN
1
3
5
5
LABORATORY ASSISTANT
1
4
5
5
HOUSEKEEPING STAFF
5
5
Source: BPEHS 2016
Based on the BPEH requirement and the number of functional
laboratories at all level, there should be 329 Laboratory
Assistants, 275 Laboratory Technicians and 14 graduate laboratory
scientific officers. Currently only less than 30% of the skilled
staffing capacity is met.
The 2015 survey showed 208 junior level cadre of laboratory
personnel in all laboratories in the country including private and
Faith- Based and Non-Governmental Organizations. Due to shortage,
the laboratory services inherited 151 persons without formal
training; working as laboratory assistants.
There are 8 mid-level scientific officers with science degree
qualification but without specialized laboratory medicine
curriculum training. Recently added to the pool; are 12 of 24
trained graduates bonded to the MOHS to support laboratory
strengthening including outbreak and emergency response. Medical
graduates are also been encouraged and supported in the field of
laboratory medicine specialization.
In terms of laboratory specialists, all disciplines
(Haematologist, Clinical Chemistry, Parasitologist, Virologist,
Microbiologist) have at least one senior scientist but most of them
are close to retirement.
Justification of a revised plan
The laboratory services form a major component of the health
systems pillar which has over the years operated with the national
laboratory strategic plan (2011-2015) to assist in implementing the
NHSSP. This plan provided guidance to all stakeholders for the
efficient operations of the public laboratories nationwide.
The laboratory provides direct cross-crossing support to many
programmes in the ministry that contribute to the attainment of
Millennium Development Goals. Data generated from laboratory
analyses contribute to programme management and decision making.
However, programmes have in the past produced individual laboratory
plans addressing their specific needs without regarding the entire
system, leading to duplication and sometimes skewed service
delivery. The first edition of the National Health Laboratory
Strategic Plan was created in 2010 to last for five years.
The 2010-2015 National Health Laboratory Strategic Plan
identified that laboratories in Sierra Leone were not able to
provide adequate support to the clinical care services and as a
result, laboratory results are not trusted and laboratory
diagnostic services are underutilised.
The implementation of the strategic plan was faced with funding
constraints due to competing demand on government. However the
following activities were achieved:
Activating the national laboratory, surveillance and
epidemiology technical working group which worked with partners to
develop the listed key tools :
National Laboratory investment plan.
Integrated Disease surveillance Strategic Plan review.
Health and Safety policy draft.
National Norms Standards for the 4 tier level laboratories.
Development of Laboratory Basic package for essential
health.
Generating the national health systems strengthening laboratory
plan.
Human Resource development :
Activation of B.Sc. Honors in Laboratory Medicine.
Increase the pool of post graduate laboratory scientists.
Support the establishment of short course FELTP program.
Support intensive short courses.
Public Health Response
Activation of a Central Public Health Reference Laboratory
Hub.
Establish diagnosis of epidemic prone diseases- Measles; yellow
fever; Influenza, Cholera.
Establishment of Molecular testing for Early Infant
diagnosis.
Support the national testing for the Demographic Health Survey
DHSS 2012 (16000) Sample.
Quality Assurance:
Establishment of National Quality Officers
Introduction to accreditations using the SLMTA process and
SLIPTA tool.
Establish national HIV EQA to 35 sites.
Laboratory Services
Increased functioning laboratories,
Increased test menu.
However key thematic areas such as regulatory, supplies and
logistics, infrastructures activities were not undertaken. These
limitations together with the burden of infectious epidemic prone
diseases immensely weakened the laboratory services. The Government
has therefore prioritised the need to improve laboratories taking
into consideration new and re-emerging challenges posed by our
National health system and also align with the IDSR.
CHAPTER 2: SWOT Analysis
The Strategic plan of 2010 - 2015 was to articulate the National
Laboratory policy with a focus to improve health care delivery and
also monitor quality implementation towards an interrupted service
delivery especially with the novel Free Health Care Initiate
(FHCI).
In 2010-2015, an Environmental SWOT analysis to assess
laboratory situation was based on field experiences and
consultative meetings with all district lead clinicians, district
laboratory supervisors, laboratory related programs such as TB,
Malaria and HIV; Forces, private and faith based organization.
Given the weak laboratory response as per health indices,
especially the limitation to meet the needs of the recent
outbreaks, the MOHS in collaboration with partners has conducted a
series of field assessments that inform the development of the
NHSSP, National Health Recovery Plan, BPEHS and the recent Health
Systems Strengthening plan. A more recent assessment with specific
focus on laboratory systems are:
A joint partner health systems assessment conducted in 2014,
revealed that only 5% of the NHSSP target, was implemented.
Post Ebola laboratory assessment was the most comprehensive as
it addressed all laboratory systems indicators - July 2015
Disease Surveillance Laboratory Inventory of stool analysis for
polio containment program November 2015.
Public health laboratories quality audit towards transition and
recovery plan February and May 2015
Western Area Laboratories site assessment (Horizontal Audit)-
2016
The focus of these assessments was to identify gaps, challenges
and best practices to serve as the platform for the development of
an integrated National Laboratory Strategic Plan for effective and
sustainable service. The elements audited as aligned in the
SLMTA/SLIPTA quality indicators systems management are as
follows:
Laboratory Profile.
1. Human Resource.
2. Infrastructure.
3. Transport and Referral.
4. Management of Consumables and Stock.
5. Maintenance of Equipment.
6. Testing Performance.
7. Specimen Management.
8. Bio-safety.
9. Public Health Functions.
10. Organization and Management.
11. Data Management.
12. Supplies of Consumables & Equipment.
13. Basic Testing Capability5
Report
Strengths
The availability of a National Health Policy 2009, National
Laboratory Policy 2010 and sound National Laboratory Strategic Plan
(2011-2015) which provide a framework for effective
implementation.
The availability of public and private laboratory structures at
district level including the majority of Community Health Centres
providing laboratory services nationwide.
Diagnostic testing services available across the country.
Basic laboratory services closer to communities through the
Global Fund and other supported programs of Malaria, TB and
HIV.
There is the existence of a management structure for hospital
and laboratory services by the Directorate of Hospitals and
Laboratory Services, under the Ministry of Health Services and
Sanitation (MOHS).
The availability of a Laboratory Service Manager and a
functional Laboratory Technical Working Group (LTWG) provides
Laboratory technical assistance and advice.
Institutions are in place that provides basic laboratory
education the existence of the B.Sc. honors medical laboratory
course.
Existing laboratory policy documents recognize the need to
establish efficient LIS.
Other Ministries and programmes require laboratory support and
can be expected to contribute to LIS strengthening.
Weaknesses
Poor human resource system for laboratory personnel.
Poor remuneration policy and working environment.
Lack of succession policy.
Inadequate funding to support implementation of policy and
strategic plan.
Acute shortage of qualified laboratory personnel including
laboratory scientists and technicians.
Lack of scheme of service for laboratory personnel which does
not reflect educational level and skills.
No system for Continuing Education of laboratory personnel.
Poor laboratory infrastructure, power and water supplies which
often leads to poor infection prevention practices, organization
and service delivery.
Poor waste disposal systems, which includes lack of incineration
equipment and absence of proper drainage for wastewater.
Weak laboratory registration and licensing system which includes
a regulatory body, service and equipment standards and SOPs.
Weak laboratories services to enable effective management of
outbreak and other diseases.
Partial implementation of laboratory services as per Basic
Package of Essential Health Services. Mostly seen is TB, Malaria
and HIV (Global Fund Supported Programmes).
Weak quality monitoring systems and inadequate supportive
supervision.
Limited Assurance Program.
Weak transport and referral of specimen.
Weak supply chain management of reagents and equipment.
Opportunities
The development of the scheme of service for laboratory
personnel.
Directorate of Training collaborating with the Tertiary
institution for Laboratory Medicine courses.
Upgrading and restructuring of existing training institutions to
produce more and better skilled laboratory graduates.
Existing procurement systems at the NPPU in place.
Graduates from affiliated sciences, such as Biology or Chemistry
who, if given additional opportunities for professional
development, could be trained to become laboratory staff.
Health systems strengthening through the national resilient plan
post Ebola which includes laboratory support.
Existence of the Laboratory technical working group.
Existence of the National Laboratory Policy.
Increased international technical and financial support for Post
Ebola Recovery and HIS.
Increased International focus on HIS and interoperability of HIS
systems.
Threats
Insufficient allocation of resources to facilitate a functional
laboratory system.
Internal and external brain drain.
Donor dependency and foreseen donor fatigue.
Uncoordinated partner donor support.
Laboratory specialist professionals almost at retirement
age.
Laboratory decentralization.
Lack of National Laboratory Professional Act.
Emergency Preparedness Laboratory Audit
Despite recurring disease outbreaks, the laboratory service has
not been able to fully support disease outbreak detection. For both
Cholera and Ebola outbreaks, laboratory service has been a
secondary service rather than be part of the primary pillar from
notification through investigations to response and control.
Recognising the acute limitations, the MOHS and key partners has
led a series of consultations and site visits to formulate National
Public Health Laboratory (PHL) systems as part of a National public
health institute. The recent Ebola outbreak has seen international
partners donating high-end technology laboratories and also
providing technical support to strengthen the network of PHL. Using
the IDSR approach the MOHS has instituted an integrated approach by
tailoring the response team to include laboratory as part of the
core team members. The report of an audit based on site visits and
consultation as below:
Strengths
Laboratory Response Manual
National Rapid Response Manual aligned to IDSR and GHSA
Training tools generated
Laboratory Response team in training.
Weakness
Coordination
Lack of clear or transparent objectives
Human resource limitation: no clear training plans for national
staff
Funding
Opportunities
GHSA laboratories prioritization
Donor commitment
Donated laboratories
University training course
Threats
Limited Government funding allocation
Donor dependency
CHAPTER 3: POLICY ENVIRONMENT
The 2010-2015 Laboratory Strategic plan translated 2010 National
laboratory policy under the umbrella 2009 Health Sector Policy.
This plan (2016-2020) is generated following review of the past
plan within the same policy environment but with the addition of
key strategic document to support a resilient health sector
delivery. However this plan has the opportunity of a clearer
defined NHSSP goal and performance markers for effective
monitoring.
NHSSP Performance Markers
Access
Quality
Equity
Efficiency
Recognizing the role of laboratory services within the national
health and social security network, the MOHS has prioritized
laboratory services as key input in the health sector performance
index towards the Presidential Agenda for Prosperity. This
all-encompassing framework includes the implementation of the NHSSP
2015-2020 through the BPEHS (2015-2020) and response to emergency
and outbreak whilst remaining compliant to international charters
such as IHR, GHSA and ECOWAS-WAHO.
This plan applies inter-program policies and strategic plan
towards IDSR as follows:
Agenda for Prosperity 2013-2015
To strengthening of health program through introducing
innovative strategies, new policies that will improve health
outcome for Sierra Leoneans
National health and Safety Policy and Manual
National TB program
TB diagnosis and treatment integrated guidelines
National AIDS Control Program
HIV Strategic Plan 2015-2020
HIV Viral Load Implementation plan
National Malaria Control Program
National Malaria Strategic Plan
National Malaria Quality Assurance Strategic Plan
IDSR:
National Emergency and Outbreak Manual
Polio Containment Protocol (2015)
REVIEW PROCESS
The review and development of the 2016-2020 strategic plan was
done by a core team under the leadership of the Directorate of
Hospital and Laboratory Services in collaboration with the
Directorate of Disease Prevention and Control, Directorate of
Health Systems Strengthening, Planning and Research and Directorate
of Training and National Laboratory, Surveillance and Epidemiology
Technical Working group. The figure below outlines the process
stage approved by the team.
Figure 2: Strategic plan process flow
National Priority Themes- 2016-2020:
The 2010 -2015 NLSP identified seven priority themes and was
expanded to 10 themes in the 2016-2020 plan as the focus moves to
tangible indicators in order to respond to national health
needs.
1. Governance (Coordination, legal framework and ethics).
2. Human Resource planning, development and management.
3. Infrastructure and Equipment.
4. Laboratory Services & Support Systems (Logistics &
Management Systems).
5. Bio risk management (Health and Safety, Bio-safety,
Bio-security and Bio-banking.
6. Information Management Systems.
7. Emergency Preparedness and Response.
8. Research, Development and Ethics.
9. Partnership &Linkages Total Quality Management
Systems.
10. Total Quality Management System (Quality Assurance).
CHAPTER 4: STRATEGIC DIRECTIONS
There are key strategic imperatives driving this plan;
LEADERSHIP- national direction of key roles and
responsibilities
HEALTH FINANCE Coordinated; focused, accountability and
transparency
OPERATIONAL show plan activity and related expenditure and
status of annual implementation.
MONITORING high level monitoring grid for equitable support
INTEGRATION Global health one health- Human and animal health
linkage
Vision, Mission and Core Values (derived from the National
Laboratory Policy and NHSSP 2015-2020)
Vision
To provide Sierra Leone with a quality and appropriate
laboratory service that is accessible and affordable to all using a
systems approach.
Mission
To establish an integrated functional laboratory system that
will provide quality service delivery and support accurate
diagnoses, treatment, prevention, surveillance, research and
forensic services.
1. Equity: Laboratory resources and services are distributed
equitably throughout the country.
2. Accessibility: Services are affordable and within reach.
3. Relevance: Laboratory services are apt for the purpose and
address the needs of the community.
4. Partnership: Promote teamwork and team spirit among all
laboratory personnel, and networking and collaboration with
stakeholders.
5. Confidentiality: Promote professionalism and ethical practice
among all staff and their relationships with patients.
6. Timeliness: Ensure laboratory results reach the patient on
time and contribute to appropriate patient management.
7. Customer focus: Always bear in mind who we are serving. The
customer may be the community, patient, clinician, individual or
the public good.
8. Integration: Promote team spirit and integration of service
delivery among all laboratory personnel and also within and between
programmes.
Sub Mission/Core Values
To establish an integrated functional laboratory system at each
level of care based on the Basic Package of Essential Services.
To upgrade the PHL, CRL and have a functional laboratory network
to enhance service delivery and respond to emerging public health
concerns and emergencies.
To support surveillance and research to inform policies and
actions.
To build capacity of Human resource laboratory needs of the
country using a systems approach.
Core Functions
This five-year strategic plan projects that the laboratory
system will oversee and implement the core functions outlined
below, with the expansion of regional reference laboratories linked
to public health laboratories to form the network of clinical and
public health Laboratory. The core functions will provide a basis
for the assessment of laboratory performance against defined
national norms and standards as set in the BPEHS and capability to
respond to outbreaks in the following areas:
Clinical Diagnosis:
More emphasis on clinical diagnostics to supplement quality of
care from at all levels. The clinical services will be offered
through the network of clinical facilities (PHU, districts and
hospitals) throughout the country.
Disease Prevention and Control
In response to the revised IHR (2005) requirements and in
contributing to disease prevention programmes, the approach will be
a combination of community and health facility laboratory -based
surveillance linking to public health laboratories for timely
microbial identification and confirmation to support
prevention.
Surveillance
With the Central Public Health Laboratory as the hub, the NPHRLS
will be linked to the national programmes and national surveillance
activities of the DPC and DPI units to ensure national capacity to
detect at least 10 of the priority epidemic prone diseases.
Integrated Laboratory Data Management
The NPHRL Systems network will serve as the national focal point
for capturing the laboratory data and linking it with the Health
information management Systems (HMIS) for planning and
decision-making.
Reference and Specialized Testing
The NPHRLS will serve to coordinate IDSR support including other
specialised testing.
Food, Water and Environmental Health and Protection
Working towards the ONE-Health strategy, to support inter-sector
collaboration linking environment, zoonosis and human health with
the MAFFS, MWR; National Standards Bureau and the Pharmacy
Board.
Total Quality Systems Management (TQSM)
Develop and coordinate all the elements of quality indicators,
with the aim of promoting quality assurance programs for clinical
and public health laboratories through training; proficiency
testing, quality audit and customer survey.
Laboratory Management and Coordination
Provide scientific and managerial leadership in developing
monitoring grid to ensure compliance with promoting, and
integrating clinical and public health laboratory science into
practice including developing standards for all health-related
laboratories.
Public Health-Related Research
Evaluate and validate new technologies for in-country use.
HR Development and Management
Through tertiary institutions support laboratory workers.
Support fast track targeted training to build the critical mass at
all levels. Institute laboratory management and leadership
training.
Networking, Partnerships and Communication
Develop and strengthen partnerships among the countrywide
network of laboratories. Develop a national map of laboratory
resources to assist partnership, communication and training.
SECTION 2: STRATEGIC OBJECTIVES, INTERVENTIONS AND TARGETS
Figure 3: Systemic Inputs
CHAPTER 1: GOVERNANCE
(Coordination, legal framework and ethics)
Organisation, Management and Coordination
Strong organizational and management systems provide a mechanism
for effective delivery of services. This is especially important
when there are many facilities offering services at different
levels.
Sierra Leone operates a four-tier laboratory system (primary,
secondary, tertiary and a combined function of public health and
reference services with a central apex hub). Apart from the
existing public health reference laboratories, all the other public
sector laboratories are attached to health facilities.
MOHS provides oversight centrally through the directorate and by
the district health management team. Given that laboratory and
hospital services are combined, the laboratory lead-in-charge
reports to the medical superintendent of the hospital and the
laboratory technician in charge of a PHU reports to the district
superintendent, who will in turn pass information to the
directorate.
At present, there is no intermediate organizational structure to
provide linkage between the districts and the Directorate.
Coordination and supervisory activities are therefore undertaken
from the headquarters. At district level, the laboratory manager
reports directly to and is accountable to the medical
superintendent. At this level the laboratory has to compete for
resources with other priority hospital departments. This state is
reflected all along the laboratory tiers up to national level.
Laboratory management and coordination is being strengthened by
the creation of a Laboratory Directorate with regional and district
management structures and strong coordination structure provided
through the National Laboratory, Epidemiology and Surveillance
Technical Working Group (LSeTWG) with redefined roles inclusive of
advisory, advocacy and technical.
Challenges:
Low priority status given to the laboratory at all levels in
resource allocation.
Limited technical and management capacity of the laboratory
managers at all levels to provide effective support and supervision
to the peripheral laboratories.
Weak management structures and skills at all levels.
Lack of an effective coordination mechanism for laboratory
service providers and funding agencies.
Limited resources at central level to provide overarching
coordination and monitoring.
Policy:
To establish an effective laboratory management structure in the
MOHS that can provide stewardship and coordination of laboratory
services at central, regional, and district levels.
Objective 1:
To strengthen the laboratory organizational and management
structures to provide oversight and coordination of laboratory
services throughout all the levels of health care by end 2020.
Interventions
Establish a directorate for the National laboratory Service at
the MOHS by end 2020.
Engagement of MOHS and administrative units to determine the
implications of setting up the directorate by end 2020
Appoint a Medical Laboratory Services Director by end 2018.
Appoint Senior Laboratory Specialist Scientists to provide
technical oversight by end 2018.
Post an administrator, accountant, personnel officer, data
officer and support staff to the directorate by end 2018.
Procure three vehicles for the directorate in 2020.
Establish clearly defined laboratory tiers with management
functions and reporting structures by end 2017.
Classify laboratories and define functions for each laboratory
tier by end 2016.
Appoint five (5) Senior Laboratory Scientists to manage the
different sections of the National Reference Laboratories by end
2018.
Appoint four (4) Provincial Laboratory Scientists to manage the
regions and the regional laboratories by end 2018.
Appoint nine (9) District Laboratory Scientists to manage
district laboratories by end 2019.
Initiate and coordinate Bi-Monthly National Laboratory activity
updates and experiences sharing meeting for all 14 districts and
National Laboratory
Strengthen the management capacity of all laboratory managers by
end 2020.
Equip all district laboratory managers with management skills by
end 2017.
Provide ongoing mentorship to national and regional laboratory
managers by end 2020.
Establish laboratory coordination mechanism by end 2018.
Redefine the role of the LTWG (Laboratory Technical Working
Group) in collaboration with Surveillance and Epidemiology
Technical working Group (SETWG) by end 2016
Establish a secretariat for the LTWG by end 2017.
Activate LTWG monthly central meetings by end 2016.
Expand quarterly Laboratory TTM to include all districts by
2017.
Institute quality audit improvement project monitoring by
2018.
Legal and Regulatory Framework and Ethics
The NLP has now been adopted by the MOHS and will be used as the
basis for developing and strengthening the laboratory system in the
country. Regulatory/legal frameworks are important to ensure
consistent delivery of quality laboratory services at all tiers.
Professional laboratory staff are guided by codes of ethics that
would ensure compliance to set standards that meet international
best practices. Ethical considerations are important in service
delivery to protect the rights and privacy of users of health
services in the handling of information and test results. A
regulatory framework specific to the laboratory system has yet to
be developed.
Currently the MDCSL licenses premises for delivery of health
services including laboratory services. There is no mechanism for
the licensing and registration of laboratory personnel and the
practice of laboratory medicine. This has led to the mushrooming of
unlicensed laboratories and the entry into practice of unqualified
staff. A National Laboratory Regulatory Council (NLRC) will be
established to regulate practice, and to prescribe and enforce
professional ethics.
Challenges:
Limited mandate and technical expertise of the National Medical
Council of Sierra Leone NMCSL in addressing the full range of
laboratory matters that require regulation
Lack of a professional regulatory body to address issues
specific to the laboratory
Lack of a written code of practice/ethics protocol on laboratory
practice
Limited monitoring of laboratories by the current assigned
agency (MDCSL).
Policy:
To provide a framework for regulation of training, laboratory
practice and observance of professional ethics in laboratory
practice in Sierra Leone.
Objective 2:
To provide a policy and legal framework for proper regulation,
training, laboratory practice and observance of professional ethics
in laboratory practice by end 2020.
Interventions:
Development of an Act for the establishment of the National
Laboratory Regulatory Council (NLRC) by end 2017
Appoint a technical committee at the MOHS to start drafting of
the Bill by end 2016.
Liaise with Solicitor Generals Office to draft the Bill for the
establishment of the NLRC by end 2016
Present the Bill to parliament for debate and enactment by end
2017
Establish and operationalize the NLRC by 2017.
Appoint members of the Council by end 2017
Hire technical and administrative staff for performing tasks
related to licensing and registration by end 2016
Draw up rules related to laboratory code of practice,
professional ethics and subsidiary legislation by end 2016
Develop a minimum standard of requirements for setting up of
laboratories by tier; review and harmonize the curriculum for
laboratory training programmes.
Develop laboratory-monitoring tools to incorporate indicators
for ethics compliance monitoring.
Institute in-service training programes on ethics.
Commence licensing of all (as defined by the Act) laboratories
and registration of laboratory personnel in 2018
Identify and start licensing all laboratories appropriately
Commence registration of laboratory practitioners who meet
requirements
Develop a transition mechanism for personnel who are practicing
but would not qualify for employment or practice under the new
legislation
Objective 3:
To strengthen community awareness of ethics for laboratory
professionals and increase demand by service users and providers at
all levels by 2017
Interventions:
Create community awareness through use of mass media on
laboratory ethics, the rights of users and methods of seeking
redress.
Ensure visible display of codes of ethics in all laboratories as
part of standard practice by 2017
Create appropriate channels for complaints management in at
least 30% of all public and private laboratories.
CHAPTER 2: HUMAN RESOURCES DEVELOPMENT AND MANAGEMENT
The most recent survey of laboratories was undertaken in 2015.
This identified 208 junior cadre laboratory personnel trained at
the Ordinary National and Higher Diploma levels .They are employed
by both the public and private sectors as laboratory assistants and
Technicians respectively.
In addition, there are 141 persons working as laboratory
assistants without formal training. Most of these have education at
secondary or BECE levels only.
Currently, there are three Senior Medical Laboratory Scientists
in the MOHS (1Biochemist, 1 Microbiologist and 1 Parasitologist who
doubles as Laboratory Manager, and three Laboratory Physicians
(Consultant Microbiology, Histopathologist and Haematologist) and
eight mid-level scientific officers at first degree level in Public
Service.
The laboratories are therefore understaffed in terms of trained
personnel to provide technical managerial leadership at secondary
and tertiary levels. The MOHS is currently supporting the formal
training of all unskilled laboratory workers in public service and
with respect to laboratory a competency assessment program is
planned to enable deployment of staff to their right scale.
Following the recent Ebola outbreak, a team of 28 Bachelors
degree graduates in Biological Sciences and Diploma in Medical
Laboratory graduate were trained in an intensive viral molecular
course for the transition of the Ebola laboratory and towards
building a Public Health Laboratory Response (PLHRT). 12 of this
team are now undergoing orientation and supported until absorbed by
the MOHS to increase h pool of skilled professionals.
A recent increase in remuneration of health workers has helped
significantly to improve staff morale and will hopefully translate
to retention of personnel in public service for a much longer
period than at present. A draft scheme of service for laboratory
personnel has been proposed that clearly defines a career path with
job descriptions to rationalize deployment and improve staff
management and efficiency.
Opportunities should be created for the laboratory scientific
officers to specialize in different laboratory fields of study
haematology and blood banking, microbiology, and chemical
pathology, since the secondary and tertiary level services require
these specialties.
Medical and Science Laboratory Technicians are trained at all
the five tertiary institutions in the country (FBC, COMAHS, Njala
University, MMCET and EPK). However, the curriculum is being
revisited and the facilities provided at these establishments (e.g.
training laboratories, equipment) needs to be greatly improved.
A curriculum for the Bachelors Degree in Medical Laboratory
Sciences has been developed and approved by the academic structures
of the University of Sierra Leone. First year classes in basic
sciences have commenced but are awaiting the completion of a
training laboratory for the continued running of the course. With
full support COMHAS should hopefully produce the first set of
graduates in three years time.
Training for medical specialists in laboratory medicine is
currently not available in country. Efforts are being made by the
Ministry of Health for medical graduates to undergo specialty
training in the West African sub-region under the auspices of the
West African College of Physicians.
During the period over which this plan operates, the MOHS should
recruit the full complement of laboratory scientists with
appropriate qualifications, skills and competences to meet the
needs of the nation.
Challenges:
Inadequate numbers of skilled laboratory professionals.
Poor personnel attraction and retention programs.
Limited opportunities for both postgraduate training and
continuous professional development.
Lack of an enabling working environment.
Delayed employment of trained and qualified staff.
Poor staff workload ratio across all laboratories.
Policy:
To ensure the availability of adequate numbers of laboratory
personnel with the appropriate knowledge, competencies and skills
to support the delivery of a comprehensive laboratory package at
each level of health care.
Objective 4:
To meet the minimum qualified laboratory personnel levels to
support the delivery of a comprehensive laboratory package at each
level of health care by end 2020.
Interventions:
Deploy adequate numbers of skilled laboratory staff to all
laboratory facilities by end 2020.
Conduct competency assessment of current staff and develop
deployment plan. By end 2016-2017
Recruit 10 technicians yearly from 2016 2020 to provide services
at Community Health Clinics (CHC) and district laboratories.
Recruit annually, over three years starting 2016 - 2018 five
senior laboratory scientists including laboratory physicians to
work at regional and reference laboratories.
Establish an Emergency laboratory response team at national and
district level by end 2017
Improve the output and quality of laboratory personnel from
training colleges by end 2020.
Develop a training plan by end 2016.
Complete the harmonization and standardization of the curriculum
for the training of technicians at diploma level by end 2016.
Improve on the training facilities of the training institutions
by end 2017.
Train a core group of scientists and laboratory physicians in
specific laboratory specialties by end 2020.
Train two scientists locally in microbiology by end 2018.
Train five scientists in molecular biology by end 2018.
Train two scientists in virology and immunology in 2018.
Commence specialist training of 4 medical doctors one each in
Hematology, Microbiology, Histopathology and Chemical Pathology by
end 2018.
Train 46 staff in QMS from 2017 - 2020 through on -the- job
training.
Develop a structure for the upgrade of community and untrained
laboratory support workers.
Develop and operationalize retention and post-training policy by
2017.
Develop and implement a scheme of service for all cadre of lab
personnel.
Conduct consultative and consensus workshop in collaboration
with the Human Resource Directorate.
CHAPTER 3: LABORATORY INFRASTRUCTURE AND
EQUIPMENTInfrastructure
The design of a laboratory is essential to ensure proper
workflow and safety of laboratory staff, other health professionals
and patients. The designation of separate work areas for reception,
specimen collection, sample processing, assays and relaxation is a
major consideration for laboratory infrastructure. Furthermore,
ensuring that there is appropriate lighting, ventilation, and bench
space is essential for efficient laboratory operations. Equally
important is ensuring restricted access to specialized areas.
Despite the importance of appropriate laboratory infrastructure, a
huge gap exists in the various levels of laboratory infrastructure
in Sierra Leone. According to the Rapid Response Assessment that
was conducted in 2015 only three laboratories met the required
internal standards.
The government plans to improve significantly on the standard of
laboratories infrastructure taking into cognisance the lessons
learnt from the Ebola outbreak. It is anticipated that the
laboratories will meet the required international standards for
quality and safety taking into consideration Infection Prevention
and Control (IPC).
Challenges:
Absence of a national standard for laboratory
infrastructure.
Inappropriately designed and poorly ventilated laboratory
space.
Irregular maintenance of laboratory premises.
Inconsistent power supply.
Inconsistent water supplies, low water pressure and poor water
quality
Lack of safe disposal facilities for water/ liquid waste from
laboratories
Lack of proper incineration facilities for solid hazardous
waste
Lack of proper storage facility
Lack of Appropriate archived room
Lack of common and dressing room
Lack of easy accessibility to laboratory by the disabled
(Ramp)
Lack of detached laboratory from hospital building
Lack of emergency exit in the laboratories
Policy:
To provide at each level of health care delivery, laboratory
facilities appropriately designed to ensure a correct, safe,
functional and operational environment for effective performance
and service delivery.
Objective 5:
To provide adequate laboratory space appropriate for each level
for effective service delivery by end 2020
Interventions:
Ensure that targeted laboratories meet minimum required
standards for infrastructure and environment by end 2020
Reviewed laboratory design to meet international standards (by
the end of 2016)
Renovate /upgrade 193 laboratories that do not meet required
quality and safety standards as appropriate for their level (To
include water and power supply) by end 2020.
Construct 9 new laboratories, 3 in each of the three regions
(east, north and south) by end 2019
Inspect and carry out annual maintenance of laboratories
infrastructure 2019
Equipment:
Most laboratory analyses in the country are still being done
using manual methods without validation of results. There are very
few automated haematology and chemistry analysers in the country.
Equipment procurement is done with little involvement of laboratory
personnel, sometimes resulting in purchase of inappropriate
equipment.
There are no policies for procurement of laboratory equipment
and procedures for installation, and for training personnel on the
use, care, and regular maintenance of such equipment.
Challenges:
Inadequate involvement of laboratory personnel in the planning
and procurement process resulting in the purchase of obsolete and
inappropriate equipment.
Bottlenecks in the distribution of laboratory reagents and
supplies.
Limited storage capacity for laboratory reagents and supplies at
facility level.
Lack of knowledge of the appropriate conditions for the storage
and distribution of reagents and supplies.
Poorly maintained cold chain.
Inadequate stock control systems (to ensure supplies are
maintained and time expired materials are disposed of
properly).
Lack of capacity at district level for procurement of
specialized equipment.
Lack of involvement of suppliers in equipment installation,
training and commissioning.
Lack of an equipment service contract system.
Lack of appropriate temperature for storage of equipment
Policy
To provide the necessary procurement directions and stock
management systems for an efficient quality laboratory service at
all levels
Objective 6
To provide technical expertise that will align international
(regional) tools and documents of equipment requirements
appropriate to support the BPEHS.
Interventions:
Ensure the procurement of appropriate and adequate laboratory
equipment and commodities for all levels of service delivery
nationwide.
Develop a national equipment and supplies management plan by
2016.
Equip each laboratory with equipment and supplies including
stock management and waste disposal to support approved testing
platform according to the Basic Essential Package (BEP) by
2016.
Develop and ensure compliance of the policy for service
contracts on all procured equipment and supplies by end of
2016.
LTWG to provide central oversight for the procurement,
installation, distribution and maintenance of all laboratory
equipment.
CHAPTER 4: LABORATORY SERVICES & SUPPORT SYSTEMS
(Logistics & Management Systems)
Laboratory Services
Most district laboratories do not have the capacity fully to
support the delivery of the minimum health package and other
programme activities. Haematology services in almost all hospital
laboratories are limited to haemoglobin estimation and occasional
manual WBC counts. Microbiology services at both PHU and hospital
level are limited to microscopy for TB, Malaria and parasitological
examinations of faecal samples, although a limited number use rapid
diagnostic tests (RDTs) for malaria, HIV, syphilis and Hepatitis B
testing. Biochemistry tests are limited to urinalysis by dipsticks
and occasional blood sugar estimation. Very few laboratories
provide Urea and Electrolyte or Liver Function Tests (LFT), and key
items in patient management. Limited histology services are offered
through the histopathology unit at central level. There are no
cytology or toxicology services. The Kenema hospital laboratory is
the most advanced laboratory in the country and has an adjoining
Lassa Fever BSL3 Containment laboratory that has the capacity for
molecular and Enzyme immuno-assay. This service is of international
standard and provides support to neighbouring countries.
The services for Malaria, HIV, TB, and Lassa Fever provide an
opportunity for the public health laboratory to build on and expand
the referral system to encompass other diseases and a much wider
range of specimens.
Challenges:
Limited testing capability at all levels due to inadequacies in
skills, equipment and reagents.
Limited infrastructure and utilities to support laboratory
service.
Weak specimen referral system.
Policy:
To provide laboratory services appropriate to each level of the
health care system that respond to the defined national health care
package.
Objective 7:
To provide laboratory services appropriate to each level of the
health care system within the defined laboratory package by end
2020.
Interventions:
Define the laboratory tests and techniques to be offered at each
level by end 2016.
Strengthen and expand the specimen referral system to include
diseases and specimens other than those currently covered by end
2018.
Define a national stock management systems protocol by end
2018.
Revise referral and feedback tools by end 2017.
Develop and distribute guidelines and provide training on
specimen packaging by end 2017.
Establish a specimen referral courier system by end 2018.
Establish a stock management protocol for all equipment,
supplies and consumables at all levels by end 2018.
Laboratory Logistics and Management System
During the EVD outbreak, the laboratory services were challenged
by the scarcity of skilled human resources and management supply
chain in support of laboratory services. This led to a major
hindrance in the delivery of quality laboratory services. The MoHs
should ensure that critical testing supplies are available when
needed to prevent delays in providing pertinent testing results to
patients. A robust equipment maintenance and calibration programme
is thus necessary for proper and consistent functioning of all
laboratory equipment and reliable test results. Adequate attention
should be given to inventory and stock management including
maintenance of infrastructure and equipment for a laboratory to run
efficiently.
A good storage system is essential to the guaranteed integrity
of laboratory commodities at all levels of distribution in
accordance with the manufacturers instruction. The delivery of
commodities to the lab facilities should be based on logistics
report which should be sent to the central warehouse through the
state procurement and supply chain management team.
Reagents and supplies:
Weak capacity for quantification and specification coupled with
procurement and distribution bottlenecks often result in stock-outs
of reagents and essential laboratory supplies. Districts attempt to
fill the gaps by sourcing equipment and reagents at district level
from the few local suppliers, posing challenges of availability,
problems of standardisation of reagents and a lack of the benefits
of economies of scale.
Challenges:
Weak inventory management.
Lack of established preventative maintenance programmes.
Lack of equipment management systems.
Lack of vendor (equipment and supplies) service contracts.
Limited systems for validation of laboratory testing
results.
Limited storage space for reagents, specimens, and supplies
nationwide.
Limited involvement of laboratory staff in the acquisition of
laboratory equipment and supplies.
Only one biomedical engineers to address in-country equipment
maintenance needs.
Service interruption due to Non-usable equipment.
Inadequate documented procedures to address notification of
physicians of critical values, delayed results and to prevent loss
of laboratory data.
Lack of guidelines on disposal of obsolete equipment and expired
reagent.
Unreliable forecasting, quantification and specifications of
supplies.
Policy:
To provide the necessary procurement directions and stock
management systems for an efficient quality laboratory service at
all levels.
Objective 8:
To provide all government medical laboratories with appropriate
equipment, and assure availability of commodities (media, sera,
reagents etc.) for efficient service delivery by end 2020.
Interventions:
Strengthen national testing norms and standards definitions
Update the national standard equipment list and specification
for procurement at the different levels of healthcare by end
2016.
Provide a common and appropriate laboratory equipment platform
for test assays by end 2016.
Develop essential supply list based on the test requirements for
the various levels of healthcare delivery by end 2016.
Institute diagnostic and public health commodity systems
Train 36 laboratory personnel on logistics and supply chain
management by 2017.
Ensure representation of laboratory personnel on local and
national procurement committees by 2017.
To develop policy for disposal of obsolete equipment and expired
reagent by 2017.
Objective 9:
To provide all government medical laboratories with
complimentary supplies and consumables for efficient service
delivery by end 2020.
Intervention: Strengthen the storage and distribution mechanism
for equipment, supplies and reagents at all levels.
Establish minimum and maximum stock levels for each laboratory
by 2016.
Provide adequate reagent storage facilities at each laboratory
according to the National Basic Essential Health Package (2016-
2020).
Provide cold storage facilities for all laboratories by end of
2016.
CPHRL to validate all laboratory reagents procured in
country.
Provide periodic in-service training in stock management of
equipment, reagents and various supplies (2016).
CHAPTER 5: BIORISK MANAGEMENTBIOSAFETY, BIOSECURITY,
BIOBANKING)
Medical laboratories handle infectious waste materials and
generate biological waste. It is important that the staff, the
public and the environment are protected from injury or
contamination by these materials.
The last Ebola outbreak led to the infection and death of
several medical and laboratory staff. The lessons learned from this
should ensure that all health care providers consider health and
safety paramount in the operations of health facilities
nationwide.
The issue of specimen repository of left over biological samples
from investigations conducted in our laboratories has become more
important than ever before. There had been no policy to guide
specimen archiving, storage, retrieval and destruction. Vital
samples from endemic and epidemic prone diseases in this country
are not stored properly and their destruction is haphazard.
Well-structured and resourced bio repositories could serve as a
vital resource to promote research and training of our future
scientists. .
Laboratory workers are also exposed to dangerous chemicals and
fire incidents and should be taught how to protect themselves from
such ugly incidents.
Challenges:
Lack of laboratory bio-security policy
Inadequate supply and hence insufficient use of PPE
Poor waste management systems including a lack of waste disposal
equipment
Inadequate skilled personnel to safely package and transport
infectious substances
Lack of training in fire safety and containment
Policy:
To promote and sustain laboratory safety and safe laboratory
practices in all laboratories in order to protect staff, products,
community, and environment.
Objective 10
To support all laboratories to implement the laboratory
bio-safety policy and adhere to safety guidelines by end 2018
Interventions
Implement the national laboratory safety policy and guidelines
by end 2018
Establish a laboratory waste management protocol by end of
2018
Procure and distribute adequate quantities of waste disposal
systems by end 2018
Procure and distribute appropriate PPE and continue to train
staff in its use till 2020
Build capacity of laboratory personnel on fire safety to address
chemical spills and contamination by end 2016
Establish national repositories for the safe storage and
security of biological specimen for use in the development of an
effective public health system by end 2020.
Develop functional inventory and a system for specimen
management (collection, transportation, archiving and retrieval of
stored specimens-Laboratory Information Management System) by end
of 2020.
Develop policies for destruction, accessing retrieval and
utilization, disposal of stored specimens by end of 2016.
Establish a National Governing body for overseeing bio banking
by end of 2016.
Establish and strengthen capacity for management, coordination,
operation and maintaining of the bio banking by end of 2018.
CHAPTER 6: INFORMATION MANAGEMENT SYSTEMS
Laboratory Information System is a paper, electronic or web
based system that processes, stores and manages data from all
stages of medical procedures and tests, with the sharing of data on
patients care, disease surveillance, and monitoring and evaluation
of laboratory performance.
Proper implementation of LIS ensures high quality actionable
data is available to users in a timely manner, it assures security
and confidentiality of laboratory data by the administrator and
eligible users.
This plan continues to recognise the weakness of the laboratory
information systems and highlighted LIS as one of the strategic
focus areas in the plan.
Policy Environment of LIS
The 2009 Health Policy affirmed goal to establish and strengthen
laboratory systems.
The National Laboratory Policy highlights the need for national
Laboratory Information Systems (LIS).
The 2011-2015 Laboratory Strategic Plan sets out mechanisms to
establish and strengthen the LIS.
The strategic plan identifies Integrated Laboratory Data
Management as a core function of the laboratory system.
Strengths
Existing laboratory policy documents recognize the need to
establish efficient LIS.
Other ministries and programmes require lab support and can be
expected to contribute to LIS strengthening.
Main challenges
Weak lab management and coordination structures.
Lack of infrastructure for data management.
No standardised system for management of laboratory data.
Inadequate supervision and monitoring of service delivery.
Poor data collection, compilation, analysis, utilization and
reporting.
Limited capacity in data management.
Inadequate data collection tools at laboratory level.
Vertical programmes running parallel data collection
systems.
No harmonisation of vertical programmes data with national
laboratory data.
No link with DHSPPI.
Opportunities:
Increased international technical and financial support for
Post-Ebola Recovery and HSS.
Increased interest and focus on HIS and interoperability of HIS
systems.
There are existing programmes to support LIS DHIS.
Increased demand for data use in decision making.
Overall laboratory investments for more cohesive service
delivery.
LIS modules in pre-service lab training and continuing
professional development.
Threats:
Continued dependency on donor support threatens
sustainability.
Power supply and telecommunications inadequacies limit the
functionality of LIS.
Inadequate skilled human resources and staff retention
challenges.
Task overload.
Policy:
To establish an efficient and integrated LIMS at all levels
Objective 11:
To establish a laboratory information and management system that
is integrated into the national health management information
system
Interventions:
Establish an integrated system for data capturing, analysis and
use at all levels
Establish a data unit at the laboratory directorate by 2017
Establish laboratory LIS TWG with defined terms of reference by
end 2016
Train district laboratory in-charges on the use of the tools and
relevant software by end 2018
Provide network and information communication technology
equipment at all levels by end 2019
Establish an electronic LIMS throughout NPHRL network by end
2017
Train specified personnel at the district laboratories in the
use of the tools by end 2018
Link laboratory data unit to national data warehouse by end
2020
Establish effective data management and sharing systems by
2018
Generate Protocol for LIS integration into HIS by 2019
Establish an electronic LIMS at NPHRL
Identify the software to be used by end of 2nd quarter in
2017
Install software and train staff by end 2017
CHAPTER 7: EMERGENCY PREPAREDNESS AND RESPONSE Public Health
Functions
Sierra Leone has experienced two major epidemic-prone disease
outbreaks within the past 5years; these are Cholera and the Ebola
Virus Disease (EVD). Given that there had been previous Cholera
epidemics, it would have been assumed that lessons learnt in
handling such would have influenced the countrys preparedness in
response to the 2014 EVD outbreak however, this was not so. During
this outbreak, many lives were lost, including 202 frontline health
service providers, further depleting the already low number of this
cadre; there was exposure of the lack of capacity and preparedness
within an already weak health infrastructure, in responding to
other outbreaks.
This section will provide direction in preparedness and response
for future outbreaks, in accordance with the Integrated Disease
Surveillance and Response (IDSR) strategy adopted by WHO AFRO
member states for improving public health surveillance and
response. The focus areas will be on Disease Prevention and
Control, Surveillance and the identification of disease outbreaks,
facilitation of an appropriate response and the implementation of
prevention and control measures.
Integrated Disease Surveillance and Response (IDSR)
The technical guidelines for IDSR in African Regions 2010
clearly highlighted the Laboratory confirmation of a disease to
allow for timely intervention to limit the impact of the health of
affected communities. Although the current drive takes into account
(one world- one health) perspective that integrates human, animal
and ecosystem health, the plan only addresses the human health with
the flexibility to link with animal and environmental effects. With
the commitment of MOH to implement IDSR, key critical development
paths are considered as per figure below.
Figure 4: Critical path of development
Challenges:
Implementation of the IDSR strategy in Sierra Leone is not
optimal at this point in time
A lack of emergency/rapid response teams (RRTs) at all levels
that is, National, District and Community
Limited training in emergency preparedness at all levels that
is, national, district and community
Policy
To improve laboratory capacity for surveillance and response
Objective 12:
To fully implement the IDSR strategy in Sierra Leone by 2020
Interventions:
Create a Laboratory coordinating office at the Emergency
Operations Centre (EOC).
Develop a Laboratory Rapid Response Operational manual, with a
costed implementation plan.
Integrate the laboratory emergency response into the overall
national response.
Train relevant national and district level personnel as part of
the rapid response teams (RRTs) for disease outbreaks.
Train 2 Laboratory scientists as part of the national level
RRT
Train 14 Laboratory Scientists as part of the district level
RRTs (one per district)
Establish RRTs at all levels, national, district and
community.
Train laboratory staff in outbreak emergency preparedness,
including laboratory activation simulations.
CHAPTER 8: RESEARCH, DEVELOPMENT AND ETHICS
The capacity of laboratories to conduct research in the country
is limited. In collaboration with the Health and Biomedical
Research Group a symposium has been organised to build technical
capacity in proposal writing and research methodology for simple
operational research that addresses the needs of the country and
various ministry programmes. Members of staff are being encouraged
to publish their work in both local and international peer review
journals.
We can now leverage on the experience and expertizes available
during the EVD outbreak and create/maintain a network of
laboratories and researchers at all tiers within the country and
internationally in other to strengthen the laboratories capacity to
conduct research.
Challenges:
Low technical capacity in proposal writing and research
methodology
Laboratories poorly equipped to conduct research
Lack of a national laboratory research policy
Inadequate funding and resources to support research and
development activities.
No National research database.
Laboratory data management (reporting format) not
integrated.
Policy:
