USG and USAID agreed that it would be in the national program's best interest to extend EGPAF for two additional years in order to address the weaknesses in the national program. The new activity will not be designed and solicited at this time. PMTCT resources will be transferred to EGPAF. Family HIV/AIDS Care and Treatment should be deleted. EGPAF should be added for FY07 following on from FY06.

Table 3.3.01:

USG and USAID agreed that it would be in the national program's best interest to extend EGPAF for two additional years in order to address the weaknesses in the national program. The new activity will not be designed and solicited at this time. PMTCT resources will be transferred to EGPAF. Family HIV/AIDS Care and Treatment should be deleted. EGPAF should be added for FY07 following on from FY06.

Table 3.3.12: Program Planning Overview Program Area: Laboratory Infrastructure Budget Code: HLAB Program Area Code: 12 Total Planned Funding for Program Area: $ 14,484,470.00

Program Area Context:

In 2004, most laboratories in Uganda could not deliver the minimum health package including HIV, TB, and STI diagnosis, due to poor infrastructure, non-functioning equipment, lack of trained staff and irregular commodities supplies. Great strides have been made since then with support from the Emergency Plan. USG has supported a wide range of activities in the sector leading to significant improvements in service delivery. As of April 2006, over 600 governmental and NGO facilities were receiving laboratory commodities for basic diagnostic services, including HIV testing. In addition, 156 laboratories have been strengthened to provide antiretroviral treatment (ART) eligibility and monitoring services. The Laboratory Technical Committee (LTC), in conjunction with the Central Public Health Laboratory (CPHL), is currently developing a rational plan for the distribution, quality assurance, commodities supply, and maintenance of CD4+ counting instruments. The plan will provide at least one instrument to all districts and will also backup support in the event of instrument failure. USG has built or renovated laboratories at Health Center III and IV and at the central and regional centers of excellence (COE), the latter serving as referral laboratories and providing relevant training. A training coordination unit has been established in the new CPHL facility. Training in rapid HIV testing, including quality assurance, has been rolled out in 56 districts to 43 trainers and 181 service providers. In districts with inadequate numbers of qualified staff, USG has provided training scholarships at laboratory training schools and the training schools have themselves have been strengthened. Overall, more than 1,700 persons have received training in HIV-related laboratory activities including logistics management. Two major constraints impede the further strengthening of human resources in this sector. The first is a severe manpower shortage in the public health sector in general and the difficulties of recruiting and retaining qualified personnel; the second is the lack of any formal laboratory management training. Laboratory management committees have been established at some of the regional COEs to improve leadership and management capacity; but these are few, and much more needs to be done. Discussions with the Uganda Management Institute suggest that both in-service and pre-service programs could be established with appropriate technical assistance; this will be explored in FY07. Focused management skills will be needed as Uganda moves towards laboratory accreditation. Another significant constraint in Uganda has been the erratic procurement of HIV-related laboratory commodities, especially HIV test kits, and an inadequate supply chain that reaches the district but not the sub-district level. In 2005, a new credit line was established with USG support to procure and distribute laboratory commodities through the National Medical Stores (NMS) and Joint Medical Stores (JMS), serving government and FBO/NGO facilities respectively. Commitments to support this credit line are primarily from the USG, and only 30% of the current need is met. However, in Round 6, the Global Fund for AIDS, TB and Malaria (GFATM) proposal includes HIV test kits and accessories that will increase supply significantly. Ministry of Health (MOH) and donors have agreed to a joint review aimed at improving planning, budgeting and monitoring of health commodities. The intention is to strengthen communications between CPHL, NMS, and health units, improve management of commodities, reporting and forecasting and address any bottlenecks. Technical assistance from the Program for Supply Chain Management (PSCM) will be useful for this process. During FY06, the availability of laboratory commodities at lower health facilities increased. To take advantage of this supply, laboratory personnel received logistics management training and pre-printed forms to report the monthly use of commodities to CPHL. Laboratories are re-supplied on the basis of reported usage, and CPHL uses the collated data to forecast procurement needs. PSCM staff are based at CPHL to facilitate this process and provide the necessary linkage to MOH and NMS. While this system is still in its infancy, and requires supervision, it will ultimately strengthen the existing network of zonal, regional and district-level supervisors. It will also maximize resource-utilization by sharing supervisory activities with other programs, such as the National TB and Leprosy Program, and the Malaria Program. To increase the level of support supervision in all activities, a common supervisory tool has been developed by the LTC that addresses both laboratory management and quality assurance of all diagnostic testing. Standard Operating Procedures (SOP) for pre-, post- and analytical phases of laboratory testing have been developed and distributed to all districts; however, not all health units have received copies or been trained

in their correct use. SOPs describe how both Internal Quality Assurance (IQA) and External Quality Assurance (EQA) should be conducted at health facilities across the country. Most lower-level laboratories assessed in the 2004 survey reported that they conducted IQA but not EQA, the latter being heavily dependent on centralized or regionalized support. CPHL will take an expanded role in conducting national quality assurance initiatives through the support supervision network. CPHL will also work with MOH quality of care initiatives and EQA programs for HIV and TB to monitor the performance of laboratory components for ART programs and other laboratory services. Proficiency testing panels will be administered during support supervisory visits and results collated to determine levels and quality of services countrywide; in addition, random samples will be collected for quality control re-testing/re-reading and CPHL will coordinate the re-training of staff in facilities where problems are identified. Uganda's 2006-2010 Health Sector Strategic Plan includes the development of a comprehensive National Health Laboratory Services Policy and the establishment of an effective management structure in MOH to provide stewardship, coordination, and management of laboratory services. While the LTC has addressed some of these functions over the past year, the demand within the sector can no longer be addressed by a voluntary body of scientists and technologists. A full-fledged department within MOH is needed instead. Discussions have taken place with the Public Service Commission and we understand a position of Assistant Commissioner has been agreed to oversee the activities of CPHL and provide the necessary advocacy for the laboratory sector within MOH. USG is supporting the development of a new structure for CPHL within MOH and a draft National Health Laboratory Services Policy document. USG will also assist the MOH to develop a five year implementation plan with realistic targets and progress indicators. The USG focus for 2007 will be to consolidate the gains made to date with particular emphasis on coordination and quality assurance functions within the laboratory sector. In the absence of effective coordination and guidance from MOH, a number of stakeholders have, in the past, acted independently. This has resulted in duplication of effort and occasional conflict between stakeholders. USG has been instrumental in reversing this trend by supporting the development of guidelines and standards, by strengthening data management at CPHL and the MOH Resource Center, and by establishing training and quality assurance coordination units within CPHL and the PMTCT Early Infant Diagnosis program. In FY2007, USG will provide a basic package of services for GFATM clients whose monitoring needs remain unmet. In addition, USG will continue to support ART providers and provide laboratory services for partners who have no laboratory capacity.

Program Area Target: Number of tests performed at USG-supported laboratories during the 1,150,271 reporting period: 1) HIV testing, 2) TB diagnostics, 3) syphilis testing, and 4) HIV disease monitoring Number of laboratories with capacity to perform 1) HIV tests and 2) CD4 tests 245 and/or lymphocyte tests Number of individuals trained in the provision of laboratory-related activities 3,771

Table 3.3.12: