Detailed Mechanism Funding and Narrative

Details for Mechanism ID: 11821
Country/Region: eSwatini
Year: 2009
Main Partner: Management Sciences for Health
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $490,000

Funding for Care: Adult Care and Support (HBHC): $65,000

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $19,500

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 09 - HTXS Treatment: Adult Treatment

Total Planned Funding for Program Budget Code: $4,473,000

Total Planned Funding for Program Budget Code: $0

Table 3.3.09:

Funding for Treatment: Adult Treatment (HTXS): $65,000

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $19,500

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Care: Pediatric Care and Support (PDCS): $30,000

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $9,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 11 - PDTX Treatment: Pediatric Treatment

Total Planned Funding for Program Budget Code: $460,000

Total Planned Funding for Program Budget Code: $0

Table 3.3.11:

Funding for Treatment: Pediatric Treatment (PDTX): $30,000

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $9,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.11:

Funding for Treatment: ARV Drugs (HTXD): $300,000

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $90,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 16 - HLAB Laboratory Infrastructure

Total Planned Funding for Program Budget Code: $1,125,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Swaziland faces a severe shortage of trained laboratory personnel and an inadequate lab infrastructure to deal with the rapidly

growing demand for HIV/AIDS and TB related diagnostic and clinical lab testing. Underlying the capacity deficits are a host of

problems that include a lack of cohesive human resource policy, lack of lab training institutions in country, a history of poor lab

systems management, and lack of career enhancement opportunities. Investments in laboratory services to support HIV/AIDS and

TB program expansion have been neglected at virtually every level, which is crippling the rapidly increasing program (both public

and non-public sector) implementation. There is one referral laboratory covering all lab services (move into a newly constructed

facility likely to be considerably delayed), five regional laboratories, eight health center laboratories and three private laboratories.

These labs are completely overwhelmed by the increasing demand for HIV/AIDS and TB related diagnostic and clinical lab

services, in addition to the other routine services that they are providing. Critical areas are HIV testing, CD4 cell count, DNA PCR

for infant diagnosis and TB sputum microscopy. Periodic stock-outs of lab reagent have been an ongoing problem. As with the

ARVs, some of the lab reagents are procured with Global Fund resources. The National Emergency response Council for

HIV/AIDS (NERCHA) orders these based on requisitions from the Ministry of Health and Social Welfare (MOHSW). However, the

communication within the MOHSW, and between the MOHSW and NERHCA, is far from ideal (see HTXD)

To date, there has not been much laboratory support, apart from PEPFAR. The Italian Cooperation has a limited program to make

renovations to lab infrastructure and to purchase equipment for the existing National Reference Laboratory (NRL) in Mbabane and

for some of the laboratories in VCT and ART centers. Clinton Foundation, together with some of the PEPFAR partners, in an effort

to promote early infant diagnosis and treatment, has been strengthening the collection and transport of DBS samples and

facilitated DNA PCR testing in South Africa.

PEPFAR, and some of its implementing partners, have been collaborating with the MOHSW's National Laboratory Services (NLS)

since 2006. PEPFAR has worked with the World Health Organization (WHO) and other stakeholders to assist the NLS in the

development of a National Laboratory Policy document. Unfortunately, this document has now been in draft for a long time and

has not been finalized. Recently, PEPFAR has moved forward from a short-term assistance plan to facilitating a broad

stakeholder process to develop a five- year National Laboratory Development Plan. This includes a detailed one-year National

Laboratory Action Plan for the first year of implementation. This plan is currently used as the blueprint for the implementation of

much needed improvements across the service. PEPFAR has provided extensive in-service training and on-site mentoring of

existing laboratory personnel on basic laboratory operations, chemistry, hematology, HIV testing, CD4 cell count testing, and TB

microscopy. With PEPFAR support, a new cadre of lab phlebotomists was developed to assist the more senior lab personnel with

phlebotomy services. Some of these phlebotomists were also trained and deployed to perform TB sputum microscopy, which has

started to relieve the pressure on TB diagnostic services. In addition, a pilot program is underway whereby phlebotomists are

deployed to more remote health clinics, without laboratories, to perform a minimum package of basic lab tests, including HIV

testing. PEPFAR is also supporting the development and implementation of systems and protocols for standard operating

procedures, quality assurance, supervision/mentoring, and strengthened laboratory management.

In FY09, the PEPFAR will continue to support the strengthening of the national lab capacity and services through technical

assistance, training and supervision.

1) The American Society of Clinical Pathologists (ASCP) and the Centers for Disease Control and Prevention (CDC) will provide

technical assistance, in collaboration with the WHO, to finalize the existing National Laboratory Policy document (including

national standards) and assist the process of converting it in legislation. ASCP will implement a schedule of periodic reviews to

assess the implementation and adherence to the National Laboratory Policy.

2) ASCP and CDC will provide ongoing assistance with the implementation of the five-year National Laboratory Development

Plan. ASCP will implement a schedule of periodic reviews to evaluate progress on implementation. ASCP will help conduct

meetings of laboratory stakeholders to apprise them of the successes and challenges with the implementation of the development

plan, and will assist in the drafting of the next year's Action Plan.

3) ASCP will begin work on developing clear standards and requirements for certification of laboratory personnel. Standards for

pre-service requirements, scope of practice, and competency assessment will be established. In addition, ASCP will also work

with the MOH to help develop and implement a national continuing education program for laboratory personnel. Standards will be

enforced by the regulatory body of health personnel in Swaziland to certify all individuals working in medical laboratories.

4) ASCP will repeat its three day training workshop in Basic Laboratory Operations that is based on the new CDC task-based

guidelines for best laboratory practices. The training is targeted towards laboratory assistants and laboratory technicians who

must manage themselves under the direction of an on-site medical officer. This training has been conducted previously, with a

‘training of trainers' component. With time, it will be conducted with increasing involvement of four local trainers; the ASCP role will

be gradually reduced to technical oversight only. Refresher training of those previously trained will be considered.

5) PEPFAR will continue to support the training and deployment of lab phlebotomists to perform basic lab functions

•ASCP will continue to conduct its trainings on phlebotomy (including both venipuncture and finger prick). This training has been

conducted previously, with a ‘training of trainers' component. It will be conducted by local trainers; the ASCP role will be limited to

technical oversight only. Refresher training of those previously trained will be considered.

•The National Institute for Communicable Diseases (NICD) will continue the assistance with the training of lab phlebotomists on

TB sputum microscopy using the CDC protocol and teaching guidelines. This training has been conducted previously, with a

‘training of trainers' component. It will be conducted by local trainers; the NICD role will be limited to technical oversight only.

Refresher training of those previously trained will be considered.

•ASCP will continue to conduct its trainings of lab phlebotomists on basic lab tests (including HIV testing). This training has been

conducted previously, with a ‘training of trainers' component. With time, it will be conducted with increasing involvement of four

local trainers; the ASCP role will be gradually reduced to technical oversight only. Refresher training of those previously trained

will be considered.

6) ASCP will continue to help build CD4 testing capacity in Swaziland and further support the CD4 testing sites with technical

assistance and training. ASCP will conduct a CD4 testing training for laboratory professionals, and will provide periodic on-site

mentoring and technical support to 12 testing sites. ASCP will work with instrument vendors to explore emerging technologies in

CD4 testing.

7) NICD will increase its support to build TB diagnostic capacity in Swaziland

•NICD will strengthen capacity for TB sputum microscopy by providing additional training, mentoring and quality assurance at all

sites, a smear microscopy re-checking program and external proficiency testing.. In addition, NICD will gradually upgrade TB labs

(high volume labs first) through the introduction of new technology i.e. the concentration of sputum samples and fluorescence

microscopy

•NICD will provide training, mentoring and quality assurance for TB culture and drug susceptibility testing at the Mbabane NRL.

Performance will be monitored through an external quality assurance program of the South African Medical Research Council

(SAMRC). Once full capacity of current equipment is reached, NICD will provide additional equipment to increase the volume of

tests that can be performed. Depending on feasibility and experience in South Africa and other developing countries, introduction

of line probe identification of drug-resistant TB may be considered.

8) NICD is currently performing the DNA PCR testing for early infant diagnosis in Swaziland (facilitated by Clinton Foundation).

Samples are being sent to South Africa and results take approximately four to six weeks to return. NICD will offer SA-based

training in the performance of DNA PCR to selected lab personnel so that, with time, this test will be made available in Swaziland

so that turn-around times may be reduced.

9) The NICD will continue to assist with the implementation of a comprehensive, and integrated quality management system by

training and supporting the newly appointed NLS Quality Improvement Manager. The Quality Improvement Manager will be

assisted to provide training and on-site mentoring to all laboratories in the country, and a routine supervision system will be

developed to focus on performance assessment and improvement. In addition, NICD will assist with the implementation of

external quality assurance (proficiency testing) for chemistry, CD4, HIV serology. The final stage of their intervention will be

performing of internal audits to determine readiness for accreditation, followed by facilitation of a formal accreditation process.

10) Management Sciences for Health (MSH) will considerably increase its support to the management of laboratory reagents and

equipments for the National Laboratory Services (NLS) more specifically by addressing the following: 1) the improvement of

selection, procurement and storage practices for laboratory reagents and equipments; 2) the development and implementation of

quantification models; 3) the determination of optimized reorder levels for the NLS "clients" and implementation of a monitoring

and evaluation system for commodity management (checks and balances, audit). Moreover, the implementation of the integrated

patient management and drug tracking system by MSH will assist with the estimation of the needs as the tests (CD4 Count, Viral

Load, and others) performed for patients on ART (and other patients) can be recorded.

11) The Department of Defense (DOD) will continue its support to the Umbutfo Swaziland Defense Force (USDF) military clinic

and lab. Laboratory related activities will be funded through non-PEPFAR funds (Foreign Military Financing, approximately

$25,000). Activities will include finalization of laboratory infrastructure improvements, provision of equipment, and technical

assistance.

12) The Southern Africa Human Capacity Development Coalition (SAHCD) will strengthen the management and leadership

capacity within the NLS and assist with the development of a human resources plan. The plan will incorporate strategies to

strengthen mid-level laboratory management capacity through short external training, on-site mentorship, sharing of best practices

and study tours for laboratory management, policy formulation, and budgeting. Furthermore, SAHCD will support the leadership to

advocate for the expansion of the current laboratory workforce, a review of the current conditions of service, and the creation of a

supervisory structure with top management at MOHSW and Public Service.

Products/outputs:

•National Laboratory Policy

•National Laboratory Development Plan, with updated Action Plan

•Laboratory personnel certification program

•Laboratory personnel continuing education program

•Modular training guidelines and local training capacity (BLOT, Phlebotomy, HIV testing, TB microscopy, Basic lab test package)

•Lab management protocols and guidelines

•Site-level standard operation procedures, quality assurance plans with supervisor guidelines, quality assessment tools,

proficiency testing

•National and facility level QA audit reports leading towards accreditation

PEPFAR will continue to be a key donor for improving laboratory services under either budget scenario. However, plans to task

shift, train phlebotomists and expand basic laboratory services into the rural areas are dependent on Compact funding. The roll

out of DNA PCR testing for early infant diagnosis will be much slower with pre-Compact funding levels.

Table 3.3.16:

Cross Cutting Budget Categories and Known Amounts Total: $147,000
Human Resources for Health $19,500
Human Resources for Health $19,500
Human Resources for Health $9,000
Human Resources for Health $9,000
Human Resources for Health $90,000