Zimbabwe Integrated Sample Transportation System (ISTS) Case Study.

Abstract

The existing national sample transportation network is fragmented and costly resulting in sub-optimal rates of testing for diagnosis and monitoring. It relies on multiple disjointed transportation mechanisms and uncoordinated service providers. We piloted an ISTS using a low cost local courier service - ZimPost. The objective of the pilot was to evaluate the acceptability, effectiveness, and cost of ISTS for HIV and TB laboratory services. ZimPost transported samples and results between 68 primary care facilities and 5 laboratories. Data on cost, turn-around time (TAT), and testing rates were abstracted from ZimPost records as well as laboratory and clinic registers for a baseline and post-pilot comparison. Semi-structured qualitative interviews with clinic and laboratory staff were conducted to assess acceptability. The pilot was completed on 30 April 2016. On average, sample collection increased by 70% with the highest increase in CD4 samples (121%). Early Infant HIV Diagnosis (EID) TAT decreased by 24 days and an 8 day TAT was achieved for CD4 and TB sputum testing. A 44% per sample cost reduction and 35% per facility cost reduction was observed between the baseline and post-pilot period. Cost-savings were driven by the decrease in the number of courier service providers and trips required as a result of combining sample types. Clinical and laboratory staff reported that the ISTS had strengthened the diagnosis and management of TB and HIV. The ISTS has been demonstrated to be an effective and affordable sample transportation system. The pilot also demonstrated the importance of a courier function that is dedicated solely to specimen transportation. However, the main limiting factor is that the courier roles may not be easily transferable to MOHCC given the current low staffing levels and high workloads which are exacerbated by the economic environment. It is recommended that MOHCC consider prioritizing specimen transportation in other health budgets e.g. results-based financing.

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Zimbabwe Integrated Sample Transportation System (ISTS) Case Study.
Boboh Kamangira1; Phibeon Mangwendeza1; Wadzanayi Muchenje1; Tatenda Shoko1; Stephanie Denamps1; Maria Rosezoil Rioja1; Raiva Simbi2; Tsitsi Apollo-
Mutasa2; Neil Moyo3; Emmanuel Ngazimbi3; Hebert Mutunzi2
1Clinton Health Access Initiative, 2Ministry of Health and Child Care (Zimbabwe), 3Zimbabwe Posts (Pvt) Ltd
Boboh Kamangira
Clinton Health Access Initiative
Email: bkamangira@clintonhealthaccess.org
Contact Information
PROJECT OVERVIEW
•Cost-savings (Table 1) were driven by
a decrease in the number of courier
service providers and trips required
due to combined sample types.
•The major driver of set-up costs was
the training of ZimPost staff on
transporting and handling all
infectious materials (Chart 1). 25% of
set-up costs were Hepatitis B
immunizations to ZimPost riders.
RATIONALE FOR USING NATIONAL POSTAL SERVICES
RESULTS (cont’d)
•Successful outcomes from the region
(Botswana, Uganda, Ethiopia).
•ZimPost has wider coverage (Figure 1)
than any other courier service in
Zimbabwe.
•Mail Room Management Service: offered
at client’s premises.
•Internet connectivity at post offices
offering an option for results transmission.
RESULTS
Chart 2. Number of samples per month: Baseline and Post-pilot.
This ST pilot has demonstrated that a dedicated courier system integrated
across sample types can drive efficiencies in terms of patient benefits and
costs. In 7.5 months, the pilot showed meaningful improvement in the key
success indicators and ZimPost riders were proven to be reliable in delivering
well packaged samples and picking up results. With the right set up and buy in
from relevant stakeholders, such a ST model should be considered for national
scale up as a way to optimize funding resources across programs and deliver
improved results for all.
CONCLUSIONS
Figure 1. Location of post offices
PURPOSE AND OBJECTIVES
The main purpose of the integrated sample transportation (IST) pilot was to
generate evidence on the feasibility, optimal scope and cost-effectiveness of
such a system. Specifically, the pilot sought to:
1. Evaluate the acceptability of an ISTS.
2. Assess the set up and operational cost requirements for an integrated
sample transport system (ISTS).
3. Assess the impact of the ISTS on patient access to treatment and
monitoring services –particularly TAT, number of patients tested and ART
initiation rates.
Scope
•68 primary health care facilities in 3 provinces, once a week/facility
unless communication came (through toll free) for urgent samples or
no samples to be collected.
•5 testing laboratories for CD4 and Sputum, 1 testing laboratory for EID.
•Pilot lasted for 7.5 months (mid-August 2015 to March 2016)
Training
•25 ZimPost staff trained over 2 days.
•Training covered handling and transportation of infectious substances
according to IATA standards as well as the documentation to be done.
Sample Tracking
•Introduced Sample and Results logbooks.
•Logbooks where signed off by ZimPost rider, health workers and
laboratory staff.
•Signed logbooks were used to support invoices raised by ZimPost.
Monitoring and
Evaluation
•The pilot employed a mixed methods design, including qualitative and
quantitative data collection (Pilot exit survey) and analysis.
•Baseline data was collected for 6.5 months before the start of the pilot
•Feedback from District Health Executives was also integrated into the
analyses.
Cost per
test
Cost per
facility/month
Baseline
Post
-pilot
Change
Baseline
Post
-pilot
C
hange
EID
–DBS
$ 6.18
$ 3.84
-
38%
$ 27.27
$ 16.33
-
40%
CD4
$ 6.53
$ 1.76
-
73%
$ 42.08
$ 32.83
-
22%
TB
–Sputum
$ 2.66
$ 0.36
-
86%
$ 17.11
$ 6.77
-
60%
Table 1. Cost per test and cost per facility by sample/test type.
Set-up and Operating Costs
1
•Sample collection increased by 70% with the highest increase in CD4
samples (121%) (Chart 2).
•Increased ART initiation rates (baseline 66.2%, post-pilot 76.4%).
•Health care workers reported that the pilot facilitated earlier treatment
initiation for both TB and HIV patients who presented at clinics.
Expanded access to diagnostics, treatment and monitoring services
2
0
200
400
600
800
Baseline Post-pilot Baseline Post-pilot Baseline Post-pilot Baseline Post-pilot
Bindura Kadoma Murehwa Total
Samples per month
EID - DBS CD4 TB - Sputum
•ZimPost were regular and consistent in transporting samples to the lab
(<24 hours average) and results to the facilities (1 day).
•EID turnaround time (TAT) decreased by 24 days between baseline and
post pilot implementation within the pilot districts.
•An 8 day TAT was achieved for CD4 and TB sputum testing. Baseline TAT
was unknown
Ensured timely access to diagnostics, treatment and monitoring services
3
Lessons Learnt:
•Having clear schedules and couriers dedicated full-time to specimen
transport leads to a more reliable system.
•The consistent use of logbooks to track specimens and results fosters
accountability.
•Implementation is more successful with the buy-in at all levels of the health
system within the pilot districts.
Challenges:
•Couriers covering long distances on more challenging terrain experienced
delays due to minor breakdowns e.g. tyre punctures.
•Bad weather (rainy season) rendered the use of motorcycles difficult.
Chart 1. Proportional distribution of set-up costs.
0.0%
20.0%
40.0%
60.0%
80.0%
100.0% Introductory
Visits
Immunizations
Transportation
accessories
Training
APPROACH (cont’d)
Figure 2. Integrated Sample Transport System model.
IST Model: CD4 and Sputum samples were tested at district labs.
EID samples were further transported to EID/VL lab (e.g. NMRL)
DISCUSSION
CONTEXT
•Sample transportation
(ST) is costly and relies
on multiple disjointed
transportation
mechanisms and
uncoordinated service
providers.
•Limited understanding
of the scope, the cost
structure and cost
drivers behind an
integrated ST network.
INTERVENTION
A reliable and regular sample transportation
system that is integrated across disease areas,
has least touch points and is affordable
IMPACT
•Decreased turnaround time (TAT)
•Increased number of patients tested
•Improved patient monitoring
•Lower costs per test and per facility
APPROACH