LABORATORY EQUIPMENT HARMONIZATION AS A TOOL FOR COST-EFFECTIVE MANAGEMENT OF LABORATORY COMMODITIES AND MAINTENANCE CONTRACTS:

LABORATORY EQUIPMENT HARMONIZATION AS A TOOL FOR COST-EFFECTIVE MANAGEMENT OF LABORATORY COMMODITIES AND MAINTENANCE CONTRACTS: EXPERIENCE FROM CÔTE D IVOIRE Christiane Adje-Toure, PhD Laboratory Branch Chief CDC-PEPFAR Cote d Ivoire

COTE D IVOIRE - COUNTRY PROFILE Area : Africa 322,0462 km 2 / 124,503 Sq miles Population: 22,6 millions (UN 2011) Capital Cote d Ivoire Political: Yamoussoukro Economic: Abidjan Official Language - French

HEALTH SYSTEM ORGANIZATION Level III 10 Laboratories (CHU, INSP, INHP, LNSP, etc ) Level II 83 District Hospital Labs 19 Regional Hospital Labs Level I 1,584 Health center Laboratories

ORGANIZATION OF BIOMEDICAL EQUIPMENT MAINTENANCE Level III CHU, INS, DIEM Biomedical Maintenance Services Level II RH/DH CREEM Level I Ateliers de maintenance, CREEM (CSU et CSR)

Organisation of Bio-medical Equipment Maintenance by MOH Only 6 on 19 regions Biomedical Maintenance Services CREEM San Pédro CRIEMM Abengourou Biomedical Maintenance Unit DIEM CRIEMM Daloa CREEM Yamoussoukro CREEM Man CRIEMM Bondoukou

COTE D IVOIRE LAB EQUIPMENT HARMONIZATION December 2011-2012

Harmonization Process Overview Cote d Ivoire laboratory leadership participates at the MAPUTO meeting *Joint site assessment LNSP-IPCI-RETROCI Evaluation of lab equipment distribution by level of the health system *Assessment of private providers of lab equipment maintenance Shared results with key stakeholders Implications of multiple brands/model Meeting and consensus with TB, HIV and Malaria program *Harmonization of lab equipment

JOIN SITE ASSESSMENT RESULTS LAB EQUIPMENT DISTRIBUTION BY LEVEL, CONTRIBUTION TO DIAGNOSTIC, etc

SUMMARY OF LABORATORY INSTRUMENTS, DISTRIBUTION AND DIAGNOSTIC CONTRIBUTION Test Instrument Instrument Diagnostic Distribution count Contribution TOTAL CD4 FACSCALIBUR 9 8% 33% 113 (4) FACSCOUNT 70 62% 39% GUAVA 32 28% 28% CYFLOW 2 2% 0% Biochemistry COBAS INTEGRA 400 5 4% 26% 123 (8) HITACHI 902 5 4% 9% KONELAB 20 14 12% 11% COBAS C111 15 12% 7% FULLY 52 42% 39% KENZA MAX 27 22% 6% HUMALYSER 2 2% 1% REFLOTRON PLUS 3 2% 1% Hematology ACT 5 DIFF 1 1% 1% 115 (5) SYSMEX XT2000i/1800i 7 6% 30% ACT DIFF 66 58% 32% SYSMEX KX21N 36 31% 34% MEDONIC CA620 5 4% 3% Viral load TAQMAN 48/AMPLIprep 2 29% 99% 7 (3) NUCLISENS 4 57% 0%

CD4 INSTRUMENT DISTRIBUTION Equipment Number FACSCALIBUR 9 FACSCOUNT 70 GUAVA 32 CYFLOW 1 TOTAL 113 80 70 73 60 50 40 30 20 10 0 9 30 2 Nombre %

CHEMISTRY & HEMATOLOGY INSTRUMENT DISTRIBUTION REFLOTRON PLUS 2 KONELAB 20 12 HUMALYSER 4 KENZA MAX 29 FULLY 52 COBAS C111 12 HITACHI 902 5 COBAS INTEGRA 400 5 0 20 40 60

ASSESSMENT OF PRIVATE PROVIDERS OF LAB EQUIPMENT MAINTENANCE

ASSESSMENT OF PRIVATE PROVIDERS OF LAB EQUIPMENT MAINTENANCE Indicators 1. Legal status, representative of a brand 2. HR available to number of machines on site 3. Comparison of maintenance cost per equipment and per partner 4. Logistic capacities 5. Stock availability 6. Causes of curative maintenance needs

1. LEGAL STATUS Letter of agreement from mother company: All companies Location All but one are located in Abidjan the capital Maintenance planning All have a plan for preventive maintenance Stock/Equipment back-up Some have equipment back-up but there is no means to check against number of machines in country Logistics: Private vehicle and public transportation Communication: Tel, Fax, Emails Human Resources: CV, trainings offered during the past year

Nombre moyen d'automates par personnes techniques 2. Biomedical Engineer Distribution per company and per Equipment EDNA et SA Biocare-ci MEDICAL ONE Meditech SARL Nouvelles Perspectives AFRIC MEDICAL BD 25 20 15 10 5 0 6 7 2 4 1 3 5 Companies Compagnies

Causes des interventions curatives 5. First Cause of Curative Maintenance 1 st April 08 to 31 March 09 Defaillances electriques Defaillances environementales Usure normale sur certaines pieces Usure accidentelle de certaines pieces Causes humaines Fluidiques Logicielles Sur-exploitation Panne optique 0 10 20 30 40 50 60 70 Nombre interventions

6. Annual cost of maintenance per machines and per partner per year Equipement Equipment 1 Equipment 2 Equipment 3 PEPFAR IP Annual cost per machine USD Number of preventive maintenance 1 2,100 2 2 3,500 2 3 6,600 2 1 5, 600 2 4 5,084 2 3 2,690 2 4 3,386 2 Equipment 4 3 6,666 2 Equipment 5 4 2,046 2 2 1,908 2

HARMONIZATION WORKSHOP

HARMONIZATION WORKSHOP - OUTCOMES Methodology review 19 1- Adjust and revise as necessary 2- Instrument requirements/qual ities reviewed: - 14 Critical, - 13 Important, - 8 Desirable 3- Additional considerations: - cost, capacity, existing coverage, dx demand, etc Arrive at consensus on: Tests by level Methodology by level Overall harmonized instrument list Minimum standardized equipment requirements by level HR requirements by level Way forward

STANDARDIZED LAB EQUIPMENT BY LEVEL Test Instrument Level III Level II Level I CD4 FACSCALIBUR x (3) FACSCOUNT x x GUAVA x PIMA CYFLOW Biochemistry COBAS INTEGRA 400 x (5) HITACHI 902 KONELAB 20 COBAS C111 x x FULLY x KENZA MAX x x HUMALYSER x REFLOTRON PLUS Hematology ACT 5 DIFF (3) SYSMEX XT2000i/1800i x x ACT DIFF II x x SYSMEX KX21N x MEDONIC CA620 HEMOGLOBINOMETRE Viral load TAQMAN 48/AMPLIprep x (3) NUCLISENS x ABI PRISM 7000 x x x

MANAGEMENT OF LAB EQUIPMENT MAINTENANCE CONTRACT

Technical Working Group MAINLAB OBJECTIVE: Provide to the MOH technical guidance in regard to lab equipment and lab infrastructure MISSIONS: Domain 1: Develop policy, strategic and guidance document Domain 2: Coordination of activities related to lab equipment and infrastructure Domain 3: Monitoring and Evalutaion MEMBERS: 24 Institutions including PEPFAR, Global Fund and MOH key departments 34 individual members Monthly Meeting

MANAGEMENT OF LAB MAINTENANCE CONTRACT FINANCE PEPFAR MOH COAG CELLULE FUDICIAIRE PNPEC MSHP COAG FOSA Automates DIEM GTTMAINLAB

DIEM ROLES Technical Assistance of the TWG MAINLAB Organize and supervise maintenance activities Develop technical contents of maintenance contract Inform the private providers Monitor and evaluate the implementation of the contract Check and approve the intervention reports of private providers before any payments Collect and analyze data for decision making Host databases

ROLE OF PRIVATE PROVIDERS Equipements installation Training of users Inform before and get approval from DIEM and PNPEC on any intervention Gradual transfer of preventive maintenance to DIEM Inform all actors of any change of activities/personnel etc Preventive and curative maintenance

SOME KEY RESULTS SINCE Sept 2011 Maintenance contract with 7 companies to maintain 257 pieces of equipment and are monitored by MoH/DIEM National database of all equipment procured under PEPFAR, Global Fund and WB/MAP (PUMLS) National database for curative and preventive interventions National SOPs developed for intervention Preventive and Curative maintenance

PROCESSUS D INTERVENTION CURATIVE 1 2 3 Signalement de la panne à la DIEM par les services utilisateurs Transmission par la DIEM de la demande d intervention aux compagnies de maintenance Echanges téléphoniques entre les points focaux sur les sites et les agents des compagnies de maintenance PROCESS FOR CURATIVE MAINTENANCE INTERVENTION Non Réparation à distance possible? 4 Oui Passage sur les sites des agents des compagnies de maintenance pour un diagnostic approprié 5 Non Pièces à remplacer? Oui 7 6 Non Coût de la pièce inférieur à 50 000? Oui 8 Transmission à la DIEM du RIT et de la facture proforma de la compagnie de maintenance 9 Etablissement par la Cellule fiduciaire d un bon de commande et transmission à la compagnie de maintenance 11 10 Réparation de l équipement Transmission à la DIEM du RIT par la compagnie de maintenance 12 Actions 3 Levels of intervention Up to 3 months 12 Transmission par la DIEM d une copie du RIT à la Cellule Fiduciaire et à tous les intervenants

1 Transmission par la DIEM d un mail de rappel aux compagnies pour la maintenance préventive PROCESS FOR PREVENTIVE MAINTENANCE INTERVENTION 2 Confirmation par mail des compagnies de la date prévue pour la maintenance préventive 3 Information par la DIEM des services utilisateurs du passage de la compagnie de maintenance 4 Passage d un technicien de la compagnie de maintenance pour l entretien préventif en présence du représentant de la DIEM 5 Transmission à la DIEM par la compagnie de maintenance d une copie du rapport d intervention signé par le technicien de maintenance, le service utilisateur et le représentant de la DIEM 6 Transmission par la DIEM d une copie du RIT à la Cellule Fiduciaire et à tous les intervenants concernés 6 Actions 3 Levels of intervention Follow the annual plan

Challenges Back-up equipment Most private companies do not provide back-up equipment Regional office Only one company has a regional office outside of Abidjan Problem with rapid intervention on site Cost of maintenance contract Only PEPFAR and Global Fund have budget allocations The MOH does include DIEM, but resources are not sufficient for adequate intervention Human Resource needs at DIEM and CREEM Spare parts for equipment National policy document for Biomedical equipment management

Way Forward Strenghten DIEM and CREEM for preventive maintenance Decentralisation of DIEM in the remaining region (13 more CREEMS) Stock of Spare parts at Country Level Increase capacity of trained bio-medical technologist Include maintenance in purchase contracts

Thank You!