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IN THIS ISSUE:
Region Facing Funding Challenges Laboratory Champions Laboratory Strengthening

Challenges of Funding for the Caribbean

Are the Golden Taps Being Turned Off?
A newspaper article of Friday, October 18, 2012, in the Trinidad Express, titled The Golden Taps Being Turned Off by Sir Ronald Sanders, alerts readers to the trending sentiments in international circles about aid to developing countries. A brief review of this article suggests that Caribbean Governments and health programme and project managers in our region should be seriously concerned about the current discussions and decisions on international aid for developing countries. More specifically, those of us holding responsibility for ensuring the quality of laboratory operations and delivery of laboratory services should carefully examine the implications of the recent European decisions on aid.
Continued on Page 3

ISSUE #2 JANUARY 2013

A publication of Caribbean Med Labs Foundation By the Caribbean for the Caribbean

EDITORIAL
Shine Bright Like A Diamond
Dr Stephen King Chairman, CMLF
Dr King is an Independent Senator in the parliament of St Lucia, Laboratory Director, and former Chief Medical Officer in St Lucia.

Letter to the Editor

s we start 2013 , let me wish all readers and all colleagues in the laboratory network peace and prosperity. There is no doubt that we are in challenging times. The international and national financial situation over the last four years has resulted in an environment of less external aid, mounting national debts and in general less real income for many individuals. Many of us had become relatively complacent, comforted and supported by fairly generous budgets propped up with external financial support. The present situation is contracting and many of us are beginning to feel the squeeze, compounded by a public demand and Government demand that we continue to provide the same or better levels of service. This is further complicated by the lack of understanding of laboratory medicine by Governments, the public and many health care professionals. We must meet these challenges and so we can. We are already changing to meet the challenges and these changes will make us better. We must respond by making our operations more cost-effective. Many strategies are being employed: implementing more efficient technology, sourcing cheaper supplies and consumables, and implementing robust quality systems so that we get it right the first time. We are implementing quality systems that mimic the Toyota approach where all our staff are involved in streamlining the workflow to ensure that every step in the process is efficient and that waste is continually identified and eliminated. This is not easy and demands that all of us are thinking and pulling as a team focussed on our output. It means that our management and governance must be sensitive and responsive to our bench top. We should also be exploring partnerships that help each of us implement the above. On reflection on our challenges and responses the reality that begins to emerge is that we are becoming better, and our metamorphosis will produce better quality, more efficient and cost-effective operations. We will be less reliant on external support and more self sustaining. Our resilience is being tested and as George Washington has said perseverance and spirit will work wonders for us. Another way of thinking about it is that diamonds are created by exposing carbon to high pressure and high temperature. So fear not for we are diamonds in the making. As Rihanna sings Shine Bright Like A Diamond.

For the last 30 years, at least, there has been a thread of concern running through meetings of many types and levels as far as medical laboratory technology is concerned. At various gatherings at the local level, at CASMET and CARECs Lab Managers meetings there are questions about adequate staffing and sourcing of medical technologists. We hear comments such as: We cannot cover our technical areas much less assign a quality manager, Emergency duty is taking a toll on the regular technologists who barely get to cover the assigned testing of the day. Where is the time for accreditation preparation? It has been indicated that 75% to 80% of all medical decisions are made based on laboratory test results. Expectations are that 100% of laboratory tests are accurate, and reliable. It is also expected that all laboratory requests are returned within acceptable time limits, in order to effect appropriate treatment. And most labs do actually bend over backwards to try to achieve these goals. But what seems to be given little attention is the actual number of medical technologists, laboratory technicians, phlebotomists etc who are needed per number of tests to be performed, per country size, per shift, etc. Is there some index that could be referred to when lab managers, for example, make a claim for increased staff at respective laboratories? When will we pay proper attention to the human resource aspects of the medical laboratory? Jasmin Hanley Former Lab Manager, St Kitts and Nevis

Challenges of Funding for the Caribbean

ARE THE GOLDEN TAPS BEING TURNED OFF?
Continued from Cover

>> What are the danger signals?

Tough economic times and austerity measures in Europe, says Sanders, have brought to the fore the concerns of politicians and the general public in European countries about the flood of funding being given to developing countries at the expense of local citizens who are being forced to tighten their belts following onerous Government spending cuts. European citizens at all levels of society are calling for aid allocations to be redirected to meet domestic needs. Even local British media entered the fray in 2012 declaring that British aid helped pay for a 2 million pound hotel in Barbados: Anger as millions in taxpayers cash go to projects in richer nations.

DID YOU KNOW THAT

There is a planned regional initiative for elimination of Mother-to-Child Transmission of HIV and of Congenital Syphilis in the Caribbean.
GOAL: To eliminate mother-to-child transmission of HIV and congenital syphilis in all the Caribbean countries and territories by 2015. A Technical Working Group (TWG) consisting of PMTCT, STI and MCH experts from the Caribbean, PLWHA, CARICOM/PANCAP representatives and UN Agencies (PAHO, UNICEF, UNFPA, UNAIDS) will coordinate and monitor implementation. Countries can be certified once they achieve the elimination targets and conditions. LABORATORY DIAGNOSTIC SERVICES MUST PROVIDE CRITICAL SUPPORT FOR THIS EFFORT.

>> Should Caribbean governments, programme managers and populations be concerned?

What Sanders is essentially saying is that there is a growing international view that Middle Income countries should not expect taxpayers of other countries to bear their burdens. These views may signal a decrease in the flow of donor resources since Caribbean countries are now in-the-main classified as Middle Income (MICs) with a few even being classified as High Income (HICs). Is Sanders view an isolated one? Further investigation reveals that the European Union has introduced a Differentiated Development Instrument to support its new approach to the allocation of aid. While this is not yet applicable to Caribbean countries receiving aid under the European Development Fund (EDF), the prediction is that its just a matter of time before significant reductions in aid to the region are realised. A November 2012 article by Adrienne Valdez titled Foreign aid, a casualty in EU budget showdown, demonstrates

the wide disparity in views on aid allocation to developing countries. Aid groups, threatened by the rising tide of opinion against the current levels of aid, felt it necessary to significantly increase lobbying efforts prior to the preparation of the 2014-2020 EU budgetary process to ensure, says Valdez, that foreign aid wont become collateral damage.

policy threats. Everyone agrees that maintaining current levels of European aid post 2013 is fundamental to sustaining Caribbean development. However, Jessop noted, Caribbean Governments response to the danger signals emanating from Europe and elsewhere has been at best lukewarm. With limited support for the Caribbean to be expected from Brussels, says Jessop, and little or no rallying of Caribbean public opinion by Caribbean politicians, it is very likely that continuing EU budgetary support to the region post 2013 will in the main decrease, with serious implications for regional development. Sanders in his commentary A dark time for the Caribbean, expresses his doubts about the level of preparedness of Caribbean Governments for the coming aid changes. New policies, says Jessop, may see funding increasingly linked to specific topical issues, such as climate change, regional security, regional integration and improved business environments and available only through regional intermediaries. He observes that neither the Caribbean public nor private sectors seem to be readying themselves for the coming changes in aid policies and the emerging shifts in development thinking.
Continued on Page 4

>> Is the Caribbean response appropriate?

In a thought-provoking article of September 2012, titled The view from Europe, David Jessop, Director of the Caribbean Council, expressed concern about the urgency of the Caribbean response to the mounting

>> Responding to a 21st Century Development Policy

Caribbean Governments and in particular medical and public health laboratories have to consider re-positioning and streamlining their operations for greater efficiency. The reality seems to be that the nature of future development assistance is changing and according to Jessop, where the EU is concerned, seemingly moving towards placing greater focus on issues related to human rights, democracy and good governance (not hugely significant challenges for the Caribbean except for Haiti). From his perspective, there is an urgent need for Governments to think beyond the traditional model of ongoing access to grants and budgetary support for public sector programmes and operations. This shift, of course, includes the need for new mechanisms of support for laboratories.

>> Will medical and public health laboratories be impacted by these projected changes?
The reality is that efforts to improve medical laboratory quality, especially over the past two decades, have received substantial extra-budgetary support from a wide spectrum of donors. In fact, while Caribbean Governments have allocated some resources to laboratory quality programmes, much of the progress made in implementation of quality systems in regional laboratories over the past decade has resulted from funding channelled to the region largely for HIV/AIDS and/or TB and malaria diagnoses by the EU, CIDA, DFID, CAREC/PAHO, the Global Fund, Clinton Foundation and more recently from the US PEPFAR programme through CDC interventions. These extra-budgetary resources have been used to support a wide spectrum of basic and fundamental laboratory needs. The unfortunate reality is that many of the gains made with these funds over the years have been lost through the lack of effective regulatory and monitoring structures at both the national and regional levels. Sustaining quality systems achievements has proven to be arguably the greatest challenge to the delivery of regional laboratory services. Funding reductions have already begun to impact the reliability and continuity of basic laboratory diagnostic services provided by public sector laboratories in several Caribbean countries. Laboratories are experiencing a significant Cash Flow Crunch leading to stock outs of key reagents and supplies; significant equipment downtime due to a lack of maintenance contracts; and overstretched and demotivated staff. This can only get worse if international funding decreases significantly.

Regional labs are facing enormous challenges as they strive to keep up with the demands of health sector efforts to exploding disease situations, and to meet international health regulations (IHR) by 2014 and the millennium development goals (MDG) by 2015. Perhaps more importantly, labs are struggling to meet the mounting demands of local populations. As the funding taps begin to turn off, if the necessary changes are not made quickly, countries risk losing major aspects of their public health laboratory services as some are already beginning to experience. Caribbean Governments must therefore meet these emerging challenges head on, rapidly introducing long-overdue legislation for private and public sector laboratory operations and enforcing the licensing of laboratories. They must now assume full responsibility for achieving and sustaining quality laboratory services. Governments must give urgent priority

Caribbean Laboratories
A Rich Source of Information for Clinical and Public Health Decisions
The Caribbean Med Labs Foundation, under its PANCAP Global Fund grant, conducted a situation assessment which found that the impact of medical and public health laboratories in the Caribbean can be substantially improved by enhancing their capacity to organise, analyse and communicate relevant information.
This is particularly important in view of the shifting burden of morbidity and mortality in Caribbean populations from communicable to non-communicable diseases. Yet, Public Health laboratories largely maintain their traditional surveillance focus on communicable diseases. Clinical laboratories also generate evidence to support Non Communicable Disease (NCD) surveillance, interventions and policy. Because many Caribbean countries face significant resource constraints, a flexible set of information management systems held together by common standards for data storage, classification and data exchange will allow individual laboratory needs to be satisfied, while at the same time maintaining integrity of the overall information network. Once such standards are agreed, technology solutions can facilitate compliance with existing systems. The information was gathered through an interactive web-based questionnaire on the website of the Caribbean Cytometry and Analytic Society (CCAS). The questionnaire was also distributed by e-mail. Preliminary results were shared at the CCAS annual meeting in Montego Bay, Jamaica, in August 2011 and participants were also asked to identify their primary areas of concern for implementation of a Laboratory Information Management System (LIMS). The following picture has emerged from the survey:
Smaller laboratories are as complex as larger facilities; but they have fewer staff and resources. Among participating laboratories, technical staff was somewhat more computer literate than clerical staff. The majority of laboratories maintain workload statistics. Anatomical Pathology was generally least diligent in this regard, but Microbiology departments did so without exception. The difference in levels of attention to statistical documentation may reflect the traditional focus on communicable disease surveillance. Ninety three percent of surveyed medical laboratories have access to IT support. However, power outages are a common challenge.

Governments must be prepared, says Jessop, to demonstrate how aid will be used effectively to diversify economies, enhance production and lead to selfsufficiency.
Health priorities should be based on reliable data, advises Karl Hofmann, Chief Executive Officer of Population Services International. Making evidence-based policy decisions must become the norm. The writing seems to be on the wall for medical and public health laboratories. Laboratories have got to become more focused on cost-efficiencies sharpening their utilization management processes and limiting wastage; measuring the true impact of their services and managing laboratory data to ensure that operational decision-making is based on evidence and that optimum patient care is their principal objective. Governments must develop feasible strategies, policies, detailed plans and strong laboratory networks to ensure that basic functions are transitioned from current external funders in a timely manner. throughout the region to: spearheading laboratory planning and implementation efforts, building a sustainable and competent human resource, refining procurement and equipment maintenance programmes and ensuring that costs are kept to a minimum, laboratory wastage is minimised and use of expensive equipment is maximized. Without appropriate action, Caribbean countries may find themselves unable to meet their international and regional commitments and having to settle for sub-standard and unreliable laboratory services to local populations in the not too distant future.
Wendy Kitson-Piggott, CMLF Laboratory and Quality Systems Specialist

While the assessment has identified major resource implications, there is an urgent need to quantify these, particularly with a view to supporting the work of the newly formed Caribbean Public Health Agency (CARPHA). However, the current information can be used to contribute to development of an implementation framework as the basis of proposals for funding by potential partners. The major conclusion is that with few existing legacy systems, the Caribbean is free to design individual national systems but with the capability to communicate with and share their information with each other, thus operating as one regional system. Importantly, the relative absence of legacy systems in which there has been considerable investment of finance and other resources creates a unique opportunity for designing a truly integrated, connected system, to support surveillance in the Caribbean Regional Network of Medical Laboratories. Results of the survey were also presented to an international audience at the annual conference of the African Society for Laboratory Medicine (ASLM) in South Africa in December, 2012.
Dr Wayne Labastide currently lectures in Immunology at the Faculty of Medical Sciences at the St Augustine Campus of the University of the West Indies. He is a valued associate of the Caribbean Med Labs Foundation.

Read a longer version of this article, with references, at: www.cmedlabsfoundation.net

CMLF Associate, Dr Wayne Labastide, an Immunologist and qualified Information Management Specialist, with a focus on and experience with Medical Laboratory Information, conducted a survey in August 2011 to determine existing and missing elements of sustainable information management infrastructure in laboratories and host institutions. The results will inform strategic decisions to address common and country-specific issues.

Preparing Laboratory Champions for the 21st Century

>> Sharing Experiences and Lessons Learned

Cayman Islands: Today, Judith, in her previous capacity as Quality Manager of the Cayman Islands Hospital Laboratory and recently appointed Laboratory Manager, can boast of taking her laboratory to the brink of an accredited status. She accomplished this through strong advocacy, planning and good leadership at the laboratory level and enormous support from the hospitals senior management team. Management ensured that the laboratory was well-equipped, had an infrastructure conducive to quality operations, and was supported by an efficient procurement system, excellent biomedical services, and an integrated laboratory information system. These were essential for providing reliable and timely information to clients. Judith admits the only reason that her laboratory is not accredited is due to the fear of failing. Staff have now committed to achieving accreditation in early 2013. Moving past accreditation to the bigger vision of an increased scope of services and even the provision of a regional reference service, says Judith, is on her laboratorys agenda. Dominican Republic (DR): Rebeca, having inherited a family laboratory business, has presided over the growth of the business from one to three laboratories. She was lucky, she says, to have had the chance to enroll in the SMLS project, and motivated by her peers in the programme, she set out to become a model and motivation for laboratories in the DR. For her, the laboratorys turning point was in fully accepting the ISO 15189 Standard as the benchmark for laboratory practice.
Judith Clarke Rebeca del Castillo Zonain

Rebeca seemingly did all the right things from the beginning. She wisely focused on providing training for staff to ensure their understanding and application of the Standard and insists that the first gap analysis against the ISO Standard was a key factor in identifying quality improvement tasks for staff and involving staff in developing quality documentation. She emphasized that streamlining her procurement and equipment maintenance systems was a critical success factor. Rebeca notes with pride, the dramatic changes in organizational culture over time as staff became accustomed to doing the right thing right. It is a challenge to sustain quality efforts, she says, but feels that the patient outcomes are worth the intense staff efforts and financial investment made. Her laboratory is now a model and classroom where others come to observe a laboratory quality system in operation.

Key Success Factors

Admittedly the quality journey is fraught with ongoing challenges - time and resources being major deterrents. But what do these regional Quality Champions see as the critical success factors for implementing and sustaining laboratory quality? Recurring themes from all five graduates included:
100% support from administrators and laboratory management a clear institutional vision, shared by all fearless and visionary laboratory leadership thorough knowledge of the laboratory standard 100% staff involvement responsibility, accountability, dedication and commitment a shared vision by all effective teamwork strong communication channels among staff, clients and stakeholders an effective staff recruitment process and structure, and above all a collective will and seriousness of purpose and a primary focus on patient care and safety.

CMLF Director, Ms Valerie Wilson, 2nd, right, after the Opening Ceremony of CCAS conference in St Kitts and Nevis, with, 2nd, left, Dr George Alemnji, Laboratory Adviser, CDC Caribbean Regional Office (CRO) ; Giselle Guevara, Quality manager, CDC CRO; and Dr John Codrington of Suriname at far left. Ms Guevara is one of the graduates of the SMLS Lab and QA Management training programme, along with Ms Jasmin Hanley of St Kitts and Nevis and Ms Condon Jarvis of Antigua and Barbuda.

adical changes occurring in laboratory medicine are pressuring laboratory managers to develop new skills that address not only the explosion of new technologies but new challenges for scarce resources from Governments that are struggling to juggle many competing priorities. This is especially true for laboratory managers in the Caribbean and other similarly resourcechallenged countries. This is the first in a series of articles in which graduates of a revolutionary project Strengthening of Medical Laboratory Services in the Caribbean which served as the catalyst for transforming laboratory quality in the region, share open and honest views about their laboratory improvement journey over the past six years. In these articles, Project graduates share their experiences and lessons learned in the hope that they will motivate, comfort and encourage fellow laboratory professionals embarking on their own quality journey.

The Project designed a three-year training programme aimed at developing management competencies using a practical and action-learning approach and developing Champions for laboratory quality Fifty-five successful managers from the private and public sector in 23 Caribbean countries completed a 3-year programme and earned a post-graduate certificate from the Michener Institute for Applied Health Sciences in Toronto, Canada.

>> How have Graduate Managers used their acquired knowledge and skills?
In this issue of CMLF news, two of the programmes graduates: Judith Clarke, Cayman Islands Statutory Body; and Rebeca del Castillo, Dominican Republic, private laboratory, share their views. Both Judith and Rebeca spoke about the significant impact of this training programme on their ability to face the many challenges encountered when advocating for laboratory quality improvement among administrators and peers who knew little about it. Rebeca acknowledged that the training gave her the confidence that small labs could also implement quality and Judith attributed many of the quality achievements in her lab to the projects success at giving focus and impetus to quality improvement efforts across the region.

Striving for a culture of sustainable laboratory quality in which doing the right thing the right way the first time and every time has been the common goal for all of these laboratory managers who have truly become Champions of Laboratory Quality.
Wendy Kitson-Piggott, CMLF Laboratory and Quality Systems Specialist

For the full version of installment one of this series, please visit our website at: www.cmedlabsfoundation.net

>> Advent of a Regional Laboratory Strengthening Intervention (2002-2007)

As far back as 2002, the Caribbean Epidemiology Centre (CAREC)-PAHO-WHO initiated an EU-funded multi-prongedproject, Strengthening of Medical Laboratory Services (SMLS) in 23 Caribbean countries.

Tammy Hendrickson

Trudy Leonce-Joseph

Haidi Tjon Kon Fat

Critical Success Factors Identified for Laboratory Strengthening

or regional projects to strengthen laboratory operations to succeed there must be active and supportive partnerships between implementing entities and policy-makers within Ministries of Health and CARICOM.

The following were identified as key critical success implementation strategies:

1 Credible regional organisation as implementing

agency.

2 Tangible support from Ministries of Health. 3 Active support for introduction of regional policies
through CARICOM.

4 National champions for laboratory quality 5 Establishment, resourcing and sustained

This is the major finding of a review of Laboratory Strengthening Regional Projects which the Caribbean Med Labs Foundation conducted in 2012, under the PANCAP Global Fund grant. The exercise involved document reviews and key informant interviews to gather data for analysis and determination of challenges, best practices and critical success factors. The review included projects implemented by the Caribbean Epidemiology Centre (CAREC) in 23 countries between 2002 and 2007 and the Caribbean Med Labs Foundation in partnership with CARICOM/PANCAP in 2011-2012. CMLF Director, Ms Valerie Wilson, and CMLF Laboratory and Quality Systems Specialist, Ms Wendy Kitson-Piggott carried out the review and analysis.

improvement to ensure national implementation and follow-up. implementation of national laboratory strategic plans, and Tangible, supportive and complementary

6 partnership between agencies working on

laboratory strengthening within the region.

This review is particularly timely, coming as it does in time for the launch of the Trinidad and Tobago-based Caribbean Public Health Agency in January, 2013. The Caribbean Med Labs Foundation presented findings of this review at the annual conference of the African Society for Laboratory Medicine (ASLM). South Africa, in December 2012.
Valerie Wilson, CMLF Director, Laboratory Management Specialist

Vision Mission

The regional champion for best practice in Medical Laboratory Services. Promote and support the achievement of quality laboratory services in accordance with appropriate standards, through advocacy, resource mobilisation, collaboration, research and education.

The broad objectives of the CMLF include:

Continued development of the supportive environment for the rapid expansion of high quality regional laboratory services Advocacy at the highest levels for the implementation of relevant laws, regulation and accreditation of regional laboratories Mobilisation of resources for laboratory strengthening efforts Mapping of a regional coordinating strategy to ensure sustained laboratory strengthening efforts.

The CMLF Board Members:

Dr. Stephen King, Chairman
Independent Senator, Laboratory Director and former Chief Medical Officer, St. Lucia.

Mr. Lawford Dupres, Deputy Chairman Ms. Ingrid Lashley, Treasurer

Former Director, Trinidad and Tobago Bureau of Standards and former Director, CARICOM Regional Organisation for Standards and Quality. Valerie Wilson Director Wendy Kitson-Piggott Laboratory and Quality Systems Specialist Director, Trinidad and Tobago Mortgage Finance Co. Ltd.

Mrs. Marvo Harper, Secretary Dr. David Picou

Legal Practitioner, Trinidad and Tobago. Former Director, Caribbean Health Research Council.

Dr. Farley Cleghorn Dr. Paula Burns

Senior Vice President and Chief Technical Officer, Futures Group, USA. Provost and Vice President (Academic), Northern Alberta Institute of Technology, Canada. Wayne Labastide Laboratory Information Systems Specialist Louise Mathura Administrative/Finance Assistant

Mr. Jones P. Madeira Dr. Sonia Roache

Manager of the Information and Protocol Division of the Judiciary of Trinidad and Tobago. Caribbean College of Family Physicians, Private Practitioner, Trinidad and Tobago.

Cheryl ONeil, Editor Caribbean Med Lab News

63A Petra Street, Woodbrook, Port-of-Spain, Trinidad, W.I. | Telephone: 868 628 5911/4765 Fax: 868 628 4765 Email: cmedlabsfoundation@gmail.com Website: www.cmedlabsfoundation.net