Southern Ethiopia - Gwent Health Link

29TH FEBRUARY TO 12TH MARCH 2008

This was my second visit to Ethiopia with the Southern Ethiopia Gwent Health Link team. I was part of a laboratory team of three, Dave Williams, Pegah Hafezi and myself.

The purpose of my visit was to participate in a CPD workshop for laboratory workers working in the SNNPR region. A total of 29 attended the course and travelled long distances to attend, with some of them taking up to four days to get to Hwassa, due to the lack of roads and transport. The course included lectures and practicals on TB, Malaria, HIV, standard operating procedures, quality assurance, patient communication and glucose meter training.

I gave a talk on the methods of glucose estimation and glucose meter training. I prepared and distributed laminated posters on the procedure for urine testing and the use of blood lancets. As Ethiopia does not use SI units I prepared and laminated conversion charts for glucose from mmol/L to mg/dL to cover the working range of the glucose meters. I gave out certificates for glucose meter training and distributed glucose meters, testing strips, controls, user manuals, control booklets, lancets and urine dipsticks. Priority was given to those who came from health centres and smaller hospitals who had no means of testing blood glucose. They were also given a questionnaire on their views of the workshop, the subject matter and what they had gained by attending.

On a visit to Yirga Cheffe last November, I talked to some laboratory technicians at the health centre and they particularly wanted a set of Monica Cheesbrough books on Laboratory Practice in Tropical Countries. I managed to source these at greatly reduced cost, if being sent to developing countries. Subsequently, 50 sets of these books were purchased for £20 per set instead of £100. Each of the people on the course was given a set for their workplace and also a set of Microscopy of Tropical Diseases, THT Learning Bench Aid Series 1-9. Both of these will be invaluable to these workers who may be working on their own in isolated health centres. The rest were given to each of the health centres, and the college library at Hwassa College of Health Science.

While in Hwassa I also visited the hospital laboratory and the HIV laboratory. The HIV laboratory now has a BD FACS Canto, flow cytometer. The hospital laboratory did not have any testing strips for their glucose meter, so I gave them some new meters, testing strips, controls etc.

I also visited the chemistry laboratory at the College of Health Science. They were short of chemicals and reagents for doing biochemistry practicals. They had an Apel PD-330UV spectrophotometer and an ME Max digital photo colourimeter for reading optical densities, but not sufficient reagents, in particular for the estimation of SGOT, SGPT, bilirubin and creatinine. They did have some reagents for manual urine tests and were able to do Benedicts test for reducing substances, Ehrlichs test for urobilinogen/porphobiliogen and sulphosalicylic acid test for protein. They had a rotary evaporator which was used in the preparation of concentrated reagents. They also had a PH meter which was used in reagent preparation and also to measure the PH of faeces which was used in the identification of shigella and amoebic disease. They also needed stains for malaria, pathogens and intestinal parasites. I obtained details of their curriculum for the course in medical laboratory science.

YIRGA CHEFFE

I am also a member of the Bryn-y-Cwm community link with Yirga Cheffe. I have a special interest in the town as I was there on a health link visit in March 2007, when the initial letter of introduction from the Abergavenny community was given to the mayor. Then, last November I spent eight days in the town as one of the group that went on the first scoping visit to make contact and meet with the leaders of the town and the members of the various groups in the town. I visited the health centre, schools, churches, and met with the leaders and staff of these, and also members of the women’s groups, youth groups, small industries and farming.

While Dave and Pegah stayed in Hwassa, I travelled with the rest of the team and spent the first two days in Yirga Cheffe. They were very pleased to see us, and the representatives of the twelve committees which had been set up during my last visit were waiting at the mayor’s office to greet us. This community link is very important as the health link want the community to be involved in the promotion and development of this exemplar health centre. The initial progress in this community link has been slow in these early stages since the visit, and it was encouraging for them to see me, as a member of this group, making a return visit.

There was a meeting between the health link and representatives of the community groups, and the memorandum of understanding between the two groups was signed. There was a talk about the aims of the health link to help their health centre, and afterwards, there were discussions between the two groups on this subject. In particular, the leader of the Muslim church, Hassen Abdela, was very concerned about the lack of drugs and antibiotics at the health centre. Biku explained that this was not an area that could by helped by the health link, but was a local issue. However, by highlighting this problem, it is to be hoped that the community will put pressure on the appropriate authorities, so this can be rectified locally. This shortage of drugs has been highlighted by the pharmacy technicians in both of my last two visits so it needs to be addressed as soon as possible.

During my stay I visited the Mayor in his office, at his request, and took a personal message from him, back to the Bryn-y-Cwm committee. I also arranged, at short notice, for one of the members of the women’s group to come to the health centre and meet with Melrose and Robyn who wished to talk to her about the views of the women about the Health Centre.

YIRGA CHEFFE LABORATORY

This was my third visit to this laboratory. On our arrival on the Sunday, Aseleffch, the laboratory technician, came straight up to me and asked if I had brought her a new microscope. This was because she had told me in November that she desperately needed a new one as hers had no light and several of the objectives did not work. She had to use the daylight shining through the window in order to see when looking at films. I explained that we had looked at microscopes in Addis Ababa and were going to buy them on our way back. By now she will be using her new microscope.

This laboratory is only in a small room but is bright and the surfaces are free from clutter and are of a material that can be wiped down easily. Equipment and materials not used regularly are stored in a cupboard thus making more room. In my opinion this is the best and cleanest laboratory of the three health centres that we visited.

I spent some time in the laboratory observing the work in progress. Aseleffch was having to work on her own and was extremely busy, as the other two laboratory technicians were away in Addis for training and because of this she had been unable to attend the CPD workshop in Hwassa. The patients came to the laboratory with a pink slip of paper with their name, age (not d.o.b), sex and the test required written on it. She then gave them a plastic pot for urine samples, or a small stick and a piece of folded card for faecal samples. The patient then went away and came back with the appropriate sample. If a blood sample was needed she took a venous or capillary sample, depending on the test required. Faecal samples were smeared onto a microscope slide, covered with immersion oil and a cover slip, and then examined under the microscope, most commonly for intestinal parasites. The urines were tested with urine dipsticks for glucose, protein, blood etc., and some were spun down to look at the deposit. Other patients required blood samples for malaria, haemoglobin, and differential cell counts which were all done by finger prick. Some venous samples were taken, but these were mainly for HIV testing which was done by a card method.

After she had done the appropriate test, the patient’s details and the results were recorded in a day book. There was a book for each test - TB, malaria, HIV and urines. The results were written on the form and given back to the patient who then went on to see the nurse or medical officer. The turnaround for the tests was very quick, about 30 minutes. This is necessary because these people have come long distances on foot and have a long journey back. One of the girls from the pharmacy gave some help in giving out the sample pots to the patients and recording the results in the books. There was no labelling or numbering of the patients sample, and the only way of tracking it was that it was kept on the appropriate pink form. The possibility for error was very high and improvements to this could be made if there were more resources and training available.

The patients are charged for their laboratory tests. The tests done at this laboratory and the cost, is as follows- (there are 18 Birr to the pound).

• Stool examination - 1 Birr
• Urine microscopy - 2 Birr
• Urine dipstick - 1 Birr
• Haemoglobin - 3 Birr
• ESR - 2 Birr
• Differential count - 2 Birr
• Blood group - 5 Birr
• Blood glucose - 5 Birr
• Pregnancy test  - 8 Birr
• Widal test - 8 Birr
• VDRL test  - 5 Birr
• HIV test - FREE
• Blood film for malaria - 3 Birr
• Gram stain - 5 Birr
• AFB - FREE

Last November the laboratory was given a haematocrit centrifuge, haemometers, ESR tubes and stand, urine analysis strips and glucose meters. Also, when I was there, I gave them glucose meters, testing strips, controls, control booklets etc. I then trained them to use the meters correctly to ensure they were controlled properly, as unless this is done, there is no way of knowing if the result obtained is correct. On this visit I checked that this was being done and was pleasantly surprised to see that they were keeping correct records and controlling the meters. I also saw that they were doing ESR tests using the apparatus given. However, they were not using the haematocrit centrifuge as they did not have any capillary tubes. I watched Aseleffch using the haemometer to do a haemoglobin. This is very encouraging to see them using the equipment that we have given. While observing I saw several cases of Ascaries. Last year this laboratory identified 800 cases of intestinal parasite of which 45% were Ascaries.

When asked what equipment was needed the list is as follows-

• Microscope (this they now have)
• Immersion oil
• Microscope slides
• Haematocrit tubes
• Marker pens
• 30% Ammonia
• Slide dryer
• Staining jars
• Cover slips
• White cell counting chamber
• Disposable masks
• 50 microlitre pipette and tips

WONDO GANET LABORATORY

This was a short visit on a Saturday morning so we did not see any work in process. The laboratory was in a small room which was not very light and was fairly cluttered. There were a lot of boxes and old non-functioning microscopes under the benches, accumulating dust and rubbish. The laboratory would benefit from a good clean and removal of unused items. They were using their microscope in another room where there was more space. I saw the ESR stand and tubes, and the glucose meters were being used, also the urine testing strips, and they now have a new microscope.

When asked what equipment was needed the list is as follows-

• Microscope (this they now have)
• CD4 counter
• White cell counting chamber

ALABA LABORATORY

We visited this on a very busy Monday morning when there were a lot of patients and they were short of staff. We did not stay long as there were patients waiting to have tests done. The laboratory was bigger than the other two but did not have very much equipment. They had a large fridge but this contained a lot of unlabelled samples and out of date reagents. This needed to be cleared out and only items which were labelled and in date retained.

When asked what equipment was needed the list is as follows-

• Microscope (this they now have)
• Haemoglobinometer (Digital)
• CD4 Counter
• Autolab (for measurement of SGOT, SGPT and other biochemistry tests)

CONCLUSION

At all three health centres I saw equipment and consumables in use that had been given by the health link. In Yirga Cheffe they were using the glucose meters correctly, controlling them and keeping records, as I had trained them to do last November. They were also doing ESR’s. Although we did not see the staff working at Wondo Ganet and Alaba, the equipment for both of these was on the bench. At Yirga Cheffe they would have been doing PCV’s using the haematocrit centrifuge they had been given, but they did not have any haematocrit tubes.

All three health centres desperately needed new microscopes, but this problem has now been rectified as they were bought in Addis prior to our return, and are now in use at each health centre.

Yirga Cheffe are desperately short of all pharmacy stock, drugs, antibiotics, antiseptic creams etc, a point brought up by the pharmacy technicians, and by the community at the meeting. This did not seem to be the case at Wondo Ganet and Alaba. We visited the storerooms at both these health centres and, in particular, at Alaba there were large stocks of drugs and antibiotics

RECOMMENDATIONS

The items of equipment and consumables given by the health link to the health centres need to be monitored to ensure that they have continual supplies of non-perishable items such as microscope slides, haematocrit tubes, immersion oil, cover slips, test tubes, ESR tubes, haemometers etc. With perishable items such as glucose testing strips, controls  and urine testing strips, the frequency and quantity of use of these needs to be monitored. We must ensure that they only have sufficient supplies of each, according to the expiry date, so that they are used within their shelf life. This should be monitored, preferably at six monthly intervals, or yearly at most, and restocked accordingly with any out of date stock removed. If they are overstocked these supplies will be wasted, and these valuable resources could have been utilised elsewhere by another health group which have no access at present to these laboratory tests.

Now that all three health centres have a new microscope each, these need to be maintained properly and the staff need to be trained in the care and maintenance to ensure they keep working at optimum performance.