Public Health administration lays generally within the purview
respective country government and with Ministry of Health. Within Ministry of
health, public health diseases form a separate ‘unit’, ‘division’, 'department' or ‘directorate’
based on the staffing, reporting lines, level of management and importance of disease burden.
Tuberculosis is public health problem categorized under the communicable
diseases group along with HIV/AIDS and Malaria. In Africa, several of the
administrative structures were established in colonial era, and does not
reflect present realities. Although post-colonial era pandemic- such as
HIV/AIDS-grow into new administrative structures, the old health structures
often readjust to the new realities. In several African countries, public
health laboratory services are a separate directorate, or unit within the
ministry of health. Due to emergency of HIV/AIDS, in general, the
administrative structure of it has direct reporting linkages with highest decision
making authority in the countries, often above the ministry of health. In this blog let’s review prevalent structure
for delivery of public laboratory services (focused on TB) in Africa. An
enabling environment in faster implementation of policy changes needed with
changing public health policies and WHO/ International health policy requirements
depends on understanding strengths and weakness of health administrative
structures, particularly, laboratory and treatment linkages.
Type 1: Laboratory services and public health services are
two separate directorates under ministry of Health. National TB program is
under the directorate of public health diseases, although national reference
laboratory (if building existed historically) is partly ‘owned’ by NTP- and
staffed by the directorate of Laboratory services. Teaching universities/academic
institutes with lots of students and interns waiting to do their degrees and
projects would like to be associated with public health labs where samples are
aplenty. This makes a university teacher/
medical microbiology in general, ideally suited to lead the National TB lab,
ex-officio. The teacher draws salary
from university, and research drive/large scale samples (ethically) from the
public health labs. Funding is partly from research studies (projects),
government (for utilities), and National TB Program (through donors). (Uganda
model)
Type 2: Laboratory services and disease control/ Public
Health are two separate directorates/ departments under the MOH. However, TB reference
Lab falls within the purview of general laboratory services and reports to
directorate of lab services. The principle technologist or in-charge of TB lab
does double reporting, in practise. The academic/teaching institutes are weak
or non-existing. Service provision occupies most of the time, and no time left
out for conducting any operational studies. Funding is both from Lab services
and also from disease control divisions. (Lesotho, Swaziland, Kenya, Eritrea,
Botswana etc., majority of Southern and East African countries come under this model)
Type 3: Laboratory services are under a parastatal body. Government-owned
commercial entity providing laboratory services at a cost to the ministry of
health. All disease control programs buy the lab services from this body. To
exist and survive, this system is government’s baby and has no notable competition
from Private labs in the country. To retain the competitive advantage, the
parastatal body also offers services to the private bodies and individuals. A board
of members duly appointed by the Ministry of health run the management. It works
for accountability, as per test costs provide operational costs. Insurance
(medical aid) organisations also support this model. Namibia is exclusive
member of this model. To be successful in this model, the price for per-test should
be determined proper costing such that not be prohibitive while obtaining the
tests. South Africa also has similar model. Although the management of public
health lab services is independent of government interference, on day-to-day
basis, the final financial issues are fully managed by MOH and private institutions
do not get availed the lab services without referral.
Key issues for efficiency in all these models are funding source, linkages
with disease control programs, sustainability of the funding, accountability
and quality management of resources. No model seems to fit ideal- although autonomously (parastatal) run lab services with commitment to public health laboratory functions and direct linkages with disease control
programs seems a better system.
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