By Dr. Poyap J ROONEY
The following discussion is a proposed strategy for the future development of the clinical laboratory services, education and research in PNG.
This article is not the first to highlight problems of poor quality results and lack of standardization; and put forward recommendations for improvements. In the 1992 National Quality Assurance Program (NQAP) – Report on Batch number 2 (1),it was recommended that:
“As part of an overall responsibility for the NQAP, participation of a committee comprising the National Department of Health (NDoH), National pathology service, central public health laboratory (CPHL) service, college of allied health sciences, University of PNG and World Health Organisation is essential. Working as a group, they can improve the efficiency of administration and management of the program; assist in the development in human resources policies for medical laboratory workers and standardization of administrative and technical procedures”
I agree wholeheartedly with these recommendations. The question is,however, why, after more than 20 years, these important recommendationshave not been taken up and we have seen a failureto improve and in fact a decline in clinical laboratory standards at PMGH andmost likely in other laboratories throughout PNG.
One can infer two major general reasons:
On one hand, there has been afailure of the general healthcare community in PNG to see these issues asimportant and a priority for our health system and on the other hand, lowmotivation and resolve from the medical laboratory community to take alead in addressing these issues and highlighting them as an important.
Today, the environment is more conducive and there are more opportunities for significant and sustainable improvements to be made.
The upgrading of the Medical Laboratory Scientist undergraduate program from a diploma to a bachelors program in 2005 has produced scientists with more knowledgeable in clinical laboratory medicine.
There are now a total of 11 qualified pathologists working as pathologists either with the PMGH and NDoH providing service or with the University of PNG providing undergraduate and postgraduate training and also service to PMGH and NDoH with another 5 currently in training (current figures from the date of writing – 2014).
The PNG Medical Society at its 2008 annual general meeting resolutions has recognized the importance of Clinical Laboratory Medicine in the National health system and the need for capacity building, standardization and accreditation in this area (2). These resolutions have been incorporated into the next National Health Plan.
The National Institute of Standards and Industrial Technology (N.I.S.I.T) are moving towards establishing an accreditation scheme for medical laboratories.
- PNG is currently enjoying an economic prosperity and stability, not experienced since independence.
The government has recognized the important role of the private sector in nation building with the drafting of a Public Private Partnership for the provision of infrastructure and services to its citizens (3).
To capitalize on this current favorable environment there needs to be a pooling and focusing of the available resources to improve clinical laboratory services. To achieve this, a new entity needs to be established, with an appropriate legal and business framework, operating with the principles of good governance and business. The new entity must have participation from both the private and public sector.
I propose here the concept of Papua New Guinea Reference Clinical Laboratory Limited (PNGRCL Ltd)as such an entity.
The PNGRCL Ltd. must have representation from all stakeholders, including:
National and international professional organizations
Government departments and regulatory bodies
Research and educational institutions
International development partners
And other relevant private sector partners.
The main functions of PNGRCL Inc. will be to:
Manage the PMGH Pathology Department with a more unified and streamlined management organizational structure, with a single line of command and a special attention to human resource development and sound and transparent financial management.
Work towards accreditation and being the national authority in setting and maintaining standards for clinical laboratories throughout the country. Accreditation to International standards would be unrealistic in the near future, but an initial national accreditation scheme based on international standards, taking into consideration the local situation and needs would be a good starting point and stepping stone to acquiring accreditation to the more stringent international bodies like International Standards Organisation (ISO) and National Association of Testing Accreditation, Australia (NATA).
Provide research capacity and opportunities, education and training at undergraduate and postgraduate levels.
Be the link to overseas professional organizations, regulatory bodies, educational and research institutions and medical equipment manufacturers.
The figure below is a schematic representation of the various possible partners in the PNGRCL Ltd. With the foundation and national ownership comprising of appropriate professional organizations – PNG Association of Pathologists (PNGAP), PNG Medical Laboratory Technicians’ Association (PNGMLTA); the University of PNG (UPNG); the National Institution of Standards and Industrial Technology (NISIT) and other government organisations. This will provide the foundation and base for the integration of the various overseas professional organizations, international accreditation authorities and developmental partners willing to support.
PNGRL Ltd Personnel Management
In establishing this new entity, certain criteria need to be established to suiteach of the various positions, in order to fill these positions withappropriately qualified personnel. These should include criteria for minimumeducation and experience. For example all clinical directors must have aMasters in Medicine (Pathology) from the UPNG or an equivalentqualification, while the general scientific supervisors must have Bachelorsdegrees in Medical Laboratory Sciences (BMLS). It would be beneficial for the general supervisors and all directors to have some specific laboratory management training.
While it is important to have appropriately qualifiedstaff occupying position and great efforts must be made to achieve this, duerecognition must be given to the contributions of past, under-qualifiedmanagement staffs that have had to fill senior management positions due topast lack of appropriately trained personnel. A reasonable opportunity mustbe given to these individuals to upgrade their qualifications and acquire theappropriate training to continue at their respective positions.
PNGRCL Ltd to spearhead Distributed Diagnostic and Rural Health Care (D2RH)
In developed countries there is a trend in modern medicine is towards the decentralisation of healthcare away from the large specialist hospitals which have traditionally housed the complex and expensive equipment required for the practice of modern medicine; towards healthcare that is more accessible outside this hospital setting (4, 5).
There has been an explosion in research and development into P.O.C.T technologies in recent years and an increase in their use. This has mainly been fuelled by the trend in decentralisation described above and the market forces resulting from this (6, 7).One of the advantages of most POCT is that it requires minimal expertise and most often the test procedure and interpretation can be performed by nonmedical personnel and often by the patients themselves.
The term distributed diagnostics and home healthcare (D2H2) describes the concepts of the distribution of diagnostic services, utilising appropriate information technology and Point of Care Testing (P.O.C.T) technologies; and making the practice of modern medicine available, outside the hospital setting. The forces, acting on the health system of the developed nations giving rise to the above trend are similar but even more powerful in countries such as Papua New Guinea. This makes a change in direction towards decentralisation intensely relevant and appropriate in our setting. Hence the concept of distributed diagnostic and rural health care (D2RH), whereby diagnostic services and with it healthcare delivery, can be made available to our rural based people.
The PNGRCL Ltd to spearhead Telepathology.
We must capitalize on the current available technologies to establish and maintain an appropriate Laboratory Information System which is to be interfaced with the hospital information system (H.I.S) and a Telepathy system which will allow the acceleration and quality assurance of many pathology services throughout the country.
The concept of telepathology and eHealth is being implemented in many parts of the world with success and is gaining momentum and support from many large international organizations (including the W.H.O), collaborating to achieve a better global access to basic health services.
PNGRL Ltd to ensure the selection of appropriate and sustainable technologies.
PNGRL Ltd will select the most appropriate laboratory equipments from the world market, which should include criteria for cost per test, technical support, personnel qualifications and training etc; supervising their installation and training of laboratory
personnel and preventative and service maintenance. The choice of equipment should be uniform across the country, as much as possible. This uniformity will have the advantage of simplifying reagent and other consumable supplies and services.
National Quality Assurance Program – 1994: Report on the results of batch number 1, May 1994.
The PNG Medical Society – 2008 Annual General Meeting – Resolutions from the Medical Symposium.
Draft National Public Private Partnership Policy Prepared by: Public
Private Partnership Task Force, 2008.
Paul Yager, Ph.D, Professor and Acting Chair, Department of Bioengineering, University of Washington, College of Engineering: Motivational Manifestos
Paul Yager et al: Microfluidic diagnostics technologies for global
public health; Nature, Vol 442, 27 July 2006.
Piia von Lode: Point-of-care immunotesting: Approaching the analytical performance of central laboratory methods; Clinical Biochemistry 38 (2005) 591 – 606
Ellis Jacobs, Point-of-Care (Near-Patient) testing, in: Kaplan and
Pesce’s Clinical Chemistry, 4th Edition, 2003, Chapter 17.