Integration of Tiered Networks within Public Health Institutes: The Ethiopian Public Health Institute (EPHI) Experience

In the last decade, Ethiopia has achieved numerous public health successes, among them early attainment of health-related Millennium Development Goals, a strong tuberculosis (TB) management programme, and progress toward eradication of Guinea worm disease [1-3]. Many of these successes are owed to health outreach in the community, but the ongoing development of strong national institutions is crucial to support healthcare at the community level. The Ethiopian Public Health Institute (EPHI) is one such institution, and a close look at its practices can help other central institutions promote public health through integration with national laboratory systems.

One part of EPHI’s mission is to lead the national public laboratory system. In addition to national reference laboratories, the tiered system includes 13 regional reference laboratories, 300 hospital laboratories, and about 3,700 health centre laboratories [4]. The number and complexity of diagnostic tests available increases with each tier of centralisation. Nine national reference laboratories, centred at EPHI, perform all of the diagnostic tests offered by the national health system on a referral basis.

Being available for test referrals is an important role of EPHI in addition to offering technical and equipment maintenance services. However, one of its major goals is to decentralise laboratory services – extending testing capabilities for more consistent availability for the more than 90 million Ethiopian citizens. To that end, EPHI supports laboratories in obtaining new instrumentation for assays like HIV viral load and DNA-PCR. EPHI also spearheads the introduction of new diagnostic technologies. Reference laboratories at EPHI have tested new technology including the GeneXpert TB test and rapid diagnostics for gonorrhoea and malaria. If a new technology is approved, EPHI publishes detailed guidelines for its implementation and coordinates maintenance contracts [5]. To ensure peripheral laboratories’ success as they take on new diagnostics, EPHI administers a national External Quality Assessment (EQA) programme, with 175 laboratories participating in evaluation of one or more assays [6].

About 20 regional and hospital laboratories use Ethiopia’s standardised laboratory information system (LIS) to share information with EPHI. These data enable EPHI to build databases that include EQA results, records of training and equipment maintenance, and disease-specific metrics. Outside of the LIS framework, EPHI also collates and analyses weekly Integrated Disease Surveillance reports from health facilities for the 20 reportable epidemic prone diseases, maternal death surveillance (MDSR), and acute malnutrition. In 2013-2014, EPHI received and responded to over 2,000 notifications of potential public health emergencies from peripheral laboratories and health facilities [7]. Ninety percent of reported cases of diseases with epidemic potential were laboratory confirmed, and EPHI coordinated rapid responses to a case of polio and outbreaks of measles, dengue, and yellow fever.

In addition to organising information from healthcare providers nationwide, EPHI also provides novel research findings. Targeting diseases that affect the people of Ethiopia, EPHI scientists and epidemiologists conduct laboratory work and epidemiological surveys that range from infectious diseases of global concern to neglected tropical diseases. The results, delivered as technical briefs or articles, include regional maps of disease prevalence and profiling drug resistance patterns, and can guide clinical decision making throughout the country [8].

A functional tiered laboratory system needs more than just equipment and protocols. Recognising that a motivated, well-trained workforce is indispensable, EPHI prioritises training and mentoring. The institute regularly hosts short-term direct training of laboratory personnel from across the country, including a surge of sessions last year on prevention, control, and treatment of Ebola. To extend the impact of training across the country, EPHI also coordinates Ethiopia’s SLMTA (Stepwise Laboratory Management Toward Accreditation) and Field Epidemiology and Laboratory Training programmes (FELTP) [9] [10].

EPHI’s roles of research, public health emergency management, and laboratory quality management were once dispersed across several sectors of the Ministry of Health. “Putting a central, autonomous body in charge of all three functions has improved Ethiopia’s health infrastructure and increased the flexibility of the health system as a whole,” says Dr. Amha Kebede, Director General of EPHI. “Integrating tiered laboratory networks with a national public health institute allows countries to link knowledge to action in order to promote public health.” In order to institutionalise the training aspect, EPHI has constructed a state-of-the-art training centre (pictured above: courtesy of EPHI) with support from the US CDC. It contains a 500 seat auditorium and 14 syndicate rooms where two are designated for hands-on laboratory training of advanced techniques. The centre aims to be fully functional by April 2016.

The framework for the integration of tiered laboratory networks with public health institutes, presented during an ASLM-WHO AFRO Freetown Consultation in October 2015, will be a critical tool for guiding country efforts to achieve successes similar to those seen in Ethiopia.

By: Laurel Oldach; Contributor: Amha Kebede; Editors: Michele Merkel, Rosalie Whedbee, Corey White

[1] Haileamlak. “Ethiopia successfully attaining the millennium development goals.” Ethiopian J Health Sci 25(2). 2015.
[2] Burki. “Ethiopia could be a model country for tuberculosis control.” The Lancet 386(10010), 2015.
[3] Fighting Disease: Ethiopia. The Carter Center. Accessed on 18 December 2015 from: http://www.cartercenter.org/countries/ethiopia-health-guinea-worm.html
[4] Ayana, Gonfa. “Experience of the Ethiopia Public Health Institute in Building the National Laboratory System”. 2015. Presentation Freetown, Sierra Leone. Access 18 December 2015 from: https://aslm.org/what-we-do/global-health-security/freetown-consultation-presentations/
[5] Federal Democratic Republic of Ethiopia Ministry of Health/EPHI. Implementation guideline for GeneXpert MTB/RIF assay in Ethiopia. June 2014, Addis Ababa. Accessed on 18 December 2015 from: http://www.challengetb.org/publications/tools/country/GeneXpert_Implementation_Guideline_Ethiopia.pdf
[6] Ayana, Gonfa. “Experience of the Ethiopia Public Health Institute in Building the National Laboratory System”. 2015. Presentation Freetown, Sierra Leone. Access 18 December 2015 from: https://aslm.org/what-we-do/global-health-security/freetown-consultation-presentations/
[7] WHO-Africa: Ethiopia country topics: IDSR. Accessed on 18 December 2015 from: http://www.afro.who.int/en/ethiopia/country-programmes/topics/4590-ethiopia-integrated-disease-surveillance-and-response-idsr.html
[8] Getahun et al. “Molecular typing and drug sensitivity testing of Mycobacterium tuberculosis isolated by a community-based survey in Ethiopia.” BMC Public Health 2015.
[9] Hiwotu et al. “Laboratory system strengthening and quality improvement in Ethiopia.” AJLM 3(2), 2014.
[10] Ethiopian Public Health Institute. The Second Strategic Plan: 2015/6-2019/20. June 2015.