When I arrived to the Bonsaaso Millennium Villages Project (MVP) site, my first impressions regarding the status of healthcare delivery were above expectations: I was pleasantly surprised about the great work that MVP and the Ghana Health Service had carried out in this cluster. I found 7 functional health centers, managed by midwives operating as doctors, assisted by a team of community health workers. The 7 clinics in the cluster are in charge of several tasks and activities for the communities they serve, such as Antenatal Care (ANC), maternal and child health, family planning, skilled-attended births as well as routine healthcare for the whole population.

Bonsaaso, which is located in the Amansie-West District of the Ashanti Region of Ghana, is one of 14 sites of the Millennium Villages Project. The mission of MVP is to work with villages to develop and implement plans for achieving the Millennium Development Goals (MDGs) in reducing poverty and hunger, HIV/AIDS, Tuberculosis, malaria, child and maternal mortality, and improving access to essential medicines, primary education, water and sanitation, gender equality, and science and technology. This project is a proof of concept that the package of interventions can be implemented simultaneously with the per capita cost developed by the Millennium Project. There are 14 clusters of villages throughout ten countries in sub-Saharan Africa, where an interdisciplinary team from Columbia University and international and national institutions are conducting research on this integrated approach to development that is led and implemented by the communities themselves.

The area where Bonsaaso is located is characterized by hot, humid and tropical climate conditions. The poor state of the roads coupled with lack of sufficient vehicles in the cluster make the healthcare delivery difficult. It takes patients on average one hour walking (distances range from 2 to 9 km - or 1 to 6 miles) to reach the health center located nearest to them. Similarly, the movement of sick patients to the reference hospital, located 40km (or 25 miles) away from the furthest point in the cluster, is equally challenging. When I arrived in the cluster in October 2010, the health centers were functional, but none of them was equipped with a laboratory. Having access to adequate laboratory diagnosis capability would increase entry points within the overall healthcare system. Therefore, the Bonsaaso cluster was selected in 2010 to be the first to demonstrate a new MVP initiative: the Tropical Laboratory Initiative.

The main goal of the Tropical Laboratory initiative (TLI) is to combine and simplify the latest technologies available for diagnostics at the point-of-care. Its purpose is to reduce the number of missed and misdiagnosed cases and also provide an entry point into clinical care for all patients. The package of diagnostics covers the main investigations required for antenatal care as well as the diagnostic tests for malaria, HIV/AIDS, tuberculosis, neglected tropical diseases and basic biochemical analysis.

The TLI project in Bonsaaso is the result of the collaborative work between the Bonsaaso Health team at MVP and the GlaxoSmithKline (GSK) PULSE program. PULSE is a new corporate responsibility initiative at GSK that empowers employees to use their professional skills and knowledge during a six-month experience within a non- profit or non-governmental organisation (NGO). As the GSK Pulse volunteer selected for this project, I joined the MVP Health team, working closely with the Health Coordinator, Eric Akosah and the Laboratory Technologist, Francis Frimpong, as well as the TLI project manager, Dr. Yanis Ben Amor. The TLI project, which was launched shortly after my arrival in Bonsaaso, is now a reality and the laboratory was opened for its first diagnoses in December 2010.

The laboratory is based in Tontokrom, one of the Bonsaaso cluster communities. Tontokrom is located strategically in the middle of the cluster (see map) and there was a pre-existing facility with ideal dimensions to be refurbished as a laboratory. When the TLI project manager and I arrived in October to initiate the project, we quickly noted the various challenges ahead. We indeed had access to a building, but that lacked access to water, electricity, reagents, or any equipment. However, the MVP health team in place was excellent. In addition, all the health personnel were thrilled about the concept of the new laboratory and especially how it would assist them in their early diagnosis.

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p>From its inception, the project was designed to have three successive and additional components. The first and main part, the level 1 of the three-tiered approach, covers the villages and the 7 health centers of the Bonsaaso cluster and was planned with the following components:

• In the center of the system, Tontokrom laboratory would be set up and operational,
• An additional laboratory staff member would be selected to run the new facility at Tontokrom in conjunction with the existing laboratory technologist, to prevent any disruption in workflow due to trainings, travels, sick days or holidays.
• Tontokrom laboratory would be connected with the seven community health clinics belonging to the Bonsaaso Cluster, A specific focus would be placed on the individual Community clinics by:
  • Training midwives and Community Health Workers,
  • Developing a minimum
  • and simple package of diagnostic tests,
  • Providing regular feedback in both directions of the system, therefore developing a high level of communication between the central laboratory at Tontokrom and the clinics in the periphery.

The second and third parts of the three-tiered approach then integrate the local initiative (level 1) with the Saint Martin’s District Hospital laboratory at Agroyesum (level 2) and finally, with the Public Health Laboratory (PHL) in Kumasi (level 3).

The first three months of the project focused exclusively on level 1, therefore on putting in place all the required components for a functional laboratory. Since Tontokrom had no access to electricity, purchasing a generator was a major requirement for this building located in the middle of the rainforest. Apart from providing equipment and reagents, access to running water or electricity, the TLI team has also been developing quality assurance and quality control (both internal and external) protocols that are easy to use and to implement locally.

In this first phase, the Community Health Workers were trained to appropriately deploy new tests and ensure bio-safety for themselves and patients. To that end, we benefited from the invaluable support of Becton Dickinson (BD) who organized a training session on phlebotomy that was part of the package given to the workers of the 7 clinics. This package of trainings also included a review of laboratory services requests by Dr. Ofori Amanfo from Saint Martin’s District Hospital at Agroyesum.

The laboratory team is now initiating level 2 that encompasses samples that the TLI is not able to analyze at the village level because of lack of adequate equipment, such as the measurement of CD4+ T cells in HIV positive patients. In order to avoid travel of patients to the Agroyesum District Hospital, TLI is developing a sample transport system between Tontokrom laboratory and the hospital, building on an already existing TB collection and transporting system from the Bonsaaso cluster to Agroyesum. We are also planning on gradually phasing out all paper-trail communication between our integrated laboratory and the 7 peripheral health centers and will replace it by RapidSMS, a system that will use text messages to request and share laboratory results.

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p>All seven of the health centers in the Bonsaaso cluster are now integral parts of this new Tropical Laboratory initiative. At the end of March 2011, I will return to my position at GSK in Spain as my time in the PULSE program will have come to an end. I believe that the biggest challenge to address in that time will be the transportation of samples due to the poor condition of the roads. The second most significant goal for me to accomplish before I leave is getting midwives and community health nurses into the habit of requesting the needed investigations to help in the early diagnosis of patients. But as you’re reading this, dozens of specimens are already being analyzed daily in the newly opened laboratory in Tontokrom, increasing the number of accurately screened cases placed on appropriate treatment and decreasing the cost and number of misdiagnosed cases. Now, we need to make sure that the patients in the Bonsaaso cluster covered under the TLI become the rule in Africa, rather than the exception.