Report on the External Evaluation of The Epidemiological Laboratory (EpiLab) Khartoum, Sudan

Background:
LHL has provided long-term support to lung health services in Sudan and in other nations.  In Sudan, LHL supports the National Tuberculosis Programme (SNTP) and the Sudan Tuberculosis Patients Association (STPA) and the Epidemiological Laboratory (EpiLab) with funds derived from its own resources and with the support of NORAD (Norwegian Agency for Development Cooperation).  This three partner programme aims to maintain the reliable delivery of essential public health services to the population (SNTP); that are responsive to the needs and wishes of those affected by tuberculosis (STPA); and able to ensure good quality and adaptation to emerging and changing needs (EpiLab).

The Epidemiological Laboratory (EpiLab) was established in Khartoum, Sudan in 2005 as an independent, non-government, non-profit organisation.  Its goal is to carry out operational research in public health and to identify, characterise and prioritise challenges to health status and health services delivery and to devise and demonstrate feasible strategies to overcome obstacles and improve the quality and effectiveness of health care delivery.

Purpose/objective:
The overall objective of the external review of the Epi-Lab of Sudan is to:
1.) Assess the progress in relation to 'targets outlined in its medium term development plan'
2.) To identify strengths and weaknesses in the Epi-Lab to prepare for its development towards a self-sustaining centre for excellence in public health research and policy guidance.

The external reviewers are specifically required to assess progress and achievements in the following areas:
A. Epi-Lab's mission, strategy and priorities in the context of LHL and Sudan's priorities and strategies;
B. Institutional capability (including administration, management, organizational setup);
C. Epi-Lab's technical advisory role (national, regional and international) and partnerships;
D. Implementation of research and other scientific activities.

Methodology:
• The team will go through relevant documentation provided by LHL and Epi-lab:
• Medium term development plan, 2004-2009. Annex of TAC 2005 report.
• TAC annual reports 2005 – 2008
• Meet project staff and partners to discuss and understand their roles and responsibilities with the project, how the components work, the strength and difficulties, and what are their suggestions.

Key findings:
The Review Team found that EpiLab has made substantial progress in its implementation of the Strategic Plan. Significant achievements have been made in its research and services development work. The methodology used is systematic, rigorous and effective. EpiLab identifies public health problems, gathers data and undertakes analyses, adapts international best practice guidelines, plans implementation in detail, introduces pilot testing in up to 14 healthcare delivery sites, provides effective ongoing supervision and support, evaluates progress, and adjusts implementation strategies prior to handing solutions over to the Ministry of Health for rollout. This was the pattern used by the National TB Programme in the early years of the decade to develop and implement “DOTS-all-over” in Sudan. The process has been applied to the management of asthma and of childhood lung diseases with impressive results. EpiLab also works in the fields of tuberculosis, particularly in the linkages between TB and HIV/AIDS; in tobacco use avoidance, particularly among TB patients and in zoonotic TB. EpiLab continues to work with the Ministry in promoting rollout of improved prevention and clinical management strategies.
The development over the last five years is even more impressive when considered in the context of the complex economic and political environment in which the institute has functioned. It would be beneficial for EpiLab to have an overarching agreement with the Federal Ministry of Health that would provide an appropriate structure in which EpiLab and relevant divisions and departments of the Ministry could formulate memoranda of understanding or other cooperative agreements. The establishment of EpiLab as a cooperative centre for the World Health Organisation (currently under consideration) should strengthen the basis of a formal arrangement with the Ministry.

Recommendations:
The 16 recommendations below are numbered according to the sections in which they are made in the body of the report. The Chapter and section headings are repeated to align the recommendations. The page number of each recommendation in the body of the report is included in brackets.

Chapter 2. EpiLab’s mission, strategy and priorities in the context of LHL’s and Sudan’s priorities and strategy

a) The relevance of EpiLab’s policies and strategies to beneficiaries

Recommendation 2.a.1:  EpiLab should make greater use of the NTP database to develop attractive, easily comprehendible routine reports that give emphasis to the distribution and utilisation of TB services, particularly illustrating the impact of gender and poverty on services utilisation in regions within states. (Page 3)

Recommendation 2.a.2: EpiLab management should pursue opportunities for mutually supportive activities between STPA and EpiLab particularly in the area of community research and health promotion.  (Page 4)

Opportunities could be offered for sections within EpiLab to regularly meet with representatives of STPA (including fieldworkers) to identify weaknesses in services delivery, discuss common issues and devise joint activities, including the evaluation of the effectiveness and efficiency of proposed activities.

b)   The contribution of EpiLab to meeting Sudan’s public health needs

Recommendation 2.b.1:  EpiLab should introduce branding or other marketing techniques to advance awareness of the EpiLab impact within the individual health care institutions, and among hospital managements, patients and the general public. (Page 5)

c)  EpiLab’s effectiveness in planning, priority setting and undertaking strategies.

Recommendation 2.c.1 EpiLab should review its current collection of section strategic plans within the context of a clearly articulated overall EpiLab strategic plan covering the next three to five years. (Page 7)

This might be most efficiently achieved in a workshop that involves the director and senior staff with section leaders and coordinators led by an experienced facilitator. The purpose would be for the participants to formulate and agree the core institutional strategy and then develop appropriate section strategies that effectively contribute to meeting the overall goals and strategies of EpiLab as a whole.

Recommendation 2.c.2 The strategic plans of sections should clearly define targets and resource requirements. Reports on progress should identify both achievements and obstacles to progress to strengthen management and processes of accountability. (Page 7)

Chapter 3. EpiLab’s Institutional Capability: Organisation, management and governance.

c)  Organisational structure and management for sustainability and excellence

Recommendation 3.c.1 EpiLab should reconsider the usefulness of their current organogram and restructure it as a document capable of explaining to staff, funding authorities and the community the range of activities undertaken and the overall way in which they are managed and controlled. (Page 13)

Recommendation 3.c.2 EpiLab senior management should consider introducing a board of management that represents the interests of the community and will support sound accountability mechanisms, facilitate fund raising, and will promote and appropriately defend the reputation of EpiLab in the community. The membership of the board should reflect EpiLab’s interests while conforming to the statutory requirements of government. (Page 13)

Recommendation 3.c.3 EpiLab should decide the future role it intends to play in advancing health promotion and health education in Sudan and the region. In so doing, it should review the organisation of currently allocated resources in this field to ensure that they are able to be used to their best advantage. (Page 14)

d)  Financial resources, their management, donor sources and sustainability

Recommendation 3.d.1 EpiLab management should develop evidence based policies on standard administrative on-costs to be earned from successful research grants and contracts.  (Page 15)

Recommendation 3.d.2 EpiLab should consider elevating the responsibility for overall resources management to the executive level through the introduction of a position of Business Manager with direct responsibility for revenue and expenditure budget formulation and supervision. (Page 15)

Recommendation 3.d.3 EpiLab management should review alternatives and adopt appropriate measures to strengthen its management structure and processes as an essential part of its transition to financial independence over the next three years. (Page 16)

4  EpiLab’s technical advisory role and partnerships

b) EpiLab as an advisor to the Federal Ministry of Health.

Recommendation 4.b.1 The EpiLab should seek a formal written agreement with the Ministry of Health. This should consist of an overarching agreement between the parties together with specific contracts or memoranda of understanding for particular activities between relevant programmes, divisions or departments and EpiLab. The overarching agreement could describe the research and advisory role of EpiLab to the Ministry. When EpiLab accepts assignments from the Ministry of Health it is strongly recommended they be formally documented and that they stipulate the expected future advisory role EpiLab is to play. (Page 18)

5. EpiLab’s implementation of research and other scientific activities

a) Assessment of the number and quality of publications produced by Epi-Lab

Recommendation 5.a.1: EpiLab staff members are strongly urged to publish their research findings in peer-reviewed scientific and medical journals. A high priority should be given to this activity in future as it is central to the development and maintenance of EpiLab’s international reputation and to its ability to attract funding. (Page 21)

b) Researchers who have received support to complete their degrees (in-country and abroad)

Recommendation 5.b.1: The results produced in many MSc theses could well have been published internationally to reach a wider audience. EpiLab staff should encourage current and future candidates to publish their work in relevant peer reviewed journals. (Page 22)

c) Quality and quantity of the deliverables of the scientific sections of the Epi-Lab.

Recommendation 5.c.1: EpiLab should routinely include a soundly based economic analysis of the impact of their findings to further strengthen the evidence for recommended changes to public health processes and/or clinical management of particular conditions. (Page 23)

Recommendation 5.c.2 Immediate attention should be given to developing a reliable cost-benefit analysis of the outcomes of the asthma research to underpin the current efforts to have new procedures adopted as routine practice in Sudanese health services. (Page 23)
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f)  Integration of TB and TB/HIV in research projects, proposals and other scientific activities in the Epi-Lab.

Recommendation 5.f.1 EpiLab represents a considerable customer of the Bionor HIV detection kit. Even more, Sudan and other nations in its region offer an enormous potential market for this type of HIV testing product provided by competing producers.  EpiLab should consider the potential price and service benefits that could be obtained by introducing competitive tendering for provision of these kits.  (Page 25)

Comments from the organisation, if any:
Progress of the Epi-lab is in line with LHL expectations