Implementation of an Integrated Sample Referral System (ISRS) in Ghana: Successes and Lessons Learnt from a Pilot Study in the Northern and Greater Accra Regions.

The outbreak of the COVID-19 pandemic exposed the fragile health system in Ghana and in particular, its specimen referral system (SRS), which for years had been limited to Tuberculosis (TB), HIV Viral Load and Early Infant Diagnosis among few laboratories. The implementation of a siloed SRS with the sole focus on TB, HIV viral load, and early infant diagnosis has been to the detriment of other diseases of public health importance. This programmatic activity aimed to assess the feasibility of an integrated specimen referral system (ISRS) in Ghana's Greater Accra and Northern Regions. Between January and November 2022, we established and piloted an ISRS through extensive stakeholder engagements using the hub and spoke model. As part of the intervention package, capacity building workshops, logistics support and transportation were provided to all program facilities. Standard paper-based log books and interviews were employed to collect data from 105 health facilities (84 in Greater Accra and 21 in Northern Region) to evaluate the ISRS's successes, challenges, and develop future scale-up recommendations. Overall, 4,239 samples ranging from suspected cases of measles, monkeypox, COVID-19, yellow fever (YF), acute flaccid paralysis, TB, Buruli ulcer, HIV viral load (VL), early infant diagnosis (EID), and meningitis were transported during the program period. The turnaround time (TAT) varied across diseases: 1-2 days for TB/COVID-19, 5-7 days for YF, 7-14 days for influenza, and 14 days - 3 months for VL/EID cases. The quality of specimens referred improved, with only 2 samples rejected during the pilot. Qualitative analysis uncovered improvements in ISRS efficiency including, sample delivery, TAT, documentation, coordination and logistics, monitoring and tracking, sample quality, and record-keeping. This preliminary programmatic activity provides evidence of the feasibility of creating a nationwide ISRS to facilitate the quick detection and management of all diseases of public health importance in Ghana.