GLI Specimen Referral Toolkit

As countries develop, strengthen and integrate their specimen referral networks, information on specimen referrals has expanded. This toolkit addresses the need for a comprehensive resource hub on specimen referrals for countries to utilize. The GLI Specimen Referral Toolkit contains both examples of existing tools already developed and in use/used by countries and stakeholders, as well as newly developed tools which have been created to standardize or fill gaps in existing tools. The existing tools were solicited from and shared by country ministries of health and other stakeholders. A full index of tools, categorized by existing tools and newly developed tools, can be found by clicking here. All revisions to the toolkit or future updates will be also found on these web pages. Please note, the tools in this toolkit are currently only available in English, except where noted for certain existing tools. Any comments or suggested edits to the tools should be sent to the GLI Working Group Secretariat: gli_secretariat@who.int.

All of the tools have been categorized into two groupings below for ease of use. The first grouping is by phase (where you are in the process of developing or strengthening your specimen referral system) and the second is by component (which area of the specimen referral system needs to be developed or strengthened).

Phases of developing and strengthening a specimen referral system

The first grouping of the tools is based on the phase of the specimen referral system development or strengthening. Each phase is part of a continuous improvement cycle. Depending on which phase your system is in, one of the six phases should be most appropriate. For example, if your system is already established at scale, the tools included in the "Ongoing monitoring and evaluation of the system" could be helpful. Once the fully-scaled system is implemented, monitored and evaluated, there may be cases where another situational assessment could be necessary, especially if the system is not yet integrated to include multiple specimen types. In this case, the phase "Situational assessment of current specimen referral systems" could be appropriate. Please note that certain tools can be included in more than one phase.

Components of a specimen referral system

Another way that the tools are grouped is by component of the specimen referral system. If you need to organize or integrate your system in a particular area, the following groupings around component (management, financing and costing, data collection, monitoring and evaluation, human resources, equipment, network design, scheduling and transport) may be helpful. All tools in each component can be downloaded together in one zipped folder and certain tools can be included in more than one component.

Component 1: Management
including Strategic Planning & Performance Management

To download all files in one zipped folder (14.5 MB), click here.
  • Workplan/budget template
  • Landscape assessment tools
  • Rapid assessment tool
  • Guidelines
  • TWG TORs
  • Examples of national policies
Component 2: Financing and costing

To download file (1.4 MB), click here.
  • Costing tool
Component 3: Data collection, monitoring and evaluation

To download all files in one zipped folder (9.3 MB), click here.
  • Registers, logsheets, chain of custody forms, etc
  • M&E framework
  • Data collection tools
Component 4: : Human Resources

To download all files in one zipped folder (18.6 MB), click here.
  • Trainings on packaging, handling, transit
  • SOPs
Component 5: Equipment

To download all files in one zipped folder (9.7 MB), click here.
  • Types of equipment available, specs, UNICEF SD ordering
  • Job aids/SOPs
Component 6: Network design, scheduling and transportation

To download all files in one zipped folder (25.2 MB), click here.
  • Job aids/SOPs
  • LabEQIP/other software options
  • Mapping tools

Index of all specimen referral tools in the Toolkit

Click on the hyperlinked title of the tool to download the individual tool or to link to the web page where the tool can be found . All newly developed tools can also be downloaded in one zipped folder by the link following the tools.

Newly Developed Tools for the Toolkit

ASLM Questionnaire for Countries - Specimen Referrals
Landscape assessment tool, most appropriate for an assessment focusing only on specimen referrals (i.e. it needs time to fill the entire questionnaire)

Specimen Transport Provider/Manager Supplemental Questionnaire
Questionnaire for couriers or an organization/company managing the transportation of specimens - short format allows for it to be added on to larger assessments

Specimen Referral Supplemental Checklist (Sub-National)
Questionnaire for referring facilities or referral laboratories on specimen referrals - short format allows for it to be added on to larger assessments

Example Workplan - Specimen Referral System
Workplan template with objectives, components and activities

Facility Segmentation Template
Use to collect a dataset on facilities either nationally or in a specific area; data allows for grouping/categorizing (segmenting) of facilities, which can inform specimen referral network design or transportation options, for example

Individual Specimen and Results Tracking Log
Data collection tools for monitoring and evaluation purposes; this log is kept usually by a courier and follows the individual specimens and results for tracking purposes

M&E Framework for Specimen Referrals
A companion guide to the GLI Guide to TB Specimen Referral Systems and Integrated Networks but solely focusing on M&E framework including activities, indicators, etc.

Referral Laboratory Specimen Reception Log
Data collection tools for monitoring and evaluation purposes; this log is kept at the referral laboratory for specimen reception, including rejection logs that categorize reason for rejection

Referring Facility Specimen Referral Log
Data collection tools for monitoring and evaluation purposes; this log is kept at the referring facility

Schedule and Routing Chart for Specimen Transportation
Template for a transport schedule, including routes, which should be provided to all health facilities, couriers and laboratories participating in the specimen referral system

Specimen Referral Data Summary Collection Form
Form to send to referring facilities, referral laboratories or transport providers in advance to report key statistics on specimen referrals - can be used as monthly/quarterly reporting summary

Specimen Referral System Budget Tool
Simplified costing tool, based on a modified GxAlert costing tool, to help countries estimate current costs of a specimen referral system (and linkages to existing tools such as USAID’s LabEQIP) and new budgets for funding applications; feeds into workplan components/activities

Specimen Referral System Dashboard
One-page dashboard template in PowerPoint, linked to Excel, to summarize key data from the system for management to monitor and track progress

Specimen Referral Compass Questions
Similar to the USAID Supply Chain Compass; for countries to do a fast, self-assessment to determine maturity of specimen referral system(s)/network; scoring determined and linked to relevant tools depending on component scores

To download all files in one zipped folder (1.12 MB), click here.

Existing Tools Already Developed and Included in the Toolkit

APHL - Guidelines for Submission of Sputum Specimens for Tuberculosis Testing
Guidance on sputum specimen collection and testing, also includes a sputum specimen collection SOP in the annex

Center for Clinical Care and Research Nigeria - Specimen Referral Form
Chain of custody form to be filled out by the referring facility, transporter and receiving facility

ChallengeTB Mozambique - Register to Monitor Specimen Transport System
Chain of custody form to be filled out by the referring and receiving facilities, including return of results

ChallengeTB Nigeria - Clustering and Routing chart for Specimen Transportation and result reporting
This chart lists referring facilities mapped to their respective GeneXpert sites, including name of site and geo-coordinates. It also describes the routing of specimen movement and provides details of the contact persons in all the service delivery points, including the couriers.

ChallengeTB Nigeria - Specimen delivery and Result reporting log sheet
This is a chain of custody log to document all events from specimen pick-up to transportation, drop-off at the GeneXpert site, pick-up and delivery of the results. It is designed to be kept by the courier.

ChallengeTB Nigeria - Summary form for specimen delivery and result reporting
This form provides monthly summary reports of the events documented in the associated specimen delivery and results reporting log sheet and is useful to monitor implementation of a specimen referral system. Data is dis-aggregated for each GeneXpert site and associated pick-up sites.

EGPAF - AIDS 2018 Poster - Can a short-haul specimen referral system work efficiently to access POC EID testing
Study comparing a short-distance specimen referral system to increase access to POC EID and the traditional referral model.

EGPAF - ICASA Satellite Symposium – Optimizing Testing and Treatment of HIV-exposed Infants
A presentation made at the International Conference on AIDS and STIs in Africa (ICASA) on integrating early infant diagnosis (EID) point-of-care (POC) testing within national EID diagnostic networks

GLI - Example of TB Specimen and Results Flow
An excerpt from the GLI Guide to TB Specimen Referral Systems and Integrated Networks that shows the flow of specimens and results

GLI Guide to TB Specimen Referral Systems and Integrated Networks
GLI’s comprehensive guide on developing and strengthening specimen referral systems, with an emphasis on TB but also a focus on integrated networks

GLI Practical Guide to TB Laboratory Strengthening
A guide on how to strengthen TB diagnostics networks, including a section on specimen collection, transport and registration

GLI Training Package - Programme Modules for Diagnostic Network Strengthening: PM3 Referral Network
A programmatic module focusing on planning and establishing a specimen referral network from the GLI training package to support GeneXpert implementation

GLI Training Package - Programme Modules for Diagnostic Network Strengthening: PM8 Integrated Diagnostics
A programmatic module focused on planning an integrated diagnostic approach, including for specimen referrals, from the GLI training package to support GeneXpert implementation

GLI Training Package: Technical Modules for Xpert: TM2 Specimen Collection and Referral
A technical module focused on TB-specific specimen collection, storage, packaging, transport and results return, including monitoring, from the GLI training package to support GeneXpert implementation

IATA - Guidance Document Infectious Substances
Guidance from the International Air Transport Association (IATA) on compliance with transporting infectious substances, including patient specimens, by air. Many countries use IATA guidance for the transport of infectious substances regardless of transport method.

IATA - Infectious Substances Shipping Guidelines
Comprehensive guidance for pharmaceutical and health professionals with details on packaging, documentation, handling, training, etc.

India - Revised National TB Control Programme Training Manual for TB Culture and DST
A training manual on TB specimen collection, handling and culture/DST testing

JSI - What Should you Deliver by Unmanned Aerial Systems?
A white paper exploring use cases for drones, including specimen transport

Laboratory Efficiency and Quality Improvement Planning (LabEQIP)
USAID’s Global Health Supply Chain Program’s GIS-based tool to improve diagnostic network efficiency, including referral network optimization

Lesotho - Specimen Identification, Collection and Processing Standard Operating Procedure (SOP)
A comprehensive SOP used in Lesotho covering labelling, collection, storage, transit, rejections, etc. of various specimen types for different diseases

Loembe, M. et al - Overview of available international resources for biological samples transport
Table listing various resources for specimen referral systems (also referenced/used in the same author’s Union Conference Africa Region Poster listed below)

Loembe, M. et al - Questionnaire Systèmes de transport des échantillons TB en Afrique Centrale (Fr)
Assessment questionnaire in French for specimen transport used in Central Africa

Loembe, M. et al - Union Conference Africa Region Poster - Specimen Transport Systems in the Central African Region
Study to assess implementation of specimen referral systems in the Central African region and examine available resources to guide strategies and policies

Malawi - AIDS 2016 Oral Presentation - Impact of POC EID Testing in Malawi
A presentation made by the Malawi Ministry of Health on piloting POC EID testing with comparisons of turnaround times using traditional vs. POC testing

MDH Tanzania - Assessment for Hub-and-Spoke Specimen Referral System
An assessment questionnaire designed by MDH in Tanzania to gather data on the EID/VL hubs in the country’s hub-and-spoke specimen referral system

MSH Rwanda - Isolate Storage, Packaging, and Transportation
Training material developed by MSH for use in Rwanda on storage, packaging and transportation of pure TB culture isolates

NexLeaf - ColdTrace Trek Brochure
A brochure for a GPS-enabled temperature monitoring device from NexLeaf Analytics to use during transportation, which can be used to inform best practices for packing, quality assurance and route planning. The device is more commonly used in vaccine transport but can also be used for specimens.

Rwanda National Reference Laboratory-RBC - Biological Sample Transportation within the National Laboratory Network
Comprehensive guidelines for the pilot and expansion of a specimen referral system, including scope, budgets/funding, timelines, SOPs, forms, etc.

Rwanda National Reference Laboratory-RBC - Sample Transport Forms, Budget, SOPs, Training Modules, etc.
A collection of eight documents that Includes presentations (Infectious Substances Shipping Guidelines Training and Transportation System of Pathological Samples), Budget, Forms (EID Requisition and Reporting Number of Results by Test Type), SOP on DBS Collection, storage and transport, Equipment, Training Module for Drivers

Senegal PNT-LNR - SOP pour le transport des crachats en vue d’une culture ou des tests de sensibilité (Fr)
SOP pour le transport des crachats pour la culture ou les tests de sensibilité en français

Swaziland - National Sample Transportation System (NSTS) Forms and SOPs
A very comprehensive set of forms, SOPs and job aids developed and provided by the Swaziland Health Laboratory Service for their NSTS

Swaziland - National Sample Transportation System (NSTS) Policy and Procedure Manual 2016
Manual introducing the NSTS, its objectives, structure, personnel, vehicles, referral documentation, packaging, information management, etc.

TBCare - Module 5 - Collection, Transport and Receipt of Specimens
Training module on specimen collection, transport and receipt, including key messages and content review questionnaire

The Journal of Infectious Diseases – Improved Specimen-Referral System and Increased Access to Quality Laboratory Services in Ethiopia: The Role of the Public-Private Partnership
A journal article on the importance of public-private partnerships (PPPs), including strengthening specimen referrals to increase access to laboratory services in Ethiopia

The Journal of Infectious Diseases – Strengthening the Tuberculosis Specimen Referral Network in Uganda: The Role of Public-Private Partnerships
A journal article highlighting the importance of PPPs to increase access to DST testing by strengthening the specimen referral network in Uganda

Uganda - Hub Specimen and Result Tracker
Logbook for use at the hub to track timing of specimen reception, testing and referrals

UNICEF Supply Division - Procurement Guidelines for Vaccine Carriers and Cold Boxes
Procurement guidelines for vaccine carries and cold boxes, which are often also used for specimen transport. The guidance includes how to order these supplies from UNICEF Supply Division in Copenhagen, Denmark.

VillageReach - Costs Associated with the Use of Unmanned Aerial Vehicles for Transportation of Laboratory Samples in Malawi
A cost analysis performed on UAVs for transport of DBS specimens under various scenarios

WHO - Framework of Indicators and Targets for Lab Strengthening Under the End TB Strategy
A monitoring and evaluation framework, including recommended methodology for calculating country-specific targets, referencing specimen referral systems

WHO Guide pratique sur l’application du règlement relatif au– Transport des Matières Infectieuses
Un guide sur le transport des matières infectieuses, y compris la classification des matières infectieuses, l'emballage, la documentation, la chaîne de froid, la planification du transport, la notification des incidents, etc. (document en français)

This toolkit was produced at the request of the United States Agency for International Development. It was prepared independently by Kameko Nichols. The Global Health Bureau, Office of Health, Infectious Disease and Nutrition (HIDN), US Agency for International Development, financially supports this toolkit through the Global Health Program Cycle Improvement project (GHPro) under the terms of Agreement, AID-OAA-C-14-00067.

DISCLAIMER

The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.