Reducing UPOPs and Mercury Releases from the Health Sector in Africa

Report Cover Image
Evaluation Plan:
2016-2021, Tanzania
Evaluation Type:
Mid Term Project
Planned End Date:
03/2019
Completion Date:
03/2019
Status:
Completed
Management Response:
No
Evaluation Budget(US $):
7,500

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Download document Terms of Reference International Consultant Midterm Review of UNDP-GEF Project .pdf tor English 134.82 KB Posted 281
Download document Final MTR Report 190319.pdf report English 4153.01 KB Posted 492
Title Reducing UPOPs and Mercury Releases from the Health Sector in Africa
Atlas Project Number: 00087082
Evaluation Plan: 2016-2021, Tanzania
Evaluation Type: Mid Term Project
Status: Completed
Completion Date: 03/2019
Planned End Date: 03/2019
Management Response: Yes
UNDP Signature Solution:
  • 1. Sustainable
Corporate Outcome and Output (UNDP Strategic Plan 2018-2021)
  • 1. Output 1.2.2 Enabling environment strengthened to expand public and private financing for the achievement of the SDGs
SDG Goal
  • Goal 15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss
SDG Target
  • 15.2 By 2020, promote the implementation of sustainable management of all types of forests, halt deforestation, restore degraded forests and substantially increase afforestation and reforestation globally
Evaluation Budget(US $): 7,500
Source of Funding: GEF
Evaluation Expenditure(US $): 7,500
Joint Programme: Yes
Joint Evaluation: Yes
  • Joint with UNDP
Evaluation Team members:
Name Title Email Nationality
GEF Evaluation: Yes
GEF Project Title: Reducing UPOPs and Mercury Releases from the Health Sector in Africa
Evaluation Type: Mid-term Review
Focal Area: Persistent Organic Pollutants
Project Type: EA
GEF Phase: GEF-1
GEF Project ID: 4611
PIMS Number: 0
Key Stakeholders: Ministry of Health, Community Development, Gender, Elderly and Children, WHO, Health Care Without Harm (HCWH)
Countries: TANZANIA (UNITED REPUBLIC OF )
Lessons
1.

The project strategy is clearly well suited to the needs and goals of all stakeholders. The project’s objectives are well aligned with the donors’ objectives. In country, the Ministries of Environment wish to meet their obligations under the Stockholm and Minamata Conventions, this project serves to meet this goal, building skills within the Ministries in the process. In all four countries, the Ministries of Health’s aspiration to improve HCWM within their hospitals have been accelerated by this project. Hence, the constellation of REDUCING UPOPS AND MERCURY RELEASES FROM THE HEALTH SECTOR IN AFRICA MTR – FINAL REPORT 81 stakeholders and the project’s objectives are well matched and could be replicated elsewhere with equal success. There are obvious economies of scale through the regional implementation.

Procurement becomes more efficient, as equipment can be purchased in bulk. the resources required to develop training materials and to conduct training are similar, no matter if one or five countries are involved. Furthermore, the exchange of experiences between the recipient countries has a positive impact.

Sterilised waste cannot be directly landfilled in some countries, when this is the case, the physical form of the waste can be changed through shredding. This is not a recommended step (see section 4.2), as it increases the overall HCW management costs. Other solutions, such as a fenced off area for HCW at the landfill or burying the waste at the landfill are alternatives. It is clear from the experience of this project that the disposal of the sterilised waste must be carefully considered during such a project’s inception phase. For small remote HCFs, the is no easy solution to ensure that collected infectious waste is sterilised, due to the high costs of transportation. Therefore, the priority of implementing non-incineration HCWM systems should be as follows:

1. Teaching hospitals are the best place to start. Firstly, they have the most skilled professionals and hence these are the facilities where it is easiest to implement a successful system. Secondly, these are the locations where medical professionals are trained. So, if the future doctors, nurses and EHOs are trained in hospitals with a well-functioning HCWM system, they will have a better understanding of the importance of good hygiene and be able to bring this knowledge to their future work places.

2. Large hospitals. 3. Smaller facilities where it is generally a greater challenge to implement HCWM systems, as these facilities have less skilled staff, frequently lack resources and often have a hectic environment, as the number of patients greatly exceeds the handling capacity. So future projects should focus on teaching hospitals and other larger hospitals to the extent possible. This is where there is the greatest return on the investment in the form of a well-functioning HCWM system. Finally, when planning the installation of autoclaves (or other non-incineration treatment technology), it is paramount to consider the treatment capacity of the equipment. It is essential that the autoclave capacity is used to the extent possible. This means that a hospital with an autoclave should also treat waste from other health facilities (cluster treatment). This also means that facilities located close to one another should not all be equipped with autoclaves. Hence, cluster or central treatment is to be prioritised, as this offers an economy of scale (obviously taking into account transport costs).


Findings
1.

The project is perfectly aligned with the GEF’s strategy, where two focal areas are persistent organic pollutants and the phase-out of mercury.

The four participating project countries have all have ratified the Stockholm Convention. which calls for “priority consideration” of alternative technologies that avoid the formation of dioxins and furans, such as non-incineration technologies identified in the BAT/BEP guidelines. Hence the countries’ respective National Implementation Plans (NIP) identify medical waste incineration as a source of dioxins/ furans and recommend the application of the BAT/BEP guidelines to help meet with the Stockholm Convention obligations.

 The project has helped the four countries with their (future) obligations under the Minamata Convention in two ways: Firstly, by conducting an inventory of mercury containing medical devices found in HCFs. Seconding, by directly contributing to the phasing-out of these instruments.

Other than reducing UPOPs and mercury releases from the health sector, the health authorities also see a substantial benefit from the project in the form of a decrease in nosocomial infections.

 The project predominantly benefits the vulnerable, in that improved hygiene and HCWM within healthcare facility betters the working conditions of the hospital staff (mostly female), the patients (frequently poor women and their children) and the visitors. So, although gender issues were not specifically addressed during the design phase, the project does comprehensively improve the conditions for these groups of people. 


2.

4.1 Project Strategy

Project Design

This section discusses the project design and relevance of the project within its international and national context. The project is obviously directly linked and highly relevant to the implementation of the Stockholm and Minamata Conventions in the recipient countries. The GEF provides funding to assist developing countries in meeting the objectives of international environmental conventions. The GEF serves as "financial mechanism" to five conventions, of which two are the Stockholm and Minamata Conventions. 9 Hence the project is perfectly aligned with the GEF’s strategy, where two focal areas are persistent organic pollutants and the phase-out of mercury.

The United Nations Sustainable Development Goals (SDG) 10 target a number of areas that are touched by the project. The three most pertinent SDGs addressed by the project are: • Goal 12, Target 12.4: By 2020, to achieve the environmentally sound management of chemicals and all wastes throughout their life cycle, in accordance with agreed international frameworks, and significantly reduce their release to air, water and soil in order to minimize their adverse impacts on human health and the environment; • Goal 3, Target 3.3: By 2030 end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases; and • Goal 6, Target 6.3: By 2030, to improve water quality by reducing pollution, eliminating dumping and minimizing release of hazardous chemicals and materials, halving the proportion of untreated wastewater and substantially increasing recycling and safe reuse globally.


Tag: Waste management Relevance Gender Mainstreaming Health Sector HIV / AIDS Sanitation Programme/Project Design Awareness raising Policy Advisory Agenda 2030 Vulnerable

3.

Results Framework/Logframe Analysis

The project strategy is well designed good and as can be seen in the logframe analysis in Table 5 the implementation is satisfactory for all identified indicators. It can be noted that the indicators in Table 5 are SMART (Specific, Measurable, Achievable, Relevant, Time-bound), as these are well defined, appropriate and easily verified. In the planning of the project, the broader development effects that are of a high priority to the UNDP, such as gender equality, women’s empowerment, improved governance and reduction of inequalities were not carefully considered. It can be said to the defence of those in charge of the project design that an intervention such as this one disproportionally benefits the weak, women and children. As noted under “Gender Issues” (page 62) a majority of hospital staff is female and benefit from the improved HCWM system through safer working conditions, as this reduces nosocomial infections. As explained in the text box in section 4.1 and elsewhere in this report, poor, women and young patients stand to gain the most when a hospital’s HCWM and hygiene improves. Therefore, although the project design did not specifically focus on these issues, they are thoroughly addressed by the project. Progress Towards Results


Tag: Implementation Modality Monitoring and Evaluation Results-Based Management Women and gilrs

4.

Component 1: Disseminate Technical Guidelines, establish Mid-Term Evaluation Criteria and Technology Allocation Formula, and Build Teams of National Experts on BAT/BEP at the Regional Level

Component 1 has several objectives. Firstly, during a regional conference the beneficiary healthcare facilities for the non-incineration HCWM systems and Mercury-free devices would be selected. The Project Document recommendation that each country chose the proposed HCFs based on the following criteria: • One central or cluster treatment facility; • Up to two hospitals with up to 300 hospital beds; and • Three rural health posts or dispensaries.

The participating countries successfully identified the participating healthcare facilities as follows: • Ghana: Trauma and Specialist Hospital; Komfo Anokye Teaching Hospital; Eastern Region Hospital; Cape Coast Teaching Hospital; and Tegbi Health Centre • Madagascar: CHU JRB Hôpital Joseph Raseta Befelatanana; CHU JRA Hôpital Joseph Ravoahangy; Andrianavalona Ampefiloha; CHU MET Hôpital Mères et Enfants Tsaralalana; CHRD Hôpital de District Manjakandriana; CSB2 Centre de santé de base Manjakandriana; and CSB2 Centre de santé de base Sambaina Manjakandriana • Tanzania: Muhimbili National Hospital; Mbagala Hospital; Sinza Hospital; Buguruni Anglican Health Centre; and Mwananyamala Hospital • Zambia: University Teaching Hospital; Ndola Teaching Hospital; Kabwe General Hospital; Mukonchi Rural Health Centre; Kapiri Mposhi District Hospital; Matero Level 1 Hospital; Chilenje Level 1 Hospital; and Kamuchanga District Hospital


Tag: Environment Policy Waste management Effectiveness Regional Capacity Building

5.

Component 2: Healthcare Waste National Plans, Implementation Strategies, and National Policies in each Recipient Country

Following the training of the national experts (Component 1), the national PIU were to evaluate and strengthen national policies, regulatory framework, and national plans for HCWM and Mercury. Based on their assessment, a detailed proposal for an intervention supported by the project for improving the policy and regulatory framework was made.

The national PIUs have all developed implementation plans and been successful in implementing these, see Component 3, so those plans will not be discussed here. The development of the national policies and regulatory improvements for each of the project countries have been a major task with many stakeholders involved in each country. The status for these efforts is briefly summarised for each of the counties in the following:


Tag: Environment Policy Waste management National Health Sector Policy Advisory

6.

Component 3a: Make available in the region affordable non-incineration HCWM systems and mercury-free devices that conform to BAT and international standards

The project encourages the use of non-incineration systems for the treatment of healthcare waste and supports the use of mercury-free medical devices. The project selected the nonincineration HCWH management systems from the Global Healthcare Waste Project that comply with the Stockholm Convention’s BAT/BEP Guidelines and that are considered cost-effective alternatives to incineration by the WHO. 16 The recommended technologies include: • Autoclaves • Hybrid autoclaves & continuous steam treatment systems • Microwave technologies • Frictional heating systems • Dry heat treatment systems • Chemical disinfection systems (e.g., ozonation) • Alkaline hydrolysis technologies (for anatomical waste and animal carcasses).

The project selected to make use of autoclaving technology. This is the most common and a proven technology. Great efforts were put into ensuring sustainability of the autoclaves: To reduce the need of corrective maintenance, necessary supporting equipment such as water treatment systems and voltage stabilizers were included in the equipment supply to guarantee a problem-free operation of the main equipment. The supplier was also to include sufficient spare-parts to cover at least 2,500 operation hours, provide training on preventive maintenance and supply operating & maintenance manuals. Finally, the technology provider was to guarantee a 10-year spare-part availability and to have a local agent for repair and maintenance available in each country.


Tag: Waste management Water resources Health Sector Technology Technical Support

7.

All autoclave buildings are well-made and were completed within a reasonable timeframe. Most selected to build new buildings based on designs provided by the project. Zambia made use of some existing building and the outcome was good. In Madagascar, at the CHU-JRB, there were some obstacles. As no 380 Volt current was available on the site, the hospital had to construct not only a building for their autoclave, but also a transformer building, so that 380 Volt current could be supplied to the autoclave. Here the regional component helped out by supplying the (very long and costly) cable that now connects the transformer to the autoclave building. The autoclave at the CHRD Manjakandriana in Madagascar is not yet connected, as the local TTM representative from Hospiteq who was meant to do the work, quit on 15 August 2018, just as the autoclaves were being installed. Due to concerns over the affordability of electricity and the high frequency of power cuts, solar panels have been installed at the CHRD Manjakandriana. Concerns have been expressed as to whether these solar panels supply enough power to operate the autoclave, this concern was expressed both by the TTM representative and by the supplier of the solar panels. 17 Discussions with the Regional Project Team has indicated that these solar panels are to provide enough power to compensate for the consumption of the autoclave and hence it is not the intent that the autoclave be operated without power supply through the grid. According to the hospital management, the power provided through the solar panels is very helpful, providing lighting in the hospital during power cuts.


Tag: Energy Environment Policy Waste management Health Sector Infrastructure Technical Support

8.

Component 3b: Demonstrate HCWM systems, recycling, mercury waste management and mercury reduction at the model facilities, and establish national training infrastructures

This component aims to integrate the non-incineration technology into the overall HCWM system and to deploy the Mercury-free devices at the model facilities. These HCF will both serve as the testing ground for these measures and as BAT/BEP demonstration sites. The steps taken by the project to these facilities were as follows: • Training facility staff in the operation and maintenance of the new non-incineration HCWM system; • Introducing mercury-free medical devices, and training staff in their use and maintenance; • Establishment and training of local maintenance teams/ technicians; • Introducing recycling activities to reduce the waste streams and identify buyers of recovered materials; • Supporting HCFs in improving the HCWM monitoring; and • To ensure long-term sustainability, each country was to establish at least one national HCWM course for medical professionals.


Tag: Environment Policy Waste management National Health Sector Infrastructure Technology

9.

Ghana

The implementation is progressing well in Ghana, all project healthcare facilities have training programmes in place for new staff where all facets seem in place: Qualified trainers, support from management and good training materials. The source separation is fairly implemented and operational with exception of the few weaknesses as noted below under the description of the individual HCFs. The actual implementation of BAT/BEP in the model facilities is discussed for each visited healthcare facility in the following paragraphs. The Cape Coast Teaching Hospital is one of the top hospitals in Ghana with 400 beds and a large number of daily outpatients. Healthcare waste is very well managed within the hospital. The hospital received 2 autoclaves each with a capacity of 260 litres and these were commissioned in April 2018. Since May 2018 the hospital has been treating all the HCW generated in its 12 wards in these two autoclaves, coming to about 60 kg per day for five days a week. This corresponds to 15.6 tonnes per year, 18 or 7.8 tonnes per autoclave per year. By comparison, the May 2018 Project Progress Report expects the annual throughput of a 260-litre autoclave to be 37.44 tonnes per year. 19 The management and staff of the Cape Coast Teaching Hospital is aware that the capacity is far from fully utilised and that their site is designated as a cluster treatment facility for the region. In early October 2018 letters were sent out to surrounding HCFs offering HCW treatment. The hospital’s plan is to offer the treatment as a “social service” where the cost for the other hospitals is modest. There are plans for outreach, where the surrounding HCFs are invited to visit the treatment facility. Given this context, and the fact that the Accra School of Hygiene does field trips to see the Cape Coast Teaching Hospital HCWM system, the International Consultant recommended that the housekeeping be improved at the autoclave treatment facility. 


Tag: Waste management National Health Sector Infrastructure

10.

Zoompak is a waste management service provider in Ghana, focussed on the transportation of domestic, industrial and hazardous waste. In 2015 the company established a 1.4 tonne/ hour autoclaving facility for healthcare waste outside Accra; at present the facility operates well below capacity treating only about 8.5 tonnes of infectious waste per month. The company can provide clients with training in HCWM, packaging and the transport of infectious waste in two cooled vehicles to their treatment facility. The project has helped Zoompak develop its medical waste business and the company attributes 50% of their clients to awareness raising and contacts made through the UPOPs project. The Ghana PIU is planning to implement HCWM training and promote the use of non-mercury medical devices at the 500 bed Accra Military Hospital, in return for the hospital having their HCW treated at the Zoompak Facility. By October 2018, Zoompak’s number of clients had increased to 82 and the operators are confident business will greatly increase over the coming years, in a large part due to an increased awareness on the importance of proper HCWM due to the project.


Tag: Environment Policy Waste management National Health Sector Infrastructure Awareness raising

11.

Madagascar

The project has made good progress in Madagascar, where efforts are undertaken to implement all project components. In Madagascar the health system has three tiers of management: central, regional and district. Health services can be accessed at four different levels: 1. University hospitals (Centres Hospitaliers Universitaires: CHU) including specialised centres. 2. Regional referral hospitals (Centre Hospitalier de Référence Régionale: CHRR); 3. District referral hospitals (Centre Hospitalier de Référence de District: CHRD); and 4. Primary care facilities (Centre de Santé de Base: CSB) that are subdivided into categories 1 and 2. A “CSB2” is managed by a doctor and a “CSB1” is generally managed by a mid-wife. Each health district typically contains 10 to 25 primary care facilities and a hospital. The project has worked with university and district hospitals, as well as primary care facilities.

The CHU-Joseph Ravoahangy Andrianavalona Hospital (“CHU-JRA”) is a 650-bed university hospital located in the Ampefiloha neighbourhood in the centre of Antananarivo. It has a well-functioning HCWM system, though it was noted that the instructional posters (as elsewhere in Madagascar) reflect the regulations from 2004. It would help healthcare staff in their work, if the posters were up-to-date and illustrated the current HCWM system. The hospital’s 1,300-litre capacity autoclave is being used, it was treating around 50 kg of infectious waste daily when the MTR mission visited. The hospital has also received a small Renault station wagon fitted to transport waste, at present the hospital receives waste from seven private hospitals and private clinics, where the waste generators pay 40,000 Malagasy ariary (approx. 11 USD) per bag of waste treated (20 kg). It is planned to also treat waste from other public hospitals in the autoclave.


Tag: Environment Policy Waste management National Regional Access to Medicines Health Sector

12.

The CHRD Manjakandriana is a 45-bed district referral hospital located about 50 km east of Antananarivo. The hospital has put a lot of effort into their waste management system and it was generally very good, though there were still a few flaws, such as a black bag lining a bin for infectious waste. It is obvious that the project has had a significant impact on the hygiene and HCWM within the hospital, and the positive effect was greatly appreciated by all staff. As mentioned under Component 3.1, the autoclave has not yet been hooked up and commissioned. The hospital has received a vehicle to collect healthcare waste from the surrounding primary care facilities (two are described below), the hospital doubts that it can cover the all 42 CSBs within the district and intends to start by collecting healthcare waste from facilities to its southeast. The hospital is technically mercury free, though some doctors still own medical devices containing mercury. The hospital has set up a collection system for recyclables that is identical to the one at the CHU-JRB. The hospital is concerned that due to its remoteness, it will not be possible to sell the recovered materials. The two visited Manjakandriana CSB2s (see below) have both also set up bins to collect four fractions of recyclable materials.


Tag: Environment Policy Waste management National Access to Medicines Health Crises

13.

The Madagascar PIU has only managed to collect six mercury containing thermometers, all were privately owned by doctors. Otherwise, some fluorescent tubes have been collected in the mercury storage boxes provided by the project. The Madagascar PIU has been in discussions with the Ministry of Environment and the Ministry of Energy, longterm the intent is that all collected mercury containing items will be managed by one of these ministries. A locked cabinet and facilities to permit multiple packing were prepared by the PIU for the temporary storage of the mercury waste at the CHU-JRA. The six model facilities in Madagascar are only using mercury-free devices. The PIU successfully distributed all received mercury free medical devices, though the intended “exchange” for mercury containing equipment failed, as it was found that the healthcare facilities owned no mercury containing equipment, as all used devices are privately owned by the doctors, nurses or patients. In the second phase of the project, the PIU is planning a one-to-one exchange of devices with private owners. Finally, in 2018 the Ministry of Public Health prohibited the purchase of mercury containing devices for the country’s healthcare facilities.


Tag: Waste management National Health Sector Capacity Building

14.

Tanzania

A training of teachers on healthcare waste management took place at the Centre for Educational Development in Health, Arusha (CEDHA) in northern Tanzania. The teachers have in return provided training at their hospitals. As will be seen below in the description of the visited hospitals, the training may well have been successful but there is still a need for capacity building within HCWM to ensure that infectious waste is properly managed. In the visited hospitals, all new staff receives a one-week training covering policies, standard operating procedures and also HCWM. The Muhimbili National Hospital is a 1,500-bed hospital that also serves approximately 1,500 outpatients daily. This is the nation’s leading hospital and it is associated with the Muhimbili University of Health and Applied Science (MUHAS). The source separation of infectious waste has been in place since 2007 and the hospital is equipped with two incinerators. The project provided further training and the management system should be well functioning. In practice, there were many surprises when the hospital was visited. Some of the outdoor waste bins used by visitors were lined with red (i.e. infectious waste) bags and other with black (i.e. general or non-infectious waste) bags. A gardener was seen collecting leaves in a red bag.


Tag: Environment Policy Waste management National Health Sector

15.

The Mwananyamala Regional Referral Hospital officially has 254 beds but in practice it hosts twice that number of patients, on top of the 1,600 to 2,000 outpatients received daily. It is located in northern Dar Es Salaam, the staff has been trained in HCWM through the Tanzania PIU, the MoH’s training course in Arusha, a WASH course held by WHO and through in-house training. The waste management system was fully functional and the hospital was in the process of drafting a hospital HCWM policy, the current draft is a generic document. The hospital received a 260-litre autoclave; as the treated waste cannot be compacted, the autoclave is currently only used to treat plastic waste for recycling. The autoclave had last operated three weeks prior to the MTR visit. Generally, it seems an informal Ministry requirement that the treated HCW should change physical form before it can be placed in a landfill, so that it is possible to distinguish between sterilised and non-sterilised waste. Therefore, at present HCW is burnt in a 15-year-old incinerator that is only operated at night, due to the quantity of black smoke emitted. The quantity of HCW burnt is 105.2 kg per day; furthermore, the hospital generated 200 kg/day of general waste. The 79-bed Sinza Hospital is located in the north-western part of Dar Es Salaam, it also receives about 1,000 outpatient visits daily. The hospital’s waste sorting system was wellfunctioning and the records indicate that 114 kg of infectious waste are generated daily, as well as 9 to 12 kilogrammes of infectious plastic waste to be recycled.


Tag: Waste management Health Sector Infrastructure Technical Support

16.

Zambia

The introduction of the non-incineration and mercury-free technologies is well under way. The introduction of HCWM at the UTH is still in progress and the exchange of mercury containing medical devices was ongoing during the MTR visit. Further training is still required at some facilities, as can be seen in the facility descriptions below. The University Teaching Hospitals in Lusaka is Zambia’s premier healthcare facility, it consists of a conglomeration of five hospitals with a total of 1,900 beds. The hospital is expanding with several large construction projects ongoing. At present the Hospitals generates around 1.5 tonnes per day of HCW. The Hospitals already had source separation of waste, but this has been improved within two of the site’s five hospitals; namely the Adult & Emergency Hospital and the Mother & Child Hospital, covering approximately 50% of UTH’s beds. 24 To achieve this, approximately 25 people followed a three-day training course to become Teachers, and containers for healthcare waste, sharps, diapers and general waste have been distributed to the wards. All new staff and medical students are also instructed in the hospitals’ procedures, including waste separation, prior to working in the wards. Despite this, the source separation of waste at the hospital still has flaws, such as whole syringes in sharps containers that should just hold needles and incorrectly sorted waste in the bins. The general waste is taken to skips; these are collected by the local authorities three times per week and taken to the waste disposal site. It was noted that these also held yellow bags (see Photo 29).


Tag: Environment Policy Waste management National Health Sector Capacity Building Technical Support

17.

The Ndola Teaching Hospital is the main hospital for the Copperbelt Province (population 2.5 million) and has 821 beds. Nine EHO work within the hospital but, unfortunately, the HCW management was rather underwhelming: The MTR saw solid waste in infectious waste containers; a scalped blade and blood-soaked bandages in the general waste; and overflowing sharps containers. The two 260 litre capacity autoclaves supplied by the project are in a new dedicated building and fully functional. It can be noted that the bin wash was still to be built, only the water supply pipe was in place. Due to the lack of an approval for the disposal of treated waste, the autoclaves are not in use. 28 Therefore, all the hospital’s HCW and some of its general waste is incinerate on-site. There is no recovery on recyclable materials within the Ndola Teaching Hospital. There are currently 19 smaller HCW generators sending their waste to the hospital’s incinerator. Once the autoclaves are treating waste, it would make sense for the project or the Teaching Hospital to ensure that they handle all their infectious waste correctly. The hospital has received non-mercury equipment and is working its way towards being mercury free.


Tag: Waste management Regional Health Sector Technology

18.

The Mukonchi Rural Health Centre has reached over one hour of driving on dirt roads. The Health Centre has 27 beds and two clinical officers are the principal medical staff. The clinic generates about 20 kg per day of infectious waste. 29 All waste is burnt in a 200- litre oil drum, as the small on-site incinerator is not functional. The waste sorting at the facility is poor, best exemplified by the laboratory where two yellow pedal bins labelled with infectious waste symbols were both lined with black bags. One bin was used for infectious waste and the other bin was used for general waste! It is essential that Health Centres have good hygiene and proper healthcare waste management procedures. This is a subject that must be taught to all medical staff and something which is already part of the curriculum for EHOs and nurses in Zambia. In the opinion of this reviewer, the project can easily help such facilities, but the provided assistance will not do much to achieve on of the overreaching goals: the reduction of UPOPs emissions. Given the Health Centre’s remoteness, it would be very costly to bring the generated HCW to an autoclave (and the required funding would be far better spent on other essentials for the clinic), likewise in the longer run, the facility will probably be troubled to procure bin liners, replacement bins or sharps containers, so the general outlook for a greatly improved HCWM system is bleak. Meanwhile, unless an autoclave is supplied or a (costly) waste transport system is established, the Health Centre’s waste will always end up being burned and hence releasing UPOPs - something that is contrary to the project’s objectives.


Tag: Environment Policy Waste management Health Sector Sanitation Capacity Building Technical Support

19.

Meeting the project objectives for UPOPs and Mercury avoidance

The project aims to reduce the amount of UPOPs releases from HCW incinerators by 31.8 g-TEQ/yr. The current calculations by the project indicate that 1,048.3 tonnes per year of HCW can be treated in the autoclaves installed by the project; resulting in a total amount of dioxins (UPOPs) releases reduced/avoided of 42.1 g-TEQ per year for the four project countries. This calculation is based on all autoclaves operating 6 treatment cycles per day for 260 days per year. As noted in section 0, most of the autoclaves currently only treat a few batches of waste per week, so the above figure of 42.1 g-TEQ per year is overestimated. This especially applies, if it is considered that some HCFs incinerate the autoclaved waste! The end-of-project target is that the amount of mercury releases from the health sector is reduced by 25.3 Kg/yr. At present it is not possible to gain an overview of the total amount of mercury collected in the project countries, 32 though the end result could well be around 25 kg. That said, it seems clear that all HCF involved in the project will most likely be mercury free by 2020, so even if the target is not met, the overriding goal of eliminating mercury containing medical devices from the hospitals will be achieved.


Tag: Waste management Health Sector

20.

Gender Issues

Both the UNDP and the Guidance for Conducting Midterm Reviews of UNDP-Supported, GEF-Financed Projects place a high priority on gender balance. The training of the national experts over a two-week period in Nakuru, Kenya included a session on gender inequality which introduced the key conventions which ensure women’s rights in Africa. This was followed by discussion session on gender inequality issues in the healthcare waste sector and an interactive session with the participation of the national experts which emphasised the need of an introductory assignment to analyse gender inequality gaps in HCWM and to develop recommendations for action. The project also underwent a Social and Environmental Screening in 2016 and in August 2018 a Gender Expert, Ms. Sabrina Regmi, visited Ghana to evaluate the situation. Her report 33 is quite critical of the project, noting that “gender equality or human rights issues concerns were not fully mainstreamed in the design phase.” She faults the project with not including dumpsite scavengers in their consultations, as these are one of the groups most affected by HCWM.


Tag: Waste management Gender Equality Gender Mainstreaming Health Sector

21.

Country Specific Topics

Each country investigated one or two topics, with the aim of gaining experience and sharing the conclusions with the other project countries. Ghana 1: Assessment of hepatitis B and C at the pilot HCF and support provision of vaccine. For the project model facilities in Ghana, all workers were screened for hepatitis B. No screening was done for hepatitis C due to costs. The screening covered all workers, including new employees and especially focussed on those involved with waste management. Other employees are also exposed to a higher risk, for example laundry workers, as needles are common in the dirty linen. It was found that only 14 of the 800 screened workers tested positive. The screening was paid for by the HCFs, and for those who tested positive, the first vaccination was also free of charge. Ghana 2: Review of key regulation on HCW. Under the PIUs guidance, several working groups conducted a comprehensive review of Ghana’s legislation, making sure that the various pieces of legislation covered the requirements to handling, storage, transport, treatment, and disposal of healthcare waste. The review activity also covered Ghana’s hazardous waste regulations, and recommendations were made to ensure the section on HCWM was comprehensive. Ghana G3: Evaluation of sharp management tools. The PIU made a survey in five project hospitals on the use of safety boxes, sharps containers and needle cutters. A total of 166 staff responded and evaluated the ease of use and safety of these three sharps management tools.


Tag: Waste management Rule of law Access to Medicines Health Sector Sanitation Infrastructure

22.

Component 4a: Evaluate the capacities of each recipient country to absorb additional non-incineration HCWM systems and mercury-free devices and distribute technologies based on the evaluation results and allocation formula

Capacity to absorb additional technologies

One task to be conducted during the mid-term evaluation is an assessment of the capacity of each country to absorb additional technologies (Outcome 4.a.1). It was agreed during the Inception Workshop and confirmed during the subsequent Project Board Meeting, both took place in September 2016 in Johannesburg, South Africa, that the allocation of resources for the second round of procurement would be based on aggregate national performance by each country during the first phase. It was agreed that the evaluation would be based on the following five factors as recommended in the Project Document: 1. The promulgation of HCWM and Mercury reduction policies 2. Successful implementation of BAT/BEP in the model facilities 3. Proper operation and maintenance of the initial batch of non-incineration HCWM systems and Mercury-free devices 4. Safe storage of healthcare Mercury waste 5. Effective national training programmes It should be clarified that item “2” in the listing is taken to refer to the successful source separation of infectious waste within healthcare facilities, as the actual treatment system is covered under “3.” No scoring system was agreed, and the MTR reviewer has decided to score all five evaluation components equally, as any other weighting of the scores could be perceived to favour one PIU over another. 35


Tag: Waste management Regional Health Sector South-South Cooperation

23.

Remaining barriers to achieving the project objectives

A key difficulty for the project is the disposal of the treated healthcare waste. The placement of sterilised waste on a dumpsite or landfill, without any change of physical form is clearly a concern in all project countries. This issue greatly hampers the project’s ability to meet its goals. It has also made it difficult to sell autoclaving as the best option for healthcare waste treatment to health authorities, even though they understand the health and environmental implications of using unacceptable incinerators currently being used in most health facilities. To fully utilise the autoclaves, it is clear that a solution must be found and implemented. Project experience to date indicates that rural health posts may be able to properly segregate and handle their infectious waste, but the quantities of waste they generate is very small and the costs of bringing their infectious waste to an autoclave facility are prohibitive. Hence, it is at present unrealistic to expect that HCW collected in rural health posts can be transported to an autoclave, as the financial means are simply not there. Much better results have been achieved by the project when working with larger hospitals. During the MTR, it was clear that there were issues with the availability of a local service technicians from TTM, the autoclave provider. To ensure that the project objectives can be met, the service technicians must be available for autoclave maintenance and repair. In some hospitals the source separation of healthcare waste is poor. It is paramount that the waste is correctly separated for the installed waste management system to work.


Tag: Waste management Challenges Rural Health Sector

24.

4.2 Project Implementation and Adaptive Management

Rating: S (see Annex D for an explanation) Management Arrangements The Project consists of five components: One regional component managed by the UNDP IRH and four national components, one for each project country. The regional component is being implemented by the UNDP IRH in close cooperation with the Montreal Protocol/ Chemicals Unit team based in Istanbul. The regional project component is carried out using the Direct Implementation Modality (DIM). The DIM is the approach when the UNDP takes on the role of Implementing Partner, meaning that it assumes the responsibility for mobilising and applying the required inputs in order to reach the expected outputs. In other words, the UNDP IRH has the overall management responsibility and accountability for the project implementation. Accordingly, the UNDP IRH must follow all policies and procedures established for its own operations.


Tag: Waste management National Rule of law Health Sector Project and Programme management Technical Support

25.

Under NIM, the UNDP is responsible for the effective and efficient use of resources to achieve the project objectives in collaboration with the implementing partner. The UNDP makes sure that funds are made available to the project, monitor the project. and take any required corrective actions. Once the National Project Board has selected the national Project Implementing Unit, i.e. the National Project Coordinator, the Project Technical Advisor and the Project Assistant, the UNDP Country Office pays their salaries and is also responsible for the local procurement according to the specifications of the PIU. The National Project Boards and the PIUs have been highly focused on the successful implementation of the project. Here their engagement has been strongly supported by their national Ministries of Health and Environment, as these are very engaged to ensure a positive outcome, as the project’s objectives match their own national goals. Their strong interest is founded in the expected positive impact on hospital safety, on the environment (elimination of POPs and mercury) and in the meeting of national obligations with respect to international conventions (Stockholm and Minamata). The countries’ reporting is generally sound and reliable, though a few of these documents occasionally overstate the progress. 38


Tag: Waste management Regional Health Sector

26.

Work Planning

To date all major project decisions have been taken in close cooperation with the key stakeholders and approved by the Regional Project Board. Hence the Regional Project Board has advised and guided the project as intended. All interviewed people were satisfied with the project management arrangements and felt that the lines of communication within the project worked well. The National Project Boards all seem to promote a close cooperation between the Ministries of Health and Environment, as these seek to address concerns that have a high national priority. The Ministries of Environment are keen to address their obligations under the Stockholm and Minamata Conventions, whilst the Ministries of Health are eager to improve hygiene and safety in their healthcare facilities. Hence the project acts as a catalyst, making the two ministries closely collaborate to address issues that are of national importance. It can be observed that there are clear benefits to implementing these activities as a regional project rather than as a national project. The most obvious advantage is the economies of scale: There are clear benefits to purchasing autoclaves, HCWM equipment and non-mercury medical devices in bulk, as this lowers the unit cost. Likewise, the cost for the preparation of training materials or of organising a training course are mostly independent of the number of recipients or participants, so again there are significant savings in a regional project.


Tag: Waste management National Regional Health Sector Communication Project and Programme management Risk Management

27.

Finance and Co-Finance

The project has undertaken purchasing activities in a timely manner. The project did face one difficulty: All major purchased were to be through the UNDP Regional Hub in Istanbul in close collaboration with the UNDP Nordic Office and its Global Procurement support Unit-Health in Copenhagen. The Nordic Office was to assume the procurement of the non-incineration technologies for each of the project countries. Unfortunately, the cost of procuring through the Nordic Office was almost 100,000 USD, thereby severely limiting the funds available for project management. Therefore, UNDP IRH undertook the procurement. First procuring the lesser package of non-mercury medical devices and thereafter undertaking the more complex procurement of the HCWM systems for the 24 model HCFs. As a result, any difficulties with shipping, customs, import duties and so forth could be identified on the smaller and simpler procurement package. To date the project is strictly adhering to the budgets set out in the planning documents. There are strong financial controls in place, as all expenditures are undertaken by the UNDP IRH and by the UNDP Country Offices.


Tag: Waste management Gender Equality Human rights Health Sector Human and Financial resources Monitoring and Evaluation

28.

External Monitoring and Evaluation

This MTR provides a thorough external and independent review of the project, offering a comprehensive assessment of the performance and progress to date. This is a strength of the GEF-UNDP programme, as these impartial appraisals can be submitted no matter what the findings are. This also applies to other programmes (for example the Belgian Development Agency), but other organisations only expect positive reviews of their projects/ programmes, something that is, in the long-term, very detrimental to the quality of their work. This project has a sufficient budget to ensure that both the mid-term and final evaluations are thorough and of a good quality. Likewise, the UNDP IRH and the Regional Project Team are clearly intending to carefully consider the recommendations of these reviews.


Tag: Environment Policy Global Environment Facility fund Civic Engagement Health Sector Monitoring and Evaluation

29.

4.3 Sustainability

The regulatory and policy framework has been developed to strengthen healthcare waste management and for the phase-out of mercury containing products. These instruments are already largely in place and all components are likely to be adopted. The training of healthcare professionals, especially EHOs and nurses, is well on the way to being strengthened in Schools of Hygiene and other teaching institutions in the four countries. This will greatly improve the HCWM skills of the future medical professionals, which in turn will support the future operation and expansion of the HCWM systems.

Financial risks to sustainability

The Project Document also focusses on income generation to help support the cost of operating the HCWM systems. Two revenue streams are foreseen: the sale of recyclables and for cluster facilities, other HCFs paying to have their waste treated in the autoclaves. These revenues will obviously help, but the revenue is likely to only cover a modest percentage of the expenses. Prior to the project, only Ghana and Tanzania had made efforts to implement HCWM systems. Following the increased awareness at the decision-making level due to the project, proper HCWM is now a high priority with the MoHs and the Ministries are evidently keen to continue and expend their HCWM programmes. Hence, the four countries have a strong ownership of the systems, these are something that the countries wished for and that filled a gap in their healthcare system. It seems very likely that the Ministries of Health and the HCF managements will allocate sufficient resources for the continued operation of the 24 model facilities. All countries also expressed plans to implement HCWM systems in more healthcare facilities. Therefore, all the necessary structures are in place for long-term sustainable solution and the recipient countries have a strong ownership of the HCWM systems.


Tag: Environment Policy Waste management Sustainability National Rural Health Sector Human and Financial resources Sustainability

Recommendations
1

The project must ensure that the non-incineration and mercury-free technologies introduced under Phase 1 of the project become or remain (as applicable) sustainable in the long-term through periodic follow-up visits.

2

Currently, the source separation in most of the project hospitals is poor. It is paramount that the waste is correctly separated for the installed waste management system to work. This will require engagement with the hospital’s top management and endeavour to ensure that staff at all levels are aware of the benefits of proper HCWM. Hereafter, the training will have to be repeated and it should target a broader group of staff so that doctors, nurses and EHOs all work together to make the system function. The difficulties currently experienced are most likely due to insufficient awareness amongst the senior staff. Hence the EHOs (and nurses) are not supported in the waste separation by doctors, and the management may be reluctant to provide the necessary materials (e, g. bin liners, protective equipment) and other support (e.g. training) to ensure that all HCW is managed properly.

3

The Muhimbili hospital stated that given the manner in which their waste is sorted at the moment, it is unsuited for autoclaving due to liquids and needles. This explanation makes it urgent to re-evaluate the waste sorting at the facility, so that the infectious waste can be autoclaved.

4

To date little progress has been made in establishing a national training programme for HCWM, it is suggested that a determined effort be made to incorporate HCWM in the curriculum of Tanzania’s five schools of hygiene, so that all future Environmental Health Officers receive instruction

5

The Project Document expects the introduction of non-incineration and mercury-free technologies at more HCFs during the second phase of the project. It is recommended to consider the installation of more autoclaves very carefully, as the project’s completion date is in April 2020. This leaves little time of the time consuming and complex issue of establishing structures to house the new autoclaves. So, if the PIU decides to purchase one or more autoclaves, very great care must be taken in selecting the receiving HCFs, so that it is certain that all necessary resources are available to rapidly establish a building for the new autoclaves.

6

When planning the second phase of the project, it is important that measures are taken to ensure that the treatment capacities of the installed (and any future) autoclaves are fully utilised. These autoclaves can complete six treatment cycles in an eight-hour working day. This means that several treatment facilities should not be placed within one city, unless there is sufficient waste to keep all the autoclaves busy. Some of the already installed autoclaves can be expected to operate at well below capacity, i.e. their waste treatment capacity is far greater than the quantity of waste generated by their host facility. To utilise this excess capacity, the PIU should work toward ensuring that all surrounding HCFs send their infectious waste to the hospitals equipped with treatment systems. Here the project can help these new model facilities with training, equipment, workshops and other actions to bring about a collaboration between the HCFs within each project region.

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