"Reducing UPOPs and Mercury Releases from the Health Sector in Africa" project mid-term evaluation

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Evaluation Plan:
2015-2021, Madagascar
Evaluation Type:
Mid Term Project
Planned End Date:
12/2018
Completion Date:
12/2018
Status:
Completed
Management Response:
Yes
Evaluation Budget(US $):
30,000

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Title "Reducing UPOPs and Mercury Releases from the Health Sector in Africa" project mid-term evaluation
Atlas Project Number: 00092732
Evaluation Plan: 2015-2021, Madagascar
Evaluation Type: Mid Term Project
Status: Completed
Completion Date: 12/2018
Planned End Date: 12/2018
Management Response: Yes
UNDP Signature Solution:
  • 1. Poverty
Corporate Outcome and Output (UNDP Strategic Plan 2018-2021)
  • 1. Output 2.1.1 Low emission and climate resilient objectives addressed in national, sub-national and sectoral development plans and policies to promote economic diversification and green growth
SDG Goal
  • Goal 12. Ensure sustainable consumption and production patterns
SDG Target
  • 12.4 By 2020, 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
Evaluation Budget(US $): 30,000
Source of Funding: GEF
Evaluation Expenditure(US $): 30,000
Joint Programme: No
Joint Evaluation: Yes
  • Joint with UN Agencies
  • Joint with UNDP Ghana, UNDP Tanzanie, UNDP Zambie, UNDP Istambul
Evaluation Team members:
Name Title Email Nationality
Peder Bisbjerg International Consultant pedergregersbisbjerg@hotmail.com
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: FSP
GEF Phase: GEF-4
GEF Project ID: 4611
PIMS Number: 4865
Key Stakeholders: Ministry of environment, ministry of health
Countries: MADAGASCAR
Comments:

Cette évaluation a été faite par le bureau régional UNDP à Istambul et concerne le projet régional qui est mis en oeuvre dans 4 pays, à savoir Madagascar, Ghana, Tanzanie, Zambie.

Lessons
Findings
1.

4 Findings

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.


Tag: Natural Resouce management Site Conservation / Preservation Health Sector Programme/Project Design Strategic Positioning Agenda 2030

2.

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.


Tag: Site Conservation / Preservation Challenges Health Sector Country Government

3.

The benefits of proper healthcare waste management entities in healthcare facilities This project tackles healthcare waste management in order to reduce the emissions of UPOPs, but as described in this text box the project also has a large positive impact on public health: With relatively modest means, infectious waste can be properly handled with hospitals and clinics, safely stored and treated. This improvement decreases nosocomial infections within hospitals; greatly increasing the safety of patients, health workers, waste collectors and scavengers; and finally eliminates the pollution caused by this waste stream. Hence, other than the environment, the principal beneficiaries of this project are hospital and clinic patients and workers, as well as any person who comes into contact with the waste stream.


Tag: Waste management Effectiveness Health Sector

4.

It is clear from the MTR’s meeting with the stakeholders, that all (donors, ministries, NGOs, private sector) found the project’s priorities highly relevant and well aligned with their own priorities. The UNDP-GEF Monitoring and Evaluation Unit in New York has expressed an interest in whether the relevant gender issues were raised in the project  design. As expressed by the projects Gender Expert, Ms. Sabrina Regmi, “gender equality or human rights issues concerns were not fully mainstreamed in the design phase” (see “Gender Issues” on page 62). That said, 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.

It can be noted that the project builds on earlier experience from similar projects, see section 3.1, and the Project Document reflects a very sensible approach to reducing UPOPs and mercury releases from the health sector. The project design is sound and the project is on track to meet its objectives. The project budget and resources are adequate to meet the targets, and this MTR found that there is a very good collaboration amongst all involved parties. This evaluator’s recommendations for improvements can be found in section 5.2.


Tag: Bilateral partners Country Government Donor Civil Societies and NGOs

5.

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: Effectiveness Project and Programme management Strategic Positioning

6.

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.

Tag: Effectiveness Health Sector Knowledge management Project and Programme management Education Capacity Building Institutional Strengthening

7.

The countries were basically left to decide, with the assistance of the regional component, what hospitals should receive HCW treatment technology. The use of autoclaving technology (rather than incineration) 14 also avoids the generation of any dioxins or furans, and is hence well in line with the project’s stated objective of avoiding releases of UPOPs. The Project Document foresees “central or cluster” treatment facilities where appropriate. The “central” treatment is a standalone facility where the sole function is the treatment of HCW. The “cluster” treatment means that a HCFs with a waste treatment system serves as a hub and serves surrounding facilities that do not have autoclaves. This is a sensible solution, as the capacity of the autoclaving system can then be fully utilised and smaller entities can also have their waste sterilised.


Tag: Waste management Effectiveness Health Sector Capacity Building

8.

This training course also made available to the participants several guidelines, SOPs, and other supporting documents developed by the regional expert team. These documents were intended to help the Master Trainers in developing national curricula and enhancing trainings at national level. These documents included:

  •  HCWM tools for the set up and operation of advanced healthcare waste management systems at facility level.
  •  Outline national HCWM plan.
  •  Guidance on human resource planning, job descriptions and capacity building
  •  Standard Operation Procedures (SOPs) for segregation of HCWM waste, sharp items; collection of waste, internal transportation of waste, storage of waste; spillage of infectious materials and mercury; maintenance of HCWM equipment; needle stick injuries; pharmaceutical waste management; and treatment for hazardous waste.

Tag: Waste management Health Sector Bilateral partners Capacity Building

9.

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.


Tag: Waste management Rule of law Health Sector Capacity Building National Institutions

10.

The national PIUs, in close collaboration with other stakeholders, especially the respective Ministries of Health, selected the model facilities that were to receive non-incineration HCWM systems and mercury-free devices. For each of the selected 24 facilities, the preparatory actions included:

  • Establishing a MOU with each model HCFs, where these facilities undertook to receive training, establish a structure to accommodate the autoclave(s) (only for facilities receiving treatment technology), make their staff available to the project, and so forth.
  •  Conducting a detailed baseline assessment for each of the 24 proposed model facilities covering quantities of waste generated, types of waste, current waste handling, waste storage, transport and disposal routes.
  •  Establishing HCWM committees at each of the HCFs.
  •  Developing and implementing HCWM policies and procedures at the facility level. • Developing and implementing HCWM plans for each of the project facilities.
  • Establishing a plan for managing mercury containing medical devices.
  •  Training staff in best practices related to HCWM.

Tag: Waste management Relevance Health Sector National Institutions

11.

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)

Tag: Waste management Health Sector Procurement Capacity Building National Institutions

12.

The Project Document foresaw that the required autoclaves would be procured by a competitive bidding process led by the UNDP Nordic Office - Procurement Support Unit – Health in Copenhagen. The costs of this office undertaking the procurement was under the GEF’s cap on project management costs (5%), but the anticipated costs of almost 100,000 USD would have greatly limited the overall project management budget. Therefore, it was decided that the procurement should take place through the UNDP IRH.

After agreement of the BoQs, the tender document was developed and published in June 2017 by the UNDP IRH. After two clarification rounds, five bids were received in July 2017. The bids were evaluated according to UNDP requirements and in October 2017 the contract was awarded to the NGO TTM from Germany. The contract covered a total of 57 different products and a total of 2,553 items. Included in this was 18 autoclaves. The purchased equipment was then shipped to the four project countries.


Tag: Waste management Relevance Health Sector Procurement

13.

All equipment for the first phase was successfully procured, shipped and distributed to the recipients. Today, with one exception, all autoclaves have been installed, commissioned and tested and are operational. Likewise, practically all HCWM equipment and non-Hg devices are distributed and in use


Tag: Waste management Efficiency Health Sector Procurement

14.

At Koforidua Eastern Regional Hospital in Ghana one of the two autoclaves was not operational as the local Agent has been unresponsive to calls to provide maintenance services.

At the Mwananyamala Regional Referral Hospital in Tanzania, one of their two autoclaves at had not operated for three weeks when the MTR mission visited. There was an issue with the autoclave control system (programming) and help had been requested from TTM and the facility was still waiting on the trained technician. It was not possible to tell how persistent the hospital had been on obtaining assistance, nor when the first request for service was made.


Tag: Waste management Health Sector Capacity Building

15.

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

 


Tag: Waste management Sustainability Health Sector Capacity Building Institutional Strengthening National Institutions

16.

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.


Tag: Waste management Effectiveness Health Sector Capacity Building

17.

The Winneba Trauma & Specialist Hospital has 146 beds and furthermore receives many outpatients. The hospital has sorted HCW for the past six years and has an autoclave with built-in shredder. The project provided support through capacity building to improve the waste segregation and by providing non-mercury medical devices. The waste management system within the hospital is well organised, though the record keeping is weak, i.e. there is little information gathered on the waste quantities and where they originate. All new staff, amounting to about 30 people per year, receive training in hospital procedures, including HCWM. The hospital’s hydroclave (not provided by the project) had not operated for about one month when the MTR visit took place, so the waste is transported elsewhere for incineration.


Tag: Waste management Effectiveness Health Sector

18.

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: Waste management Effectiveness Health Sector Private Sector

19.

The Ghana PIU has successfully distributed all received mercury-free medical devices to five healthcare facilities in Ghana. 21 For the past four years, as the Ghana Health Service’s policy has been to only purchase mercury free equipment, it has therefore not been possible to realise a one-to-one exchange as foreseen in the project implementation strategy, as there were only small quantities of mercury containing equipment to be found within the hospitals. At present all the collected mercury equipment is stored at three regional EPA offices.

 


Tag: Waste management Effectiveness Health Sector Education Capacity Building Youth

20.

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.


Tag: Waste management Effectiveness Health Sector Capacity Building

21.

The CHU-Mère Enfant Tsaralalàna (CHU-MET) is a teaching hospital that currently has 55 beds; a lot of construction work is ongoing and the hospital will be expanded to 200 beds in 2019. The hospital specialises in maternity and children. The hospital’s HCWM system is exemplary, where all facets for the proper segregation of waste are in place: Bins are clearly labelled, equipped with the correct colour liners, sharps containers are in place and an instructional poster (dated!) can be found above the waste station (see Photo 16).

The hospital did not receive an autoclave from the project, as there was no suitable site within the hospital’s cramped footprint. It is planned that the waste will be transported elsewhere for autoclaving, right now the treatment contract is being drafted. So, at present the hospital burns the collected infectious waste in its existing incinerator, an obsolete piece of equipment which is solely operated at night, presumably so that any black smoke is invisible to the neighbours. All solid waste generated by the CHU-MET is collected by the city’s waste collection service.

During the MTR visit, the hospital was in the process of setting up an ambitious, but well thought out, system for the collection of recyclables (and specific waste). The hospital is planning four fractions (see Photo 17): plastic; diapers (remember, this is a maternity and children’s hospital!), food waste; and paper/ cardboard.


Tag: Waste management Effectiveness Health Sector Capacity Building

22.

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: Waste management Effectiveness Health Sector Capacity Building

23.

The Madagascar PIU has implemented the collection of recyclable materials at all six model sites (see descriptions above and Photo 17). The Project Technical Advisor has made a thorough survey of about 25 facilities that could purchase the various fractions of recyclable materials. Some of the facilities were visited by the MTR and found very promising (see Photo 22), so it seems clear that any recyclables collected in Antananarivo will be reused. For the healthcare facilities in Manjakandriana, the costs of transport may exceed the value of the recovered materials, so here the shipping of the recyclables to a treatment site for reuse may be a real challenge. If the collected materials cannot somehow be sent for recycling, there is no reason to source separate the general waste at these facilities, and the practice should be discontinued.

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.


Tag: Waste management Effectiveness Health Sector Capacity Building

24.

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.


Tag: Waste management Effectiveness Health Sector Education Capacity Building

25.

The hospital generates 500 kg/day of infectious waste and this is treated in the hospital’s two incinerators, both were in operation during the MTR visit.

Potentially the autoclave located at the Muhimbili National Hospital could also receive waste from the new Muhimbili Unit with 500 beds, as well as a Cardiac Hospital and an Orthopaedic Hospital, each with 300 beds, these healthcare facilities all belong under the Muhimbili Organisation. Obviously, it makes sense to utilise the autoclave’s treatment capacity to the fullest extent possible.

The hospital is mercury free, though the one-to-one exchange of non-mercury for mercury devices did not take place, due to poor communication between the participants. The hospital has no programme for recovery of recyclables from the general waste.


Tag: Waste management Effectiveness Health Sector Capacity Building

26.

At present the 9 to 12 kilogrammes of infectious plastic waste are treated in the hospital’s 260-litre autoclave. All other infectious waste is currently transported to another hospital for incineration. The hospital wishes to have the ability to compact the treated healthcare waste before it is taken to landfill, so that the physical form of the waste is changed. So once the hospital has a compactor, it will use the new autoclave to treat the healthcare waste. Long-term, the hospital expects to use the autoclave as a cluster facility, serving surrounding hospitals.


Tag: Waste management Effectiveness Health Sector

27.

Tanzania has focussed on the recycling of plastic that was previously infectious, rather than recovering recyclable materials from the general waste stream. All visited facilities were producing blocks of plastic and the PIU has identified a recycling facility in Mbagala that will collect the plastic blocks from the HCFs and transport these to their sorting facility; the facilities will receive 500 TSH per kg for plastic (0.22 USD/kg).

There were no mercury containing medical devices in use within the HCFs visited in Tanzania and all collected mercury containing equipment is currently stored within the participating hospitals. No location has been identified for a centralised mercury storage.


Tag: Waste management Effectiveness Health Sector Education Capacity Building

28.

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 


Tag: Waste management Effectiveness Health Sector Capacity Building

29.

The EHO responsible for the operation of the autoclaves still wishes for clearance from the local government to place sterilised waste on local landfill, where after he plans to start treating infectious waste. Both the MoH and ZEMA have voiced concerns over placing sterilised was on a landfill, where scavengers will be unable to distinguish between treated and untreated waste. So, at present the autoclave is not used for treating waste.

The Chilenje Level 1 Hospital 25 in Lusaka received assistance from the project in improving waste management procedures and in phasing out mercury. The hospital has 950 beds and is a warren of wards. The EHO staff have done a very good job in setting up the HCWM system (see Photo 30). Bins were located strategically, everything was clearly labelled, sharps containers were (generally) used correctly, and so forth. The hospital did not receive waste treatment equipment from the project, though it is the national PIU’s intent to supply the hospital with autoclaves during the second phase of the project. 26 At present all infectious waste, about 750 kg per day, 27 is burnt in a defective incinerator that is only operated at night (a tactic presumably utilised so that the surrounding inhabitants cannot see black smoke).


Tag: Waste management Effectiveness Health Sector

30.

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.

The Kabwe General Hospital is the largest hospital in the Central Province, a territory that measures 700 km from east to west. The hospital has 444 beds and receives over 100 outpatients daily. The hospital received two 260-litre capacity autoclaves, equipment for HCWM within the hospital and non-mercury medical devices. The HCWM is well functioning within the hospital, where a lot of effort has been put into the location of bins, labelling and training of staff. All collected HCW is autoclaved through two daily cycles with the new machines. Unfortunately, as the hospital is unsure whether the yellow bags of sterilised HCW can be placed on the local dumpsite, the decision has been to incinerate the treated HCW on-site in the hospital’s incinerator. This is quite contrary to the project’s stated aim of promoting non-incineration technologies, as when the waste is burnt after sterilisation, there will still be the same quantity of dioxins and furans released into the atmosphere.


Tag: Waste management Effectiveness Health Sector

31.

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!


Tag: Waste management Effectiveness Health Sector

32.

The intent is that a large local recycling company Waste Master (Z) will collect the waste in two fractions (one paper/ cardboard and one plastic) and then sort it further prior to resale. At present the sorting at Waste Master (Z) is manual but the company is receiving a license to build and operate a materials recovery facility (MRF). Waste Master (Z) already collects recyclables from three large private hospitals in Lusaka and handles about 10 tonnes of materials per day.

At present there has only been action at the UHT, for the Chilenje and Matero Level 1 Hospitals matters are still at the discussion stage. 30 This seems a shame, as there is obviously an outlet for any recovered recyclable materials. At present the private hospitals supplying Waste Master (Z) in Lusaka receive about 1.15 kwacha per kg of mixed plastic and 0.70 kwacha per kg of paper/ cardboard. The project could have done a lot more to facilitate the establishment of recycling schemes at the two hospitals over the past two years.


Tag: Waste management Effectiveness Health Sector

33.

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 Effectiveness Health Sector

34.

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.


Tag: Waste management Effectiveness Gender Equality Health Sector Capacity Building Women and gilrs

35.

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 Effectiveness Health Sector

36.

Madagascar 1: Introduce WASH FIT and GGHH in the health care facilities supported. The staff at Madagascar’s six model health facilities received training by Global Green and Healthy Hospitals (GGHH) in August 2017 by Mr. Luqman Yesufu, where the objective is to reduce the environmental footprint of the health sector. National goals for improving the management of healthcare waste were formulated; a focal point was identified in each of the six model health facilities and now they participate in the regular webex offered by GGHH.

All the model health facilities were trained in the Water And Sanitation for Health Facility Improvement Tool (WASH FIT) by Ms. Arabella Hayter, a WHO Expert, in 2017, and subsequently by the national trainers in 2017 and 2018. The WASH FIT first assessment has been performed for each model health facility, a WASH FIT committee was created and an annual improvement plan developed. To date there have been two follow-up meetings with the model health facilities and the national Technical Working Group.

Madagascar 2: Identify and prepare a central treatment of health care waste management. The hospital CHU-JRA was identified for central treatment of healthcare waste, this facility has been identified as a cluster facility and received a big 1300 litre capacity autoclave.

Madagascar 3: Autoclave maintenance video. During the training provided by the Mediclave technicians in August 2018, a video on the autoclave operation and maintenance was shoot and the first draft of the videos is under review. The video will be made for both English and French speaking audiences.

 


Tag: Waste management Effectiveness Health Sector Capacity Building

37.

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

Tag: Waste management Relevance Health Sector Procurement

38.

Component 4b: Expand HCWM systems and the phase-out of mercury in the recipient countries and disseminate results in the African region

The second phase of this project continues after this MTR. Here, following the recommendations from this report, each country will seek to improve its existing system and expand the system to more facilities. Likewise, as indicated under the description of Component 3b, the coverage of the national training program will be further expanded.

The Project Document foresees that the project results and replication tools are disseminated nationally and regionally through existing conferences on environment and health, such as the annual WHO and infection control conferences.

The project is already disseminating its results and the Ghana national HCWM curriculum developed under the project is now used by the West Africa Health Examination Board and is the basis for all HCWM training in West Africa.


Tag: Waste management Sustainability Health Sector Knowledge management

39.

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.


Tag: Waste management Effectiveness Health Sector

40.

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: Effectiveness Implementation Modality Project and Programme management

41.

The NIM means that the responsibility for the project execution lies with the national governments. Here the national implementing entities (see above) assume full responsibility for the effective use of UNDP resources and the delivery of outputs in the signed project document. The implementing entities report on project progress against the agreed work plans, following the reporting schedule and formats laid out in the Project Document.

 


Tag: Relevance Human and Financial resources Implementation Modality Project and Programme management Country Government

42.

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: Oversight Project and Programme management

43.

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.

 


Tag: Waste management Relevance Health Sector Project and Programme management Country Government

44.

The regional component has acted in a very professional manner throughout the project implementation: Training materials and training courses have been of a high quality. Advice to the four countries, procurement and technical support has all been excellent. The MTR commends the Ghana PIU for not planning any autoclaving facilities for Accra, as the private company Zoompak already owns a large autoclave facility designed to serve the capital. Instead of installing competing autoclaves within the city, the Ghana PIU has supported Zoompak in raising awareness about the facility and about the importance of good HCWM systems, helping Zoompak double their number of clients over the past two years.

At present the project has one significant shortcoming. All four countries are reluctant or unwilling to directly landfill sterilised waste. It is felt that the waste should be physically altered and the consensus is that all sterilised waste should be either shredded or compacted. There is a logic to this: If yellow (or red) bags are used as a warning, telling all people that the bag contains dangerous (infectious) waste, then using the same colour bag when placing sterilised waste on a landfill, could lead scavengers (and others) to believe that the waste in yellow or red bags is not dangerous. This would be a very dangerous situation for those handling the waste at the disposal site.

 


Tag: Waste management Sustainability Health Sector Capacity Building

45.

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.


Tag: Efficiency Operational Efficiency Procurement

46.

Project Level Monitoring and Evaluation Systems

The project has a well-functioning monitoring and evaluation system. The PIUs use their contact persons within the 24 model facilities, especially the responsible EHOs, to report back whenever assistance or other support is required. All hospital staff the MTR talk to found the support from the PIUs effective and said that it was provided in a timely manner.


Tag: Efficiency Monitoring and Evaluation Project and Programme management

47.

4.3 Sustainability

Rating: L (see Annex D for an explanation)

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.


Tag: Waste management Sustainability Resource mobilization Health Sector Country Government

48.

Socio-economic risks to sustainability

As already mentioned in this report, the principal socioeconomic risk factor is for the remote rural health posts. These operate on a very limited budget and could well face difficulties in keeping their HCWM system operational, as there may be insufficient funds to pay for bin liners, transport of the collected HCW to a treatment centre and so forth.


Tag: Sustainability Health Sector Regional Institutions

49.

Institutional framework and governance risks to sustainability

There are no institutional framework and governance risks to the sustainability of the project. In all four countries the health sector has a strong institutional framework and good governance. Considering the number of highly skilled professionals working in these facilities, operating a highly desired HCWM system will not be an issue.


Tag: Sustainability Health Sector Country Government National Institutions

50.

Environmental risks to sustainability

There are no direct risks to sustainability. Although the HCFs are unwilling to place sterilised waste in a landfill without altering its physical form, there are no environmental or regulatory clauses that prevent this. So once the physical form for the treated HCW is physically altered to the satisfaction of the autoclave operators, the waste can be reliably disposed of.

The project collects mercury containing medical devices and places these in temporary storages. Long-term this waste will have to be disposed of as a hazardous waste. Although this future disposal does not pose a sustainability risk to the project, it will have to be addressed and resolved at some stage by the national governments.

All countries are on track to become nations where all HCFs are mercury free within a few years


Tag: Waste management Sustainability Health Sector

51.

The national curriculum in Zambia for Environmental Health Officers and Nurses both incorporate a teaching module on healthcare waste management. The classes are similar and the course content for Environmental Health Officers is discussed here. EHOs have a 64-hour course on Health-care Waste Management, where half the course is lectures and the other half practical work during the first half of their third year of studies. This course was updated within the last five years and covers both the incineration of HCW, as well as “non-incineration treatment options: steam treatment technologies e.g. autoclaves; microwave treatment technologies, ...” 31 This curriculum is followed at all of the country’s health science schools (there are approximately ten). Other than EHO and Nurses, Environmental Health Technologists and Clinical Officers (“night physicians”) are also taught comprehensively about HCWM.

It can be noted that there is no refresher course on HCWM available of EHOs, something that the public health experts the MTR Consultant met recommended. Likewise, an orientation/ information package for HCW transporters would be desirable and is currently lacking.


Tag: Waste management Effectiveness Health Sector Education Capacity Building

52.

Tanzania 1: Introduction of bio-digestion plant in one of the project facilities. A biodigestor was established at the Mwananyamala Regional Referral Hospital in 2018 (see Photo 39). It has in operation since September 2018 and substantial gas production is expected by December 2018. During the MTR visit on 17 October there was already gas production and it was demonstrated how the gas can be used to heat water. The digester is fed with placenta from the maternity ward, rice and vegetables. The system seemed to be working well, so it will be interesting to see if this remains true in the long-term. The initial intuition was that this system is sustainable.

 


Tag: Waste management Effectiveness Relevance Health Sector

53.

Zambia 1: Initialize recycling of non–infectious waste. The PIU is initiating the collection of recyclables at UHT, for the Chilenje and the Matero Level 1 Hospitals, as described earlier in this section. The PIU is also working to establish a local production of safety boxes from recycled materials. This initiative is still at an early stage: The Kabwe General Hospital has collected five bags of discarded syringes (see Photo 40) and the intent is that a plastic recycler in Kabwe named Solid Tech will utilise the collected materials to produce sharps safety containers. It seems a matter of bringing the syringes to Solid Tech, so that the pilot production can be initiated.


Tag: Waste management Effectiveness Relevance Health Sector

54.

The most common measure is to have a special fenced off area at the landfill where the healthcare waste is placed. Unfortunately, such a solution only works at a controlled landfill where there are guards, otherwise scavengers will simply cut through the fence to access the waste (the plastics in hospitals waste have a good value when recovered for recycling). At present all the sterilised waste is destined for uncontrolled dumpsites with scavengers, and hence the reluctance to use these for the sterilised waste.

 


Tag: Waste management Sustainability Health Sector

55.

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: Efficiency Monitoring and Evaluation Project and Programme management

56.

Stakeholders Engagement

The project is close to the needs and goals of all stakeholders. The project’s objectives are well aligned with the donors’ objectives. In each country, the Ministries of Environment wish to meet their obligations under the Stockholm and Minamata Conventions, this project serves to meet these goals, building skills within the Ministries in the process. The engagement is best demonstrated by the fact that all fourteen buildings that were to house the new autoclaves have been completed. The recipient countries were responsible for the supply of these structures, as well as utilities such as a power connection and water supply. That all 14 HCFs were successful in achieving this in a timely manner indicated a very high level of engagement in all four countries.


Tag: Bilateral partners Country Government

Recommendations
1

Regional Project Team The following are measures that should be taken by the Regional Project Team:

The placement of sterilised waste on a dumpsite or landfill, without any change of physical form is clearly a concern in all project countries. These concerns are discussed in section 0 and at present this issue greatly hampers the project’s ability to meet its goals. To fully utilise the autoclaves, it is clear that the sterilised waste must be shredded or otherwise altered prior to landfilling. The Regional Project Team is already aware of this and shredders are included in the new Catalogue of HCWM Equipment, so that the countries will receive shredder during the second project phase.

In some countries, there are several autoclaving facilities within one city, this especially applies to Tanzania where all the treated waste comes from hospitals in the greater Dar Es Salaam area. It should be examined whether one shredder 39 (or compactor, as is preferred by Tanzania) could be installed at either the landfill or a central location, and handle all the sterilised waste. There could be considerable savings by not installing compaction/ shredding equipment at each hospital.

2

It is essential that the solar panel system at the CSB2 Manjakandriana provides enough power to compensate for the consumption of the autoclave. A meter shall be installed and the PIU shall regularly check if the electricity produced is sufficient to compensate the electricity consumed by the autoclave

3

The instructional posters for hospitals and clinics on how to properly manage HCW should be updated, so that they reflect the existing system.

4

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

5

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.

6

 The Project Document states that “an additional 12 rural health posts are to be supported during the second phase of the project.” It is strongly recommended that the project focusses on larger hospitals in the second phase. Rural health posts may be able to properly segregate and handle their infectious waste, but the quantities of waste they generate is small and the costs of bringing this 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 (and as the facilities have far more pressing problems).

 

7

The Project Document recommends to “Increase composting activities, which will significantly reduce the volume of the waste that needs to be transported to the landfill/dump site. Organic waste makes up the majority of HCF waste. By developing composting activities on the premises, HCFs could reduce waste collection rates charged by the municipal service providers, while generating some additional income through the sale of compost.” This advice should be disregarded. While it is environmentally sound guidance to collect and treat organic waste, this activity, like other forms of waste treatment, costs money and it is very unlikely that the compost can be sold. Therefore, the Regional Project Team should only encourage the on-site composting of garden waste (not food waste) for use within the hospitals’ green areas.

8

National PIUs

The following are the recommendations for a Phase 2 of the project for all countries:

  1. The Project Document expects the introduction of non-incineration and mercuryfree 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.
  2.  In 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 eighthour 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.
  3. 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.
9

Madagascar

The following are the recommendations for a Phase 2 of the project in Madagascar:

  •  It is essential that the solar panel system at the CHRD Manjakandriana provides enough power to compensate for the consumption of the autoclave. A meter shall be installed and the PIU shall regularly check if the electricity produced is sufficient to compensate the electricity consumed by the autoclave.
  •  The instructional posters for hospitals and clinics on how to properly manage HCW should be updated, so that they reflect the existing system.
10

Tanzania

The following are the recommendations for a Phase 2 of the project in Tanzania:

  1. 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 an 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 work. The difficulties currently experienced, for example at the Muhimbili National Hospital (see section 0), 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
  2.  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.
  3. 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. The best approach is probably to set up a working group with the key stakeholders (Ministry of Health, MUHAS, schools of hygiene, the PIU, WHO, etc.) to develop a curriculum covering HCW for these five schools. The working group should develop the teaching materials, organise a training of teachers in the material (e.g. a one-week course for all lecturers who are to teach HCWM). Ideally, a shorter course, say 3 or 5 days, for existing Environmental Health Officers should also be developed and taught, so that EHOs who have already graduated also receive training. Longer-term, outside the scope of this project, Tanzania should also put into effect modules teaching HCWM in the curriculum for nurses and medical doctors.
11

Zambia

The following are the recommendations for a Phase 2 of the project in Zambia:

  1. The HCWM system at the UTH must be fully implemented and made functional. It is essential that the country’s premier teaching hospital has a well-functioning HCWM system. See recommendation no. 1 for Tanzania for suggestions as to how this issue is best addressed.
  2. The recycling company Waste Master (Z) is a perfect opportunity to easily recover recyclable materials from hospitals in Lusaka. Efforts are starting at the UHT, for the Chilenje and Matero Level 1 Hospitals matters are still at the discussion stage. The PIU should encourage and facilitate the process, so that plastic, paper and cardboard are recovered at these three hospitals.
12

There are clearly issues with the availability of a local service technicians from TTM. During the MTR visits, this was an issue in Ghana, Madagascar and Tanzania. The service technicians must be available for autoclave maintenance and repair, and should be readily available. The autoclave at the CHRD Manjakandriana should have been started up in mid-August, but as the TTM local service technician quit his job, this machine had still not been connected in October 2018. It is essential that this issue is resolved with the TTM main office.

1. Recommendation:

Regional Project Team The following are measures that should be taken by the Regional Project Team:

The placement of sterilised waste on a dumpsite or landfill, without any change of physical form is clearly a concern in all project countries. These concerns are discussed in section 0 and at present this issue greatly hampers the project’s ability to meet its goals. To fully utilise the autoclaves, it is clear that the sterilised waste must be shredded or otherwise altered prior to landfilling. The Regional Project Team is already aware of this and shredders are included in the new Catalogue of HCWM Equipment, so that the countries will receive shredder during the second project phase.

In some countries, there are several autoclaving facilities within one city, this especially applies to Tanzania where all the treated waste comes from hospitals in the greater Dar Es Salaam area. It should be examined whether one shredder 39 (or compactor, as is preferred by Tanzania) could be installed at either the landfill or a central location, and handle all the sterilised waste. There could be considerable savings by not installing compaction/ shredding equipment at each hospital.

Management Response: [Added: 2020/01/23] [Last Updated: 2021/02/04]

The management accepts the recommendation : Periodic follow-up visits and regular meetings with model hospitals, project staff and the technical working group to ensure sustainability of the best environmental practices introduced in HCWM and use of mercury free medical devices.

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Periodic visits of the model hospitals using the autoclaves: meetings with model hospitals
[Added: 2020/01/23]
UPOPs project staff 2019/03 Completed Quarterly visits realized
Quarterly meetings with the technical working group to discuss relevant challenges faced by the model hospitals and provide solutions to sustain the best environmental practices in HCWM in the model health facilities
[Added: 2020/01/24]
UPOPs project staff, technical working group 2019/03 Completed
2. Recommendation:

It is essential that the solar panel system at the CSB2 Manjakandriana provides enough power to compensate for the consumption of the autoclave. A meter shall be installed and the PIU shall regularly check if the electricity produced is sufficient to compensate the electricity consumed by the autoclave

Management Response: [Added: 2020/01/23] [Last Updated: 2021/02/04]

The management accepts the recommendation : Adjustment work of the installation of the solar panel system by the service provider and on-site visit of MOH and MOE technicians at the hospital CHRD Manjakandriana in November 2018

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Request of adjustment work of the installation of the solar panel system by the service provider
[Added: 2020/01/24]
Project staff, service provider 2018/11 Completed
On-site visit of MOH and MOE technicians and project staff at CHRD Manjakandriana
[Added: 2020/01/24]
Project staff, MOH technicians (SEM, SILO, DHRD, DRSP Analamanga), MOE (Stockholm C) 2018/11 Completed The electricity consumption of the hospital is reduced by 60% and it will be largely sufficient for a bi-weekly operation of the autoclave at CHRD Manjakandriana
3. Recommendation:

The instructional posters for hospitals and clinics on how to properly manage HCW should be updated, so that they reflect the existing system.

Management Response: [Added: 2020/01/23] [Last Updated: 2021/02/04]

The management accepts the recommendation : Printing updated job aids on segregation of HCW in the model hospitals is planned in 2019

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Workshop to update and validate the job aids for model hospitals
[Added: 2020/01/24]
Project staff, technical working group 2019/03 Completed
Workshop to update and validate the job aids for model hospitals
[Added: 2020/01/24]
Project staff, technical working group 2019/05 Completed Job aids already updated
Printing the updated job aids for model health facilities
[Added: 2020/01/24] [Last Updated: 2020/03/17]
Project staff 2019/06 Completed Job aids already displayed on the wards of the model hospitals History
4. Recommendation:

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

Management Response: [Added: 2020/01/23] [Last Updated: 2021/02/04]

The management accepts the recommendation : Only one teaching hospital CHU Morafeno Toamasina will receive an autoclave to treat without incineration its own waste and waste from a second new model hospital CHU Analankininina Toamasina. An on-site preparation of these 2 new model hospitals is planned on February 11 till 15 by the MOH technicians (DGEHU, SSENV and national trainer) in Toamasina to facilitate and accelerate as possible the readiness of these new sites.

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Conduct an on-site visit of the 2 new model hospitals: collect of baseline data, prepare environmental authorization, identify the needs for making available a functioning building for the autoclave…
[Added: 2020/01/24]
Project staff, MOH technicians (national director, DGFS, SSENV) 2019/02 Completed
Close follow-up of the actions identified to accelerate as possible the readiness of these new sites
[Added: 2020/01/24]
Project staff, MOH technicians (national director, DGEHU, SSENV) 2019/12 Completed
5. Recommendation:

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.

Management Response: [Added: 2020/01/23] [Last Updated: 2021/02/04]

The management accepts the recommendation : All the 4 model hospitals equipped with the autoclave for non-incineration treatment of HCW received also a vehicle for safely transport of HCW conform to ADR standards. They will be encouraged and supported to treat the waste of neighboring public and private health care facilities.

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Workshop with the model hospitals and technical working group
[Added: 2020/01/24]
Project staff, technical working group 2020/03 Completed
Conduct an advocacy on collaboration between model hospitals and neighboring public and private health care facilities
[Added: 2020/01/24] [Last Updated: 2020/04/09]
MOH persons in charge (DGFS, DHRD, SSENV…), project 2020/03 Completed It will be continued after the end of the project (by MOH persons) History
6. Recommendation:

 The Project Document states that “an additional 12 rural health posts are to be supported during the second phase of the project.” It is strongly recommended that the project focusses on larger hospitals in the second phase. Rural health posts may be able to properly segregate and handle their infectious waste, but the quantities of waste they generate is small and the costs of bringing this 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 (and as the facilities have far more pressing problems).

 

Management Response: [Added: 2021/01/30] [Last Updated: 2021/02/04]

Key Actions:

7. Recommendation:

The Project Document recommends to “Increase composting activities, which will significantly reduce the volume of the waste that needs to be transported to the landfill/dump site. Organic waste makes up the majority of HCF waste. By developing composting activities on the premises, HCFs could reduce waste collection rates charged by the municipal service providers, while generating some additional income through the sale of compost.” This advice should be disregarded. While it is environmentally sound guidance to collect and treat organic waste, this activity, like other forms of waste treatment, costs money and it is very unlikely that the compost can be sold. Therefore, the Regional Project Team should only encourage the on-site composting of garden waste (not food waste) for use within the hospitals’ green areas.

Management Response: [Added: 2021/01/30] [Last Updated: 2021/02/04]

Key Actions:

8. Recommendation:

National PIUs

The following are the recommendations for a Phase 2 of the project for all countries:

  1. The Project Document expects the introduction of non-incineration and mercuryfree 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.
  2.  In 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 eighthour 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.
  3. 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.
Management Response: [Added: 2021/01/30] [Last Updated: 2021/02/04]

Key Actions:

9. Recommendation:

Madagascar

The following are the recommendations for a Phase 2 of the project in Madagascar:

  •  It is essential that the solar panel system at the CHRD Manjakandriana provides enough power to compensate for the consumption of the autoclave. A meter shall be installed and the PIU shall regularly check if the electricity produced is sufficient to compensate the electricity consumed by the autoclave.
  •  The instructional posters for hospitals and clinics on how to properly manage HCW should be updated, so that they reflect the existing system.
Management Response: [Added: 2021/01/30] [Last Updated: 2021/02/04]

Key Actions:

10. Recommendation:

Tanzania

The following are the recommendations for a Phase 2 of the project in Tanzania:

  1. 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 an 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 work. The difficulties currently experienced, for example at the Muhimbili National Hospital (see section 0), 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
  2.  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.
  3. 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. The best approach is probably to set up a working group with the key stakeholders (Ministry of Health, MUHAS, schools of hygiene, the PIU, WHO, etc.) to develop a curriculum covering HCW for these five schools. The working group should develop the teaching materials, organise a training of teachers in the material (e.g. a one-week course for all lecturers who are to teach HCWM). Ideally, a shorter course, say 3 or 5 days, for existing Environmental Health Officers should also be developed and taught, so that EHOs who have already graduated also receive training. Longer-term, outside the scope of this project, Tanzania should also put into effect modules teaching HCWM in the curriculum for nurses and medical doctors.
Management Response: [Added: 2021/01/30] [Last Updated: 2021/02/04]

Key Actions:

11. Recommendation:

Zambia

The following are the recommendations for a Phase 2 of the project in Zambia:

  1. The HCWM system at the UTH must be fully implemented and made functional. It is essential that the country’s premier teaching hospital has a well-functioning HCWM system. See recommendation no. 1 for Tanzania for suggestions as to how this issue is best addressed.
  2. The recycling company Waste Master (Z) is a perfect opportunity to easily recover recyclable materials from hospitals in Lusaka. Efforts are starting at the UHT, for the Chilenje and Matero Level 1 Hospitals matters are still at the discussion stage. The PIU should encourage and facilitate the process, so that plastic, paper and cardboard are recovered at these three hospitals.
Management Response: [Added: 2021/01/30] [Last Updated: 2021/02/04]

Key Actions:

12. Recommendation:

There are clearly issues with the availability of a local service technicians from TTM. During the MTR visits, this was an issue in Ghana, Madagascar and Tanzania. The service technicians must be available for autoclave maintenance and repair, and should be readily available. The autoclave at the CHRD Manjakandriana should have been started up in mid-August, but as the TTM local service technician quit his job, this machine had still not been connected in October 2018. It is essential that this issue is resolved with the TTM main office.

Management Response: [Added: 2021/02/04]

Key Actions:

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