Mid-Term Evaluation: Reducing UPOPs and Mercury releases from the Health Sector in Ghana

Report Cover Image
Evaluation Plan:
2018-2022, Ghana
Evaluation Type:
Mid Term Project
Planned End Date:
12/2018
Completion Date:
03/2019
Status:
Completed
Management Response:
Yes
Evaluation Budget(US $):
30,000

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Title Mid-Term Evaluation: Reducing UPOPs and Mercury releases from the Health Sector in Ghana
Atlas Project Number: 00089426
Evaluation Plan: 2018-2022, Ghana
Evaluation Type: Mid Term Project
Status: Completed
Completion Date: 03/2019
Planned End Date: 12/2018
Management Response: Yes
UNDP Signature Solution:
  • 1. Sustainable
Corporate Outcome and Output (UNDP Strategic Plan 2018-2021)
  • 1. Output 1.4.1 Solutions scaled up for sustainable management of natural resources, including sustainable commodities and green and inclusive value chains
SDG Goal
  • Goal 12. Ensure sustainable consumption and production patterns
  • Goal 17. Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development
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
  • 17.16 Enhance the Global Partnership for Sustainable Development, complemented by multi-stakeholder partnerships that mobilize and share knowledge, expertise, technology and financial resources, to support the achievement of the Sustainable Development Goals in all countries, in particular developing countries
Evaluation Budget(US $): 30,000
Source of Funding: Non Core: Global Environment Fund Trustee
Evaluation Expenditure(US $): 25,000
Joint Programme: No
Joint Evaluation: Yes
  • Joint with Madagasca, Zambia and Tanzanie
Evaluation Team members:
Name Title Email Nationality
Peder Bisbjerg Mr pedergregersbisbjerg@hotmail.com
GEF Evaluation: Yes
GEF Project Title: Reducing UPOPs and Mercury releases from the Health Sector in Ghana
Evaluation Type: Mid-term Review
Focal Area: Persistent Organic Pollutants
Project Type: FSP
GEF Phase: GEF-5
GEF Project ID: 4611
PIMS Number: 4865
Key Stakeholders: Ghana Health Services, Ministry of Health, WHO
Countries: GHANA
Comments:

This is  a regional programme that comprising four countries: Ghana, Zambia, Tanzania and Madagaca. It will be evaluated from the regional level.

Lessons
Findings
1.

4 Findings

4.1Project 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. 9Hence the project is perfectly aligned with the GEF’sstrategy, where two focal areas are persistent organic pollutants and the phase-out of mercury.


Tag: Global Environment Facility fund Programme/Project Design SDG Integration

2.

The objective of the World Health Organisation “is the attainment by all peoples of the highest possible level of health. Health, as defined in the WHO Constitution, is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” 11Henceany project that improves the safety of staff, patients and visitors in healthcare facilities (see the text box in this section) most definitely aligned with the goals of the organisation.

The organisation Health Care Without Harm works to “transform health care worldwide so that it reduces its environmental footprint, becomes a community anchor for sustainability and a leader in the global movement for environmental health and justice.” Again, reducing the environmental footprint of healthcare facilities is a cornerstone of this project.


Tag: Environment Policy Health Sector Programme/Project Design

3.

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 theBAT/BEP guidelines to help meet with the Stockholm Convention obligations.


Tag: Waste management Health Sector Implementation Modality Programme/Project Design

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.


Tag: Relevance Gender Equality Human rights Programme/Project Design

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: Gender Equality Women's Empowerment Sanitation Programme/Project Design Women and gilrs

6.

Component 1: Disseminate Technical Guidelines, establish Mid-Term Evaluation Criteria and Technology Allocation Formula, and Build Teams of National Experts on BAT/BEPat 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: Health Sector Results-Based Management

7.

The project under took the core training of the national experts over a two-week period in Nakuru, Kenya from 28 November to 10 December 2016. There were national experts who participated. The quality of the training materials is high and all participant that the MTR interviewed spoke warmly of the quality of the training. The teams underwent comprehensive training in non-incineration HCWM systems, policies, waste assessments, UNDP GEF and WHO tools, national planning, BAT/BEP guidelines, mercury phase-out, international standards, and other technical guidelines and well as project implementation related activities (Gantt charts, critical path analysis, budgeting, monitoring, etc.).


Tag: Waste management National Capacity Building

8.

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 wasmade.


Tag: Transborder Policies & Procedures Project and Programme management

9.

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 non-incineration 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. 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 Technology Civil Societies and NGOs

10.

The recipient countries were to supply the building for the autoclave, as well as utilities such as a power connection and water supply. Here the Regional Project Team provided technical assistance such as building designs and layouts.

The project countries were offered the possibility four different mercury-free devices by the Regional Component; (1) mercury-free aneroid sphygmomanometers, (2) automatic sphygmomanometers, (3) digital blood pressure monitors, and (4) digital thermometers. Based on the National Action Plans, the project countries completed their Bill of Quantities for mercury-free devices.


Tag: Effectiveness Service delivery Technical Support

11.

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

All autoclave buildings are well-made and were completed within a reasonable time frame. 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.

 


Tag: Challenges Efficiency Regional

12.

 

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: Waste management Effectiveness Capacity Building

13.

In the following, the status is provided for each country, covering the progress made to date toward meeting the end of project targets. For each target, the progress will be described following the order in Table 9, starting with the training of healthcare facility staff, then the status for the HCW management, recycling activities, mercury storage, distribution of mercury-free devices, and finally the establishment of a national HCWM training programme. For all healthcare facilities that were visited during the MTR mission, a brief description is given, these are ordered starting with the largest hospital and the descending to the smaller facilities. The four countries have been ordered alphabetically.

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: Qualifiedtrainers, 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 Sanitation Capacity Building

14.

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.


Tag: Waste management Health Sector Sanitation Service delivery Capacity Building

15.

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:


Tag: Waste management Effectiveness National Regional Health Sector

16.

The CHU-Joseph Raseta Befelatanana(CHU-JRB) is a 397-bed teaching hospital located in Antananarivo. The hospital received a 260-litre autoclave, twenty-two240-liter wheelie bins, three 660-litre containers; 32 waste bins to collect recyclables and a station wagon for waste collection vehicle. The waste management system was well functioning, though not perfect (see Photo 18). The autoclave was about to be taken into continuous operation when the MTR visited. The working area for the autoclaveis well organised, with a storage area where general and healthcare waste are stored separately; the received healthcare waste can be weighed upon reception. There are separate storage areas for treated waste and recovered recyclables.


Tag: Waste management Effectiveness Health Sector Sanitation

17.

The CSB2 Manjakandrianais a small primary care facility located next to the district hospital. The facility provides community health services, such as maternity and births, as well as vaccinations. The facility received training in healthcare waste management through the project and was very satisfied. At present the facility burns its infectious waste in a pit behind the clinic, so the future outlook of this waste being autoclaved is promising(the clinic is within 50 metres of the new autoclave at the CHRD Manjakandriana).


Tag: Waste management Challenges Human and Financial resources Capacity Building

18.

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.


Tag: Waste management Health Sector Capacity Building

19.

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 HCWMto 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 Challenges Health Sector Capacity Building

20.

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, theMoH’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.


Tag: Waste management Effectiveness Health Sector

21.

Tanzania has focussed on there cycling 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 Tanzaniaandall collected mercury-containing equipment is currently stored with in the participating hospitals. No location has been identified for acentralised mercury storage.

 

 


Tag: Waste management Challenges Health Sector Capacity Building

22.

Zambia

The introduction of the non-incineration and mercury-free technologies is well underway. 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. 24To achieve this, approximately25 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: Waste management Health Sector

23.

The Ndola Teaching Hospital is the main hospital for the CopperbeltProvince (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. Therefore, all the hospital’s HCW and some of its general waste is incinerated on-site. There is no recovery on recyclable materials within the Ndola Teaching Hospital.


Tag: Waste management Health Sector

24.

The Kabwe General Hospital is the largest hospital in the Central Province, a territory that measures 700km 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 hospitalis 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 Challenges

25.

Zambia

The Kapiri Mposhi District Hospital is located 60km north of Kabwe along the main road. The hospital has 134 beds and takes care of about 50 outpatients daily. Prior to the project, the hospital only separated sharps from all other waste, today it has a well-functioning HCWM system. Given that the hospital has no autoclave, and as its incinerator is falling apart, the collected HCW is burnt in a pit. Hence the measures taken at the hospital do not contribute to a reduction in the release of unintended dioxins and furans to the atmosphere.


Tag: Waste management Challenges Health Sector

26.

A storage site for mercury-containing waste has been installed within the Ministry of Health compound. It is a converted 20’ container complete with shelving, lighting, a spill response kit and a containment area below its base in case of spills. It is intended to warehouse all mercury-containing waste collected within the country. The storage unit was licensed by ZEMA.

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, ...” 31This 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.


Tag: Waste management Health Sector Capacity Building

27.

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 HCFsincinerate the autoclaved waste!


Tag: Waste management Effectiveness

28.

Gender Issues

Both the UNDP and the Guidance for Conducting Midterm Reviews of UNDP-Supported, GEF-Financed Projectsplace 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: Gender Equality Capacity Building Women and gilrs

29.

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 Cat 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.


Tag: Waste management Health Sector

30.

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.


Tag: Waste management Rule of law

31.

Ghana 3: 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: Knowledge management

32.

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. LuqmanYesufu, 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.


Tag: Waste management Sanitation Oversight

33.

Madagascar 2: Identify and prepare a central treatment of healthcare 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 1300litre capacity autoclave.


Tag: Waste management Health Sector

34.

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: Communication Knowledge management

35.

Tanzania 1: Introduction of bio-digestion plant in one of the project facilities. A bio-digestor 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: Sustainability

36.

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

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 waste5.Effective national training programmes

Tag: Oversight 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: Communication Knowledge management

39.

Component 5: Monitoring, adaptive feedback, outreach and evaluation

This component covers the project’s reporting, monitoring and evaluation. The present status can be found in Table 13below.

To summarise, the project is well on track to achieving the developmental objective.

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 Challenges

40.

4.2 Project Implementation and Adaptive Management

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/ChemicalsUnitteam 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: Implementation Modality Oversight Project and Programme management

41.

The National Project Components are executed following theNational Implementation Modality (NIM) and are implemented by the project’s national implementing entities which are the following:

  • Ghana: Ministry of Health
  • Madagascar: Ministry of Environment, Ecology and Forests; and Ministry of PublicHealth
  • Tanzania: Ministry of Health, Community Development, Gender, Elderly and Children
  • Zambia: Ministry of Health; and Ministry of Lands, Natural Resources and Environmental Protection

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

42.

Regional Project Board

  • UNDP IRH Manager
  • A senior level official designated by each of the Project Participating Governments
  • A representative from HCWH
  • A representative from WHO

Tag: Oversight

43.

National Project Board

The National Project Board makes decisions for the project at national level, especially when the National Project Coordinator requires guidance. A representative from the project’s national implementing entity(i.e. the Ministry) chairs the Board which meets at least twice every year.


Tag: Oversight Project and Programme management

44.

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.


Tag: Oversight Project and Programme management

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 Human and Financial resources Policies & Procedures 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.

Every second week there are conference calls between the Regional Project Team and the four national PIUs where progress and problems are discussed. This allows the Regional Project Team to closely monitor and evaluate each PIU’sprogress. Each PIU submits a monthly Progress Report. Furthermore, the International Chief Technical Expert makes frequent visits to all four countries, allowing for a close monitoring of the implementation and hence also an early warning when a PIU encounters difficulties. The Regional Project Team has been very proactive in rapidly following up and taking action when possible difficulties were identified.


Tag: Monitoring and Evaluation Project and Programme management

47.

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.


Tag: Human and Financial resources Monitoring and Evaluation

48.

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 HCFswere successful in achieving this in a timely manner indicated a very high level of engagement in all four countries.


Tag: Communication Partnership Country Government

49.

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 of1 the HCWM systems.


Tag: Waste management Sustainability Sanitation Capacity Building

50.

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 MoHsand 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.

 


Tag: Sustainability Human and Financial resources Ownership

51.

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 Rural

52.

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

53.

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.


Tag: Environment Policy Sustainability

54.

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 almost100,000 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 2017by 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: Human and Financial resources Procurement

55.

Work Planning

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. Two other benefits were observed: Firstly, the four countries are keen to exchange experiences and lessons learned. These interactions assist the project countries in resolving any difficulties they may face. Secondly, there is clearly a competitive spirit between the four countries and all are eager to make good progress, as not to be outdone by others. It must be remarked that this project builds on earlier experiences (see section 3.1), so the proposed solutions are “proven” technology and not at risk of unexpected obstacles.


 


Tag: Project and Programme management Awareness raising Capacity Building

56.

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 sterilized 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 Challenges Project and Programme management

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

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.

3

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.

 

1. Recommendation:

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: 2019/05/07] [Last Updated: 2021/02/15]

This recommendation is very relevant in order to ensure the long-term sustainability of the project. Already, the 2019 Annual Work Plan included quarterly visits to the pilot facilities

 

 

Key Actions:

Key Action Responsible DueDate Status Comments Documents
The PIU will conduct quarterly follow-up visits to the health facilities to assess the status of the non-mercury devices. Focus shall be placed on the current numbers, vis-a-vis the numbers that were provided, their effectiveness in health service delivery, ease of usage and maintenance issues. In this respect, the PIU shall also analyze the records generated through the operation of the non-incineration technologies to assess the frequency of operation, the level of waste treated and frequency of maintenance when there are technical challenges. The PIU shall also pay attention to the communication systems between the operators, management and staff of the hospital to ensure that there is enough communication, collaboration and management support for the continuous operation and maintenance of the non-incineration equipment.
[Added: 2019/05/07]
Project implementation unit 2020/03 Overdue-Initiated
2. 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: 2019/05/07] [Last Updated: 2021/02/15]

This recommendation is accepted. Having taken the decision to purchase one more autoclave for a new health facility in Ghana, the PIU in consultation with the Ministry of Health and UNDP has selected a health facility that is committed to best practices in HCWM and have adequate resources to build a structure in time for the delivery of the autoclave around June 2019

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Maintain strong engagement with the selected health care facility to ensure that the structure is completed before the arrival of the autoclave.
[Added: 2019/05/07]
Project Implementation Unit 2019/06 Overdue-Initiated
Ensure due diligence in the selection of the new health care facility receiving support from the project
[Added: 2019/05/07]
Project Implementation Unit 2019/06 Completed This activity has been fully implemented
3. 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: 2019/05/07] [Last Updated: 2021/02/15]

This recommendation is accepted. Considering the amount of waste that can be processed by the autoclaves installed in the pilot HCFs in Ghana, it was discussed and agreed at the national Steering Committee meeting that the project should promote a cluster treatment system.

Key Actions:

Key Action Responsible DueDate Status Comments Documents
Provide support to the project’s facilities to develop a cluster management plan to enhance the operation of the non-incineration technologies as a cluster treatment facility. The plan among others, includes a management structure for the operation of the facility, charges for additional facilities in the cluster system and arrangements for the transportation of infectious waste to the treatment site.
[Added: 2019/05/07]
Project Implementation 2019/06 Completed
Procure tricycles for HCFs to support the transportation of waste from the additional facilities
[Added: 2019/05/07]
UNDP Ghana CO 2019/09 Overdue-Not Initiated
Explore the opportunity of having an agreement with Zoompak for them to expand their services to health facilities in the project’s regions using the autoclaves in the project’s facilities. Due to the company’s advanced logistics and market experience this arrangement could provide a more efficient transportation system and consistent income to enhance the continuous operation and management of the autoclaves
[Added: 2019/05/07]
Project Implementation Unit 2020/03 Overdue-Not Initiated

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