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"Reducing UPOPs and Mercury Releases from the Health Sector in Africa" project mid-term evaluation
Commissioning Unit: Madagascar
Evaluation Plan: 2015-2021
Evaluation Type: Project
Completion Date: 12/2018
Unit Responsible for providing Management Response: Madagascar
Documents Related to overall Management Response:
 
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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