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Waste Management in Namibia

Improvement Report
Aziz Abdallah

Topics: Waste management

Region and Country: Namibia

Organization: USAID Health Care Improvement Project
The Report

Healthcare waste is a by-product of healthcare that includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices and radioactive materials. If the waste is not handled properly, it can injure or cause other harm to the waste handlers, health care workers, or the community.

Assessments conducted in Namibia in September 2004 found that only 22% of health facilities had policies/guidelines for health care waste, sharps, and infection control measures in their units.  Only 60% of facilities segregated their waste segregation, with the remaining using all sorts of bags and boxes.  Puncture-proof sharps containers were used in only 2% of the facilities.  Due to the lack of sharps containers and practices like recapping, there was a high rate of needle stick injuries among healthcare workers and waste handlers: 93% of staff interviewed reported at least two needle stick injuries.  Most facilities had no access to a functional incinerator.  Knowledge of post exposure prophylaxis (PEP) was insufficient, with over 55% of staff not receiving PEP after an exposure to blood/body fluids or a sharps injury. 
The objectives of the HCI project are to:
·      promote medical injection safety
·      improve health care provider knowledge on infection control and occupational safety
·      promote safe management of health care waste

HCI’s approach to promoting safe management of health care waste involves improvement of medical waste disposal including sharps disposal and strengthening of the procurement and logistics system for commodities such as sharps containers, supported by a safe injection program to reduce prescription and demand for injections and occupational safety for health care workers.

Policy level advocacy
The project established a multidisciplinary team, the National Injection Safety Group (NISG) was constituted with representatives from the Ministry of Health and Social Services (MOHSS), the World Health Organization, Centers for Disease Control, USAID, and other stakeholders. The group met periodically to assist with the development and monitoring of injection safety and waste management guidelines. 
HCI worked with MOHSS and other stakeholders in drafting a National Waste Management Policy. The policy provides guidelines for collecting, transporting and incinerating sharps and other medical waste. The policy also covers all types of private providers in the country. A National forum has been established where MOHSS and municipalities are working together on developing and implementing a National waste management plan. The forum is also investigating the possibility of testing new technology for waste management.
Infection control and waste management committees
Thirty-four district infection control teams were also established for the development and supervision of waste management plans and provision of accelerated service expansion and ongoing support.
Commodity management
At the start of the project, very few facilities had continuous access to safety boxes for discarding sharps as well as color coded waste disposal bags for discarding medical and infectious waste. Based on these finding, URC worked closely with MOHSS to develop a short-term strategy for providing these supplies using the project funds. The project procured over 350,000 safety boxes, personal protective equipment for waste handlers, and color coded disposal bin liners. 
The medium-term strategy was to help the Central Medical Stores to develop a procurement strategy for safety boxes as well as PPEs. The procurement of commodities was then transitioned to MOHSS and integrated with the government tendering system. URC provided training to procurement officers on forecasting and ordering, promoting the use of stock cards and collecting data on monthly consumption that is then submitted to the procurement agency. The MOHSS continues to procure standard sharps boxes and all facilities are reporting having standard sharps boxes. The project also advocated for the improvement of status and proper management of incinerators. 
Capacity building
HCI worked to integrate waste management into pre-service training modules at University of Namibia School of Medicine and Nursing, National Health Training Center, five Regional Health Training Centers, and Polytechnic. The project is also providing on-the-job training on topics such as management of medical waste, how to monitor implementation (including reporting of needlestick injuries), and how to conduct facility assessments.  HCI has also developed posters and wall charts along with simple job aids for healthcare workers to promote rational use of medical injections and safe disposal of sharps and medical waste.
Training is followed up by supportive supervision during joint visits, developing/reviewing supervision tools, and by regular reports on the program.  As a result, waste management practices have improved significantly between September 2004 and September 2011. 
Working with the community
HCI is using community educators to raise awareness within the community regarding rational use of medication in order to reduce demand for unnecessary injections and ensure proper disposal of infectious waste produced by some community members, such as insulin-dependent diabetic patients. The educators are reaching out to the community with Injection Safety and Waste Management messages translated into vernacular languages. The project also established linkages with municipal councils to harmonize the regional waste management plans and for capacity building of municipal council’s staff.
HCI is also working closely with MOHSS to liaise with private health care providers to assess the existing injection and medical waste management practices and to support private providers to develop and implement interventions to improve injection and medical waste management practices.
Monitoring and evaluation
HCI, together with MOHSS staff, developed various facility monitoring tools. 
Indicators monitored by each facility include:
·      availability of policies at facility level,
·      availability of safe injection and waste management commodities,
·      injection and phlebotomy process,
·      waste segregation using color coded bags and sharps boxes at the point of use,
·      presence of sharps in the compound of the facility,
·      use of sharps containers that are leak proof, puncture proof, closeable, and stackable,
·      replacement of sharps containers when they are ¾ full to avoid overfilling that can result in needles piercing the sides,
·      temporary waste storage areas with no access to the public, and
·      access to a functional incinerator.
Quarterly assessments are performed to evaluate progress and identify good practices as well as quality gaps. The assessments are followed by quarterly Plan, Do, Study, Act (PDSA) meetings where results are evaluated and shared and improvement plans are adjusted according to need. HCI will support the MOHSS with continuous monitoring and evaluation at all participating facilities as well as the national and regional improvement interventions.

Through this work, sharps containers that were only seen in 2% of 32 hospitals at baseline are present in 98% of 190 facilities reporting by end of June 2011. The presence of used needles and sharps on the facility grounds decreased from 62% of facilities to less than 1%. The project also advocated for the improvement of status and proper management of incinerators. The procurement and installation of 17 new incinerators, and repair of old incinerators has greatly improved the waste treatment practices in Namibia. Access to a functional incinerator among 198 facilities reporting increased from 60% to 98.5% in September 2011. In addition to the above, most facilities have also begun distribution of safety boxes to diabetic patients for home use, which was well received.


Lessons learned

·      Waste management is generally underfunded, requiring advocacy for increased allocation of resources by the government.
·      Ongoing supervision is needed to maintain improved waste segregation practices.
·      District budgets need to include an allowance for incinerator repairs, supplies, and replacement costs.
·      While the commonly used method of waste treatment is incineration, alternative, environmentally friendly ways of waste treatment should be explored.
·      The supply chain for waste management commodities continues to be a challenge, specially the color-coded bags and infection prevention and control products such as alcohol hand-rubs. 
·      Waste management practices have room for improvement. Waste handlers sometimes choose not to use the gloves, goggles and respirators, thinking that the use of safety boxes and waste segregation plays a more important role to protect them from exposure to infectious waste. Cleaners perceive the surgical gloves as being superior to the heavy duty gloves. The majority of staff also thinks that masks provide protection against diseases even in a non risky environment. As a result, they are misusing the two items mentioned.
·      Non-functional incinerators are still an important and chronic problem. Districts very often have to help each other because of breakdowns of existing incinerators, which adds transportation challenges to the difficult task of managing infectious waste.
·      Some facilities do not have adequate storage space for the health care risk wastes. The wastes are therefore left out in an open space, which is not the standard and thus posing a risk to both patients and healthcare workers.
Key Recommendations:
·      Engagement of MOHSS and other stakeholders at all levels and continuous communication is key to a successful implementation;
·      Create an enabling environment through development of policies and guidelines;
·      Improve supply chain management system for injection safety and waste management commodities
Next steps
·      Ensure districts incorporate waste management activities and budgets in the overall Government of the Republic of Namibia district plans.
·      Develop strategies for effective and environmentally friendly disposal of pharmaceutical glass vials.
·      Finalize the review of the Integrated Waste Management guideline and distribute 1,000 copies.
·      Train and mentor two staff for data quality assessments.
·      Strengthen the reporting system and compliance for post-exposure prophylaxis.